[Senate Hearing 110-583]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-583
 
 IMPROVEMENTS IMPLEMENTED AND PLANNED BY THE DEPARTMENT OF DEFENSE AND 
   THE DEPARTMENT OF VETERANS AFFAIRS FOR THE CARE, MANAGEMENT, AND 
              TRANSITION OF WOUNDED AND ILL SERVICEMEMBERS

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

                                HEARING

                               before the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 13, 2008

                               __________

         Printed for the use of the Committee on Armed Services


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                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

EDWARD M. KENNEDY, Massachusetts     JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia        JOHN WARNER, Virginia,
JOSEPH I. LIEBERMAN, Connecticut     JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island              JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii              SUSAN M. COLLINS, Maine
BILL NELSON, Florida                 SAXBY CHAMBLISS, Georgia
E. BENJAMIN NELSON, Nebraska         LINDSEY O. GRAHAM, South Carolina
EVAN BAYH, Indiana                   ELIZABETH DOLE, North Carolina
HILLARY RODHAM CLINTON, New York     JOHN CORNYN, Texas
MARK L. PRYOR, Arkansas              JOHN THUNE, South Dakota
JIM WEBB, Virginia                   MEL MARTINEZ, Florida
CLAIRE McCASKILL, Missouri           ROGER F. WICKER, Mississippi

                   Richard D. DeBobes, Staff Director

              Michael V. Kostiw, Republican Staff Director

                                  (ii)

  




                            C O N T E N T S

                               __________

                    CHRONOLOGICAL LIST OF WITNESSES

 Improvements Implemented and Planned by the Department of Defense and 
   the Department of Veterans Affairs for the Care, Management, and 
              Transition of Wounded and Ill Servicemembers

                           february 13, 2008

                                                                   Page

Mansfield, Hon. Gordon H., Deputy Secretary of Veterans Affairs; 
  Accompanied by Hon. Patrick W. Dunne, Rear Admiral, U.S. Navy 
  (Retired), Assistant Secretary of Veterans Affairs for Policy 
  and Planning...................................................     7
Chu, Hon. David S.C., Under Secretary of Defense for Personnel 
  and Readiness..................................................    15
Geren, Hon. Preston M., III, Secretary of the Army...............    16
Schoomaker, LTG Eric B., USA, Surgeon General of the Army and 
  Commander, U.S. Army Medical Command...........................    22

                                 (iii)


 IMPROVEMENTS IMPLEMENTED AND PLANNED BY THE DEPARTMENT OF DEFENSE AND 
   THE DEPARTMENT OF VETERANS AFFAIRS FOR THE CARE, MANAGEMENT, AND 
              TRANSITION OF WOUNDED AND ILL SERVICEMEMBERS

                              ----------                              


                      WEDNESDAY, FEBRUARY 13, 2008

                                       U.S. Senate,
                               Committee on Armed Services,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:32 a.m. in room 
SD-106, Dirksen Senate Office Building, Senator Carl Levin 
(chairman) presiding.
    Committee members present: Senators Levin, Kennedy, Bill 
Nelson, E. Benjamin Nelson, Webb, Warner, Inhofe, Sessions, 
Chambliss, Dole, Thune, and Wicker.
    Committee staff members present: Richard D. DeBobes, staff 
director; and Leah C. Brewer, nominations and hearings clerk.
    Majority staff members present: Gabriella Eisen, counsel; 
Gerald J. Leeling, counsel; and Peter K. Levine, general 
counsel.
    Minority staff members present: Michael V. Kostiw, 
Republican staff director; William M. Caniano, professional 
staff member; David G. Collins, research assistant; Lucian L. 
Niemeyer, professional staff member; Diana G. Tabler, 
professional staff member; and Richard F. Walsh, minority 
counsel.
    Staff assistants present: Fletcher L. Cork, Jessica L. 
Kingston, Ali Z. Pasha, and Brian F. Sebold.
    Committee members' assistants present: Bethany Bassett and 
Jay Maroney, assistants to Senator Kennedy; James Tuite, 
assistant to Senator Byrd; Bonni Berge, assistant to Senator 
Akaka; Christopher Caple, assistant to Senator Bill Nelson; 
Andrew R. Vanlandingham, assistant to Senator Ben Nelson; Jon 
Davey, assistant to Senator Bayh; M. Bradford Foley, assistant 
to Senator Pryor; Gordon I. Peterson, assistant to Senator 
Webb; Jennifer Cave and Sandra Luff, assistants to Senator 
Warner; Anthony J. Lazarski and Nathan Reese, assistants to 
Senator Inhofe; Lenwood Landrum and Todd Stiefler, assistants 
to Senator Sessions; Mark J. Winter, assistant to Senator 
Collins; Clyde A. Taylor IV, assistant to Senator Chambliss; 
Adam G. Brake, assistant to Senator Graham; Lindsey Neas, 
assistant to Senator Dole; Jason Van Beek, assistant to Senator 
Thune; and Erskine W. Wells III, assistant to Senator Wicker.

       OPENING STATEMENT OF SENATOR CARL LEVIN, CHAIRMAN

    Chairman Levin. Good morning, everybody. The committee 
meets this morning to review actions taken over the last year 
to improve living conditions, outpatient care, and processes to 
help our severely injured and ill servicemembers as they 
transition to care provided by the Department of Veterans 
Affairs (VA) into civilian life and to discuss actions in 
progress or yet to commence.
    Our witnesses this morning were scheduled to be: Deputy 
Secretary of Defense Gordon England--and before I identify the 
other witnesses, let me say that I understand that Secretary 
Gates had a fall last night on the ice and broke his shoulder 
and therefore now he must be represented by Gordon England at 
another hearing that Secretary Gates was supposed to be at 
himself. Is that correct?
    Secretary Geren. Yes, sir, that's correct.
    Chairman Levin. It's our hope that you would express to 
Secretary Gates our, first of all, hopes for a very speedy and 
prompt recovery. We obviously want him back in action. We 
understand totally, of course, why the Secretary cannot be with 
us this morning.
    Our other witnesses are: Deputy Secretary of Veterans 
Affairs Gordon Mansfield; Secretary of the Army Pete Geren; 
Under Secretary of Defense for Personnel and Readiness David 
Chu; and the Surgeon General of the Army, Lieutenant General 
Eric Schoomaker.
    We understand Admiral Dunne is here with you, Secretary 
Mansfield, this morning. We welcome you, of course, as well, 
Admiral.
    Our Nation has a moral obligation to provide quality health 
care to the men and women who put on our Nation's uniform and 
are injured and wounded fighting our Nation's wars. On February 
18, 2007, the headlines of the Washington Post read ``Soldiers 
Face Neglect, Frustration at Army's Top Medical Facility.'' A 
series of articles by Dana Priest and Ann Hull served as a 
wakeup call regarding the care and treatment of our wounded 
warriors. The articles that appeared in the press a year ago 
described deplorable living conditions for servicemembers 
living in outpatient status at Walter Reed, a bungled 
bureaucratic process for assigning disability ratings that 
determined whether a servicemember would be medically retired 
with health and other benefits for the member and for his 
family. They described a clumsy handoff from the Department of 
Defense (DOD) to the VA as these injured soldiers try to move 
on with their lives. We also learned that these problems were 
not limited to the Army or to Walter Reed.
    A lot has been accomplished in the wake of these articles 
and much more needs to be done. This committee held a hearing 
on March 6, 2007, to address the shortfalls in the care of our 
wounded warriors. At that hearing we concluded that it would 
require the coordinated efforts of the VA Committee and the 
Armed Services Committee to address the issues in a 
comprehensive manner.
    This led to a rare joint hearing of the Committee on Armed 
Services and the Committee on Veterans Affairs on April 12. The 
committees continued to work together to pass the Dignified 
Treatment of Wounded Warriors Act on July 25, 2007. This 
comprehensive bipartisan legislation that addressed the care 
and management of our wounded warriors was drafted, marked up, 
and passed by the Senate in record time.
    This act, enhanced by provisions in the House-passed 
Wounded Warrior Assistance Act of 2007, became the Wounded 
Warrior Act that was included in the recently signed National 
Defense Authorization Act for Fiscal Year 2008. The Wounded 
Warrior Act represents major reform and was supported by 
veterans service organizations. It advances the care, 
management, and transition of recovering servicemembers; 
enhances health care and benefits for families; and begins the 
process of fundamental reform to the disability evaluation 
systems of DOD and the VA.
    We require the DOD in this law to use VA standards for 
rating disabilities and to use the VA presumption of sound 
condition in determining whether a disability is service-
connected. We increase the disability severance pay for certain 
servicemembers. We required the DOD and the VA to jointly 
develop a comprehensive policy on improvements to care and 
management of recovering servicemembers. We established centers 
of excellence for traumatic brain injury (TBI), post-traumatic 
stress disorder (PTSD), and traumatic eye injuries, and we 
authorized respite care for seriously injured servicemembers.
    The Wounded Warrior Act addresses nearly all the findings 
of the various commissions that have examined the issues 
regarding the care and treatment of our wounded warriors. The 
most significant exception is the recommendation of the Dole-
Shalala Commission to restructure the VA disability 
compensation system. The essence of that recommendation is a 
restructuring of the VA disability compensation benefit. It 
falls, the recommendation, primarily in the jurisdiction of the 
House and Senate Veterans Affairs Committees, both of whom are 
examining it.
    The VA has just recently awarded a contract to develop 
information regarding changes in the composition of disability 
payments, as recommended by the Dole-Shalala Commission, and 
some veterans service organizations have already expressed some 
questions about this change.
    Working together in an approach that is consistent with the 
Wounded Warrior Act, the Departments of Defense and Veterans 
Affairs established a high-level senior oversight committee, 
co-chaired by the Deputy Secretary of Defense and the Deputy 
Secretary of Veterans Affairs, to oversee analysis of and 
changes to the DOD and VA systems, to improve the care and 
treatment of our injured and ill servicemembers. We hope to 
learn this morning what the Departments have accomplished thus 
far, what initiatives are in the works, and if any additional 
legislation is needed to accomplish their goals.
    The Army has established the Army medical action plan 
(AMAP) to develop a sustainable system for the medical 
treatment and rehabilitation of injured and ill soldiers, to 
prepare them for successful return to duty or transition to 
civilian status. I'm confident that Secretary Geren and General 
Schoomaker will have more to say about that.
    Finally, we are proud of the fact that our military 
doctors, nurses, and medics have courageously provided 
outstanding medical care to those who are wounded. This care 
begins on the battlefield itself, where these providers are at 
great personal risk as they tend to the wounded. Many 
servicemembers who would have died in earlier conflicts are 
surviving injuries incurred in Iraq and Afghanistan because of 
the loving care and the advances in battlefield medical 
treatment that exist now, that didn't exist before, but also, 
and we want to reiterate this, because of the skill and the 
bravery of our combat medical teams.
    Seriously injured troops are rapidly evacuated to world-
class medical facilities, where they receive state-of-the-art 
care as inpatients.
    Today's hearing is about the actions taken by the 
Departments of Defense and Veterans Affairs and by the Army to 
implement the Wounded Warrior Act and recommendations made by 
various commissions over the many months.
    I'd like to add that although Senator Lieberman is not here 
with us today, he has requested that his statement be entered 
into the record, and without objection, it will be.
    [The prepared statement of Senator Lieberman follows:]

           Prepared Statement by Senator Joseph I. Lieberman

    Chairman Levin, thank you for convening this important hearing on 
the status of our wounded warriors.
    Almost a year ago, we learned from press reports that many of our 
recovering servicemembers at Walter Reed Army Medical Center were not 
receiving adequate medical services or were living in unacceptable 
conditions. Along with many of my colleagues, I promised to fix these 
problems and improve the quality of care given to those who have served 
honorably. I am heartened that this committee and many others in 
Congress stood up and fulfilled their moral responsibility by including 
Wounded Warrior legislation in last year's National Defense 
Authorization bill. We have made significant improvements, but we still 
have more challenges to solve.
    In the coming weeks, I plan to introduce legislation to address two 
pressing problems. My first proposal will increase and improve 
incentives for the recruitment and retention of uniformed mental health 
providers. One in six Operation Iraqi Freedom/Operation Enduring 
Freedom servicemembers has a diagnosable condition of post-traumatic 
stress disorder. However, if we do not have enough uniformed providers 
in place, we will not have the manpower to treat all servicemembers who 
need help. The need for uniformed providers cannot be overemphasized in 
light of their dual missions to not only deploy to combat zones, but 
staff garrison military treatment facilities across the globe. 
Uniformed mental health professionals are also critical because those 
returning from combat strongly prefer to receive care from a fellow 
servicemember. As we learn more about the mental health conditions that 
arise from repeated tours of duty, we must have the uniformed workforce 
in place to meet the demands of our returning servicemembers and the 
long-term challenges facing the Department to improve both the access 
to and the quality of mental health care.
    My second piece of legislation focuses on suicide prevention in the 
military. Our military's most valuable resource is the people who serve 
our country in uniform. In the past year, there have been a number of 
disturbing reports in the news concerning the Army's suicide rate, 
which was higher in 2007 than any other time this statistic has been 
tracked by the military, and significantly higher than in the civilian 
population. We must reverse the current trend. My legislation will 
create a new prevention program, modeled on the Air Force's highly 
successful aircraft accident prevention program, at the Department of 
Defense to investigate all suicides. An independent body, assembled by 
a four-star general, would produce a confidential report, including 
recommendations to address any recognized deficiencies. We must have 
the protocols in place to make sure we are able to determine when a 
servicemember needs help or immediate attention, and I believe my 
proposal will go a long way in preserving our most valuable resource--
our men and women in uniform.
    We can all agree that taking care of our wounded warriors must 
remain a national priority. Many obvious deficiencies have been 
corrected, and now I call upon my colleagues to tackle the remaining 
challenges before us. We have asked our servicemembers to accept near-
impossible trials and tribulations on the battlefield. The least we can 
do is to provide them with the best possible care and the attention 
they deserve.

    Chairman Levin. There is a vote scheduled for 10:30 this 
morning. I hope that we can complete our opening statements and 
begin questions even before the vote.
    Senator Warner.

                STATEMENT OF SENATOR JOHN WARNER

    Senator Warner. Thank you, Mr. Chairman.
    Mr. Chairman, this is a most unique piece of legislation, 
and one of its hallmarks is the strong bipartisan effort that's 
been put in on both sides of the aisle, and one of the 
stalwarts on our side, Senator Sessions, has been at the 
forefront of this. I'm going to invite him now to deliver the 
remarks for our side of the aisle.
    Senator Sessions.
    Senator Sessions. Thank you, Senator Warner. I do care 
about this deeply, as I know you do, and thank you for your 
leadership and that of Senator Levin.
    I welcome our panel members. It's a distinguished group and 
I think your appearance here today represents by your very 
positions the commitment the DOD has to fixing the problems 
that we've seen. Images of a mold-infested room at Walter Reed, 
which was home to a recovering servicemember will not and 
should not be forgotten. We're all accountable for the 
conditions at Walter Reed and its impact on families. We're all 
answerable to the American people for the full and complete 
resolution of those problems.
    There's just no doubt that when we commit our men and women 
to harm's way if they are injured, there is a deep bond we have 
with them, I think, that cannot be disputed, that we will do 
whatever we can to assure they have the finest medical care 
possible.
    The independent review group established by Secretary Gates 
in February 2007 described the situation that overwhelmed 
Walter Reed as a ``perfect storm.'' It involved the confluence 
of an increase in operational tempo as a result of the war, the 
decision of the commission on BRAC to close Walter Reed, 
inattention by leaders to processing delays, and antiquated 
disability evaluation processes, a breakdown in outpatient care 
and transition to the VA. In addition, the DOD lacked the tools 
to adequately identify TBI and its overlap with PTSD.
    We now realize that the problems were far broader than just 
the Walter Reed site, and I believe that progress in addressing 
shortfalls in care is underway. Congress provided $900 million 
in supplemental funding to DOD in fiscal year 2007 for the 
purpose of aiding wounded and ill servicemembers with TBI and 
PTSD. The Army has activated a new Warrior Transition Brigade 
focused solely on helping wounded and ill soldiers to heal. As 
of February 4, 2008, 9,782 soldiers, both Active and Reserve, 
are assigned or attached to a warrior transition unit (WTU).
    The Army now has broken ground on a new and greatly 
expanded hospital at Fort Belvoir, VA, which will be completed 
ahead of the BRAC schedule and will improve services for our 
wounded and ill military personnel, especially for orthopedic 
and mental health concerns. I know Senator Warner is very proud 
of that hospital that will be at Fort Belvoir.
    It is evident by our panel today that the DOD and the VA 
are working together, rather than at odds. Yet, according to 
the DOD's recent survey of wounded and ill servicemembers, one 
in four rate ``poorly'' for their experience with the medical 
evaluation board process. One in five rates ``poorly'' for 
their ability to access care and appointments as soon as 
needed.
    Studies conducted in the last year reassure the American 
people that the men and women who volunteer for our military 
and are sent into harm's way will receive the best medical care 
in the world. I quote from the report of the Gates panel, which 
said: ``Through advances in battlefield medicine and evacuation 
care the Department has achieved the lowest mortality rates of 
wounded in history.''
    I quote also from the report of the commission appointed by 
President Bush, co-chaired by Senator Robert Dole and Secretary 
Donna Shalala: ``The medical care at Walter Reed Army Medical 
Center and other military treatment facilities (MTFs) is 
compassionate and complete. The specialized services and 
programs for amputations and burns in particular are world 
class.''
    So this hearing will examine the response of our government 
to the shortfalls for servicemembers who are outpatients during 
the long-term healing they require. The Wounded Warrior Act is 
itself a significant contribution toward that goal. I was 
privileged to be a part of that significant bipartisan effort, 
along with many members of this committee and the Veterans 
Committee.
    The new law will ensure cooperation between the DOD and VA, 
open new avenues of treatment for TBI and psychological health, 
and begin the process of reforming the disability evaluation 
system for our Nation's veterans of war, in other words 
achieving nearly all the goals of the Dole-Shalala Commission. 
So we look to the Committee on Veterans Affairs for leadership 
on the important work which remains--modernization of the 
benefits and compensation for our Nation's veterans, and in 
particular eliminating duplication between DOD and VA.
    Senator Burr, the ranking member of that committee, has 
announced his intention to pursue the needed reforms through 
legislation to create a modern, less confusing and more 
equitable system for today's wounded warriors. We shall forget 
neither the images of Walter Reed nor the stories of so many 
wounded veterans and their families who, as a result of a lack 
of care and perceived lack of fairness, lost trust in the 
government that they served. Nor shall we ever forget the 
statement of General George Washington, who said: ``The 
willingness with which our young people are likely to serve in 
any war, no matter how justified, shall be directly 
proportional to how they perceive the veterans of earlier wars 
were treated and appreciated by their country.''
    Mr. Chairman, thank you, and I look forward to this 
excellent panel today.
    Chairman Levin. Thank you, Senator Sessions.
    Let me start with Secretary Mansfield and then we'll go to 
you, Secretary Chu. Are you going to be giving the statement 
for Secretary England?
    Dr. Chu. Yes, sir, I'll give Secretary England's prepared 
remarks.
    Chairman Levin. Thank you.
    Secretary Mansfield?

  STATEMENT OF HON. GORDON H. MANSFIELD, DEPUTY SECRETARY OF 
 VETERANS AFFAIRS; ACCOMPANIED BY HON. PATRICK W. DUNNE, REAR 
 ADMIRAL, U.S. NAVY (RETIRED), ASSISTANT SECRETARY OF VETERANS 
                AFFAIRS FOR POLICY AND PLANNING

    Secretary Mansfield. Thank you, Chairman Levin and members 
of the committee. I appreciate the opportunity to appear before 
you today. I'm especially pleased to be accompanied by Admiral 
Dunne, Secretary Geren, Secretary Chu, and General Schoomaker.
    The VA and the DOD have a positive, good news report to 
give you today on our enhanced partnership to ensure today's 
Active Duty servicemembers and veterans receive the benefits, 
care, and services a grateful Nation has promised them. They 
have surely earned that and I know, Mr. Chairman and members, 
that you and the committee members are here to make sure that 
it happens.
    I'm especially pleased to have had the opportunity to have 
worked with Gordon England, the Deputy Secretary of the DOD. 
Over the past year Gordon and I have had a unique opportunity 
to focus the attention of both Departments on the needs of 
those we serve, our servicemembers and veterans. We have 
concentrated attention on the need for a seamless transition 
from the DOD to the VA.
    I want to publicly thank him for his leadership, which has 
allowed us to accomplish so much. As he has said, the ties 
between the two organizations have been strengthened and lines 
of communication are now available across the two Departments.
    The Senior Oversight Council (SOC) has been operational 
since May 8, 2007, but it is important to note that serious 
high-level cooperative efforts in the areas of health care and 
benefits delivery predate the SOC. VA and DOD formed a Joint 
Executive Council (JEC) in February 2002. You later codified it 
in statute in November 2003. The JEC's responsibility--and I 
quote from its standup document--is ``The JEC will work to 
remove barriers and challenges, assert and support mutually 
beneficial opportunities, recommend to the two secretaries the 
strategic directives for joint coordination and sharing efforts 
between and within the two Departments, and oversee the 
implementation of those efforts.''
    I believe it is important to identify some of the positives 
produced under the auspices of the JEC from its start. Dental 
care for Reserve and National Guardsmen was taken care of--the 
North Chicago VA and U.S. Navy cooperative effort to form the 
first joint Federal health care facility non-sequitar; and the 
Traumatic Servicemembers' Group Life Insurance which has been 
effective thanks to Congress since December 1, 2005. As of 
January 31, we have paid 4,111 claims for a total of $254.4 
million to seriously injured servicemembers.
    We now have more than 95 memoranda of understanding (MOUs) 
covering 153 military sites; VBA counselors inserted at MTFs; 
data-sharing efforts; and the joint incentive fund that 
Congress authorized to fund 66 projects for $160 million 
between the two organizations.
    So in short, the JEC provided a starting point for the SOC. 
I want to commend and thank Dr. David Chu for his past and 
continued efforts and cooperation as my DOD partner on the JEC.
    The SOC, established by direction of the two secretaries 
following, as you mentioned, Mr. Chairman, hearings here on the 
Hill, established eight lines of action, which generally 
defined the issues needing resolution. They include: the 
disability evaluation system; TBI and PTSD case management; 
data-sharing efforts; facilities; legislation and public 
affairs; personnel, pay, and financial support; and what we 
call a clean sheet review, or after we've looked at all these 
issues, if you were starting over how would you start and what 
would you build that would be different from what we have 
today.
    Our excellent joint DOD and VA staff, provided through a 
special office by Melinda Darby and Roger Dimsdale, identified 
these lines of action from the issues presented in numerous 
reports, investigations, or commissions which reported last 
year, as you mentioned, Mr. Chairman--Dole-Shalala, Gerry 
Scott's commission, the Marsh-West commission, and Secretary 
Nicholson's commission that the President directed that he take 
part in. All were reviewed completely to come up with a 
comprehensive plan of action.
    Currently the SOC is overseeing the efforts to apply the 
decisions made from these line of action recommendations. For 
example, the Federal recovery coordinators or case managers' 
decision has resulted in VA Federal recovery coordinators 
standing up an office, hiring the first eight individuals, 
training them, placing them in MTFs, and having them start the 
process of fulfilling that requirement which you directed for 
us.
    In another area, we have started a pilot project to have 
the VA complete one single medical exam, which will allow first 
DOD under their responsibility to make the decision whether 
this individual is fit or unfit to continue to serve on Active 
Duty, and if the individual is not fit to serve on Active Duty 
to allow the VA to use that same information to process a claim 
for disability benefits when the individual is discharged. This 
pilot has gotten one case already through the process. The 
examinations are taking place in the Washington, DC, area and 
the cases are going to the VA office in St. Petersburg for 
decision. This pilot will run for approximately 1 year starting 
last November, going to November this year, and will give us 
the starting point for more efforts on how to make sure that 
this transfer from Active Duty to veteran status becomes 
seamless and the information is transferred and used by both at 
the same time.
    We realize we have more work to do, data-sharing for 
example, where we move to the ability to transfer patient data 
between our two systems. We're doing more than we ever had 
before. We're sharing data. We're moving toward making it 
operational, and I think I can report to you that more efforts 
are going forward in that area than ever before. It's a hard 
area. There are a lot of issues to deal with, and we continue 
to work on that at a high level.
    We're also working together on TBI and PTSD issues--care, 
research, and treatment, as we see a greater emphasis on these 
issues, and a new center of excellence is under construction 
and will be taking place at the new Bethesda location.
    Currently the SOC is prepared to come together whenever 
required to make decisions required by the dedicated VA and DOD 
staff which oversee the efforts on each of these lines of 
action. We continue to address any issues which may arise 
regarding cooperation between the two Departments. Gordon 
England, David Chu, and I continue to discuss these issues as 
needed. The remaining requirements stemming from the National 
Defense Authorization Act passed last session will keep us 
focused intently on continuing improvements.
    The issue of a new disability benefit system as proposed by 
the President through the Dole-Shalala report remains an open 
item. The VA has contracted for two studies which will allow us 
to move forward in this area. The studies are due for 
completion in approximately 6 months. They deal with transition 
payment and then compensation and quality of life issues in a 
to-be-proposed system.
    The issue of rehabilitation medicine continues to evolve as 
we treat and evaluate the patients returning from the 
battlefield, entering acute care treatment, and initial 
rehabilitation and MTFs before they transition to VA polytrauma 
centers and medical centers.
    Finally, we are working to ensure better involvement and 
care of the family members of these individuals.
    That concludes my statement and I await your questions.
    [The joint prepared statement of Secretary England and 
Secretary Mansfield follows:]

    Joint Prepared Statement by Hon. Gordon England and Hon. Gordon 
                               Mansfield

    Chairman Levin, Senator McCain, and members of the Senate Committee 
on Armed Services, we deeply appreciate your steadfast 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.
    We're delighted to have with us Secretary of the Army Geren, Under 
Secretary of Defense for Personnel and Readiness Chu, Surgeon General 
of the Army, Lieutenant General Schoomaker, and Assistant Secretary of 
Veterans Affairs for Policy and Planning Dunne.
    The administration has worked diligently--commissioning independent 
review groups, task forces, and a Presidential Commission to assess the 
situation and make recommendations. Central to our efforts, a close 
partnership between our respective Departments was established, 
punctuated by formation of the Senior Oversight Committee (SOC) 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.
    Specifically, we have endeavored to improve the Disability 
Evaluation System (DES), established a Center of Excellence for 
Psychological Health and Traumatic Brain Injury, established the 
Federal Recovery Coordination Program, improved data sharing between 
the Department of Defense (DOD) and Department of Veterans Affairs 
(VA), developed medical facility inspection standards, and improved 
delivery of pay and benefits.

                       SENIOR OVERSIGHT COMMITTEE

    The driving principle guiding SOC efforts is the establishment of a 
world-class seamless continuum 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 co-chaired by the Deputy Secretary of Defense and 
Deputy Secretary of Veterans Affairs. Its members include: the Service 
Secretaries, the Chairman or Vice Chairman of the Joint Chiefs of 
Staff, the Service Chiefs or Vice Chiefs, the Under Secretaries of 
Defense for Personnel and Readiness and Comptroller, the Under 
Secretaries of Veterans Affairs for Benefits and Health, the Office of 
the Secretary of Defense General Counsel, the Assistant Secretary of 
Defense for Health Affairs, the Director of Administration and 
Management, the Principal Deputy Under Secretary of Defense for 
Personnel and Readiness, the Assistant Secretary of Veterans Affairs 
for Policy and Planning, the Deputy Under Secretary of Defense for 
Plans, and the Veterans Affairs Deputy Chief Information Officer. In 
short, the SOC brings together on a regular basis the most senior 
decisionmakers to ensure wholly informed, timely action. Supporting the 
SOC decision-making process is an Overarching Integrated Product Team 
(OIPT), co-chaired 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 makes recommendations regarding resource 
decisions.

                   MAJOR INITIATIVES AND IMPROVEMENTS

    The two Departments are in the process of implementing more than 
400 recommendations of 5 major studies, as well as implementing the 
Wounded Warrior and Veterans titles of the recently enacted National 
Defense Authorization Act (NDAA), Public Law No. 110-181. We continue 
to implement recommended changes through the use of policy and existing 
authorities. For example, in August 2007, the Secretaries of the 
Military Departments were directed to use all existing authorities to 
recruit and retain military and civilian personnel who care for our 
seriously injured warriors. Described below are the major initiatives 
now underway.

                      DISABILITY EVALUATION SYSTEM

    The fundamental goal is to improve the continuum of care from the 
point-of-injury to community reintegration. To that end, in November of 
last year, a DES Pilot test was implemented for disability cases 
originating at the three major military treatment facilities 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 source disability rating. 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.
    The pilot addresses those recommendations that could be implemented 
without legislative change from the reports of the Task Force on 
Returning Global War on Terror Heroes, the Independent Review Group, 
the President's Commission on Care for America's Returning Wounded 
Warriors (Dole/Shalala Commission), the Veterans Disability Benefits 
Commission (Scott Commission), and the DOD Task Force on Mental Health. 
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 seamless transition of our wounded, ill, or injured 
from the care, benefits, and services of DOD to the VA 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. The VA is poised 
to provide benefits and compensation to the veterans participating in 
the pilot as soon as they transition from the military.
    The pilot covers all non-clinical care and administrative 
activities, such as case management and counseling requirements 
associated with disability case processing, from the point of 
servicemember referral to a Military Department Medical Evaluation 
Board (MEB) through compensation and provision of benefits to veterans 
by the VA. Expansion of the pilot is being considered to address:

         Performance measures--The pilot evaluation plan 
        includes extensive quantitative and qualitative performance 
        measures to ensure our servicemembers obtain all benefits and 
        entitlements due under both DOD and VA law. Although no 
        servicemembers have completely transitioned from the pilot to 
        veteran status, we expect a reasonable sample population to 
        have processed through by mid-June. We'll complete our initial 
        analysis at that time and make a determination regarding 
        expanding the pilot.
         Site assessment--The following criteria will be 
        thoroughly analyzed by both Departments: resources, IT 
        architecture development and fielding, case management 
        effectiveness, training requirements, DES workload (for DOD and 
        VA) in expansion areas, and costs;
         Case management--Most importantly, pilot expansion to 
        a broader population will require training and certification of 
        DES and VA administrative and case management personnel. It is 
        anticipated that certification of the case managers and 
        determination of the appropriate case manager staff size will 
        be the overriding factors that limit or allow expansion of the 
        pilot to other areas.
         Phased expansion--Unlike the pilot's Physical 
        Evaluation Board phases, which are consolidated in the NCR, the 
        medical assessment and MEB phases occur across the departments 
        at numerous Medical Treatment Facilities (MTFs) and Veterans 
        Health Administration sites. Phased expansion of the pilot 
        should allow MTF site preparation and training on a manageable 
        timeline.

    The pilot is part of a larger effort including medical research 
into the signature injuries of the war and updating the VA Schedule of 
Rating Disabilities. Proposed regulations to update the disability 
schedule for traumatic brain injury (TBI) and burns were published in 
the Federal Register on January 3, 2008.

            PSYCHOLOGICAL HEALTH AND TRAUMATIC BRAIN INJURY

    Improvements have been made in addressing issues concerning 
psychological health (PH) and 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, veterans, and families who deal with these important 
health conditions.
    The DOD has a broad range of programs designed to sustain the 
health and well-being of every service and family member in the total 
military community. Because no two individuals are exactly alike, 
multiple avenues of care are open to create a broad safety net that 
meets the preferences of the individual. This continuum of care 
encompasses: prevention and community support services; early 
intervention to protect and restore before chronicity, and before the 
member does something rash; service-specific deployment-related 
preventive and clinical care before, during and after deployment; 
sustained, high-quality, readily available clinical care along with 
specialized rehabilitative care for severe injuries or chronic illness, 
and transition of care for veterans to and from the VA system of care; 
and a strong foundation of epidemiological, clinical and field 
research.
    Our Departments have partnered in the development of standard 
clinical practice guidelines for Post-Traumatic Stress Disorder (PTSD), 
Major Depressive Disorder, Acute Psychosis, and Substance Use 
Disorders. These guidelines help practitioners determine the best 
available and most appropriate care for PH conditions. In an effort to 
ensure that providers are trained in best practices, we are partnering 
in providing training in evidence-based treatment for PTSD.
    TBI can result in decreased reaction time, impaired decisionmaking 
and judgment, and decreased mental processing. Mild TBI or concussion 
can reduce mission effectiveness and increase risk to the injured 
servicemember and others in the unit. Objective cognitive performance 
information can give the commander critical information for informed 
risk decisions in mission planning and execution while providing 
medical providers with an objective assessment of the extent of the 
injury and a method of tracking recovery. To facilitate the evaluation 
and management of TBI cases, DOD has a program to collect baseline 
neurocognitive information on Active and Reserve personnel before their 
deployment to combat theaters. The Army already has incorporated 
neurocognitive assessments as a regular part of its Soldier Readiness 
Processing in select locations. Additionally, select Air Force units 
are assessed in Kuwait before going into Iraq.
    To ensure all servicemembers are screened appropriately for TBI, 
questions have been added to Post-Deployment Health Assessment and 
Post-Deployment Health Reassessment. That same information is shared 
with VA clinicians 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. To augment staffing levels, DOD has 
partnered with the Department of Health and Human Services (HHS) to 
provide uniformed Public Health Service officers in MTFs to increase 
available mental health providers for DOD. DOD and the VA also continue 
to improve the Mental Health Self Assessment Program. Program 
expansions, documented in an updated report to Congress submitted in 
February 2007, included:

         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; and
         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 PTSD and depression.

    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 an anti-stigma campaign (the Army's Mental 
        Health Advisory Team 5 survey shows that stigma and fears of 
        seeking help are being reduced, but there is more to do);
         Establishing effective outreach and educational 
        initiatives;
         Promulgating a tele-health network for clinical 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 fiscal year 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. Of the $600 million operation 
and maintenance funds, $566 million (94 percent) has been distributed, 
including $315 million for PH and $251 million for TBI. The remaining 
balance is reserved for expansion of promising demonstration programs 
and for additional costs that emerge as the plans are executed.

                            CARE MANAGEMENT

    To improve care management, the complexities between our two care 
management systems are being reduced through the Federal Recovery 
Coordination Program, which will identify and integrate care and 
services for the wounded, ill, and injured servicemember, veteran and 
their families through recovery, rehabilitation, and community 
reintegration.
    New comprehensive practices for better care, management, and 
transition are being implemented. These efforts include responses to 
requirements of the NDAA 2008 regarding the improvements to care, 
management, and transition of recovering servicemembers. Progress is 
being made toward an integrated continuity of quality care and service 
delivery with inter-Service, interagency, intergovernmental, public and 
private collaboration for care, management and transition, and the 
associated training, tracking, and accountability for this care. Our 
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 injured.
    The joint FRCP trains and deploys Federal Recovery Coordinators 
(FRCs) to support medical and non-medical care/case managers in the 
care, management, and transitioning of seriously wounded, ill, and 
injured servicemembers, veterans and their families. The FRCP will 
develop and implement web-based tools, including a Federal Individual 
Recovery Plan (FIRP) and a National Resource Directory for all care 
providers and the general public to identify and deliver the full range 
of medical and non-medical services. To date, the Departments have:

         Hired, trained, and placed eight FRCs at three of our 
        busiest MTFs as recommended by the Dole/Shalala Commission. 
        Additional FRCs will be hired as needed beginning in May;
         Developed a prototype of the 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 are also in the process of:

         Developing 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;
         Producing a Family Handbook in partnership with 
        relevant DOD/VA offices;
         Identifying workloads and waiver procedures for 
        medical case/care managers, non-medical care managers, and 
        FRCs; and
         Developing demonstration projects with States such as 
        California for the seamless reintegration of veterans into 
        local communities.

    DATA SHARING BETWEEN DEPARTMENTS OF 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 the 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, and 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 recovery plan for use by FRCs 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 the VA's successful eVet website.

                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 continuing an aggressive inspection of MTFs on an 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 submit to the Secretary of the Military Department a detailed plan 
to correct the deficiency, and the commander will periodically 
reinspect 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 fiscal year 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 
also benefit from a collaborative effort between DOD and the Department 
of Labor (DoL). The DoL Pre-Separation Guide, which informs 
servicemembers and their families of available transition assistance 
services and benefits, is now available at http://www.TurboTAP.org.
    Another resource tool for transitioning servicemembers is the 
expanded Small Business Administration's Patriot Express Loan program. 
The Patriot Express Loan offers a lower interest rate and an 
accelerated processing time. Loans are available for up to $500,000 and 
can be used by wounded warriors for most business purposes. DOD has 
also expanded Wounded Warrior Pay Entitlement information on the 
Defense Finance and Accounting Service (DFAS) website and other 
organizations have linked to the website; in July 2007, the DFAS posted 
an easily understood decision matrix on eligibility for Combat-Related 
Injury Rehabilitation Pay (CIP) which allows wounded warriors to 
determine their eligibility for CIP on the website. Additionally, 
through use of streamlined debt management procedures, DFAS remitted, 
canceled, or waived debts for over 14,126 wounded warrior accounts 
totaling approximately $13.17 million as of January 29, 2008.
    DOD and the VA have shared information concerning Traumatic Injury 
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. The VA 
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.
    We are creating a compensation/benefits website and handbook that 
will help servicemembers and veterans make informed decisions about 
their futures. The VA has just commissioned two studies to implement 
the recommendations of the Dole/Shalala Commission. The first study 
will evaluate the levels and duration of transition benefit payments to 
assist veterans and their families while they are in a vocational 
rehabilitation program. The second study will develop recommendations 
for creating a schedule for rating veterans' disabilities based upon 
current concepts of medicine and disability, taking into account the 
loss of quality of life and loss of earnings resulting from service-
connected disabilities. Results of the study will to be provided to the 
VA by August 2008.

                               CONCLUSION

    The SOC and its Overarching Integrated Product Team continue to 
work diligently to resolve the many outstanding issues while 
aggressively implementing the recommendations of 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.
    One of the most significant recommendations from the task forces 
and commissions is the shift in the fundamental responsibilities of the 
DOD and VA. The core recommendation of the Dole/Shalala Commission 
centers on the concept of taking the DOD out of the disability rating 
business so that DOD can focus on the fit or unfit determination, 
streamlining the transition from servicemember to veteran.
    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 
provisions recommended by Dole/Shalala. 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 Levin, Senator McCain, and members of the committee, thank 
you again for your generous support of our wounded, ill, and injured 
servicemembers, veterans and their families. We look forward to your 
questions.

    Chairman Levin. Thank you, Secretary Mansfield.
    Secretary Chu?

 STATEMENT OF HON. DAVID S.C. CHU, UNDER SECRETARY OF DEFENSE 
                  FOR PERSONNEL AND READINESS

    Dr. Chu. Mr. Chairman, I thank you for the opportunity to 
represent the DOD this morning. Again I convey Secretary 
England's apologies that he could not be here. He very much 
looked forward to this session and asked that I present his 
planned opening remarks. He does have a statement for the 
record which I hope you will accept.
    Chairman Levin. We will.
    Dr. Chu. It is indeed a great privilege to join Gordon 
Mansfield, who has been our strong partner in the SOC that he 
described and in the JEC established earlier. The two 
Departments have worked very closely, as he has outlined, and 
strengthened thereby the ties between the two Cabinet agencies 
so that we can indeed provide veterans the support that they 
deserve.
    Gordon Mansfield has summarized the lines of action, the 
eight lines of action that are the mechanism through which the 
SOC exercises its responsibilities. These lines of action are 
jointly staffed, co-chaired by personnel from DOD and the VA, 
and have created a very strong partnership between the two 
agencies. They have succeeded in accomplishing a great deal in 
a short period of time. We have, as Gordon Mansfield reported, 
appointed the first Federal response coordinators. We have the 
disability evaluation pilot underway and 120 people are in 
various stages of evaluation in that pilot system. We have 
established the Center for Psychological Health and Traumatic 
Brain Injury. We are, I believe, on track to completing by the 
end of this year a set of software changes that will allow 
existing electronic data to be shared between the two agencies, 
which I know has long been a subject of great concern to all.
    We have proposed to Congress and we hope Congress will 
support an accelerated and enhanced set of changes at the new 
Walter Reed campus in Bethesda, where the Naval Hospital is 
currently located.
    We have benefited in these decisions from the studies that 
were done earlier and, of course, from the actions of Congress. 
In the earlier studies there are over 400 recommendations 
offered to the Department, over 300 on the subjects of PTSD and 
TBI alone.
    While a great deal has been done, we recognize that we are 
not finished. These lines of actions will be adding to their 
agendas, particularly with the additional instruction of 
Congress in the National Defense Authorization Act for Fiscal 
Year 2008. We meet as necessary to accomplish these goals.
    Secretary England asked that I underscore that he and 
Gordon Mansfield and their respective teams are completely 
dedicated to resolving all the issues between the two 
Departments and to putting the long-term care of the men and 
women in uniform where it should be. We view this as a 
partnership between the two Departments and a partnership with 
Congress, the caregivers within our Departments, and with other 
agencies of the Federal Government, as well as agencies at the 
State and local level.
    Secretary England did ask that I underscore one other issue 
which you raised, Mr. Chairman, and Secretary Mansfield touched 
on in his opening statement. That is, we do hope Congress, in 
future legislation, will address a central issue raised in the 
Dole-Shalala proposal, and that is a new and different 
disability compensation system for our veterans, one that would 
more sharply delineate the responsibilities of the respective 
Departments, focusing DOD on the key military question of 
fitness to serve and focusing the VA on the question of support 
for those who cannot.
    I am joined this morning by Secretary Geren and General 
Schoomaker, who will be ready to provide details on the 
progress the Army has made in its specific efforts to care for 
the Army's wounded personnel.
    Thank you for this opportunity and I look forward to your 
questions.
    Chairman Levin. Thank you, Secretary Chu.
    Secretary Geren?

 STATEMENT OF HON. PRESTON M. GEREN III, SECRETARY OF THE ARMY

    Secretary Geren. Thank you, Mr. Chairman. Chairman Levin, 
Senator Warner, and members of the committee: Thank you for 
providing General Schoomaker and I the opportunity to come 
before your committee today and talk about the progress that 
has been made over the past year. I'd also like to thank every 
one of you for your unwavering support of soldiers, families, 
and our United States Army. Our Congress and particularly this 
committee are full partners in building the Army that we have 
today.
    I also want to thank you for your Wounded Warrior Act and 
the initiatives, which you included in last year's 
authorization bill. You included initiatives that will help 
soldiers; initiatives that will help families; and you also 
provided the flexibility so that the Army could continue to 
meet the dynamic challenges in our modern health care world, 
and we appreciate that. We thank you for that partnership in 
your legislation and the partnership over this last year.
    Twelve months ago almost to the day, the Washington Post 
ran their story on the shameful conditions at Walter Reed. The 
report sparked outrage across our Nation, but nowhere more so 
than among the ranks of soldiers and veterans, nowhere equal to 
the outrage, the rage felt by soldiers. Soldiers take care of 
soldiers. Soldiers give their lives and limbs for each other. 
Strip away everything else and at its core that is what the 
Army is all about: Soldiers taking care of soldiers.
    When soldiers learned that some of their own had violated 
their duty to our wounded, they demanded action and stepped up 
and took action. Today, 12 months later, we are a better Army, 
with good news to report to this committee, because of the good 
work and hard work of soldiers, but with the acknowledgment 
that there remains much to do.
    Mr. Chairman, I'd like to ask you if I could introduce four 
of the soldiers who have been great leaders in this effort over 
the past year who have joined us today.
    Chairman Levin. We'd be honored to have you do that.
    Secretary Geren. Thank you, Mr. Chairman.
    Colonel Terry McKendrick, who is Brigade Commander at 
Walter Reed--Terry, would you please stand up--his Command 
Sergeant Major Jeff Hartless; Company Commander Major Steve 
Gominter; and his First Sergeant, Matthew Dewsberry. They've 
done an outstanding job and deserve a great deal of credit for 
their leadership. [Applause.]
    Chairman Levin. Thank you, Secretary Geren, for introducing 
to us these great soldiers. Again, we're honored to be in their 
presence.
    Secretary Geren. Thank you, Mr. Chairman.
    The Army, the DOD, and the VA, and Congress' response has 
gone well beyond the problems identified in the Washington Post 
series of articles. We all realized that we had an opportunity 
not to just fix the problems highlighted in the articles, but 
transform our health care and disability system to better meet 
the needs of those who have borne the battle--our wounded, ill, 
and injured, and better support their families.
    It is an opportunity to do something big, complicated, and 
important that does not come along very often, and together 
we've made progress, and we thank you for that partnership.
    Today Lieutenant General Schoomaker and I will discuss the 
progress the Army has made and join this panel in discussing 
the progress the DOD has made working with Congress and 
particularly with this committee, and identify areas that we 
must continue to improve.
    A year ago, outpatient care in the Army was called medical 
hold for Active Duty and medical holdover for Reserve 
components. The names themselves, ``hold'' and ``holdover,'' 
and the fact that there were two systems give you a good sense 
of the problems that underlay the Army system. A year later, 
the Army has completely transformed outpatient care. The old 
system, with fragmented leadership, that was not staffed, 
resourced, nor organized to meet even the pre-September 11 
needs of outpatient soldiers, was overwhelmed by the increase 
in patients that came with the casualties of war. Preexisting 
seams were stretched and snapped by the surge in wounded, ill, 
and injured. The Guard and Reserve were organized separately 
from the Active Force, with a widely held perception, if not 
the reality, of different standards of care. Mental health 
issues had not received the attention nor the resources they 
required, leaving the needs of many soldiers and family members 
unmet.
    Today, there are no more hold or holdover units. In their 
place, we have our wounded warriors in 35 WTUs located at major 
posts in CONUS and abroad, Active, Guard, and Reserve together, 
one Army.
    The care and support of our soldiers in our WTUs is driven 
by a mission statement, with leadership, officer and NCO, 
organized in support of that mission, with a triad of care, the 
squad leader, the nurse case manager, and the primary care 
manager, supporting every wounded, injured, and ill soldier.
    Our soldiers in the WTUs are being moved into the best 
barracks on the post and over the last 8 months nearly 2,500 
personnel have been added to Medical Command to support our 
wounded warriors. Every WTU today has an ombudsman and now 33 
and soon all of our WTUs will have a Soldier Family Assistance 
Center, bringing dispersed family services together into a one-
stop shop for soldiers and families.
    In mental health care, the Army, working with our sister 
Services, OSD, and the VA, and with strong leadership and 
support from Congress, has made investments in personnel, 
infrastructure, and programs to care for soldiers who suffer 
from TBI, PTSD, and other mental and emotional illnesses, and 
help their families with the challenges of supporting their 
soldiers suffering from these invisible wounds of war, with 
much left to do in this area.
    In the Army, we're teaching every one of our one million 
soldiers how to identify symptoms of PTSD and TBI and how and 
where to go to get help. Every soldier is required to take that 
class. So far, 800,000 soldiers have received the training, and 
the program is available to families. It is good substantive 
training, but, perhaps more importantly, it is a major step 
forward in reducing the stigma associated with mental health 
care.
    We're seeking to hire over 300 additional mental health 
professionals to meet the needs of soldiers and families, 
adults and children. We are short of this goal and face a 
challenging market for the people we need. The direct hire 
authority that you provided to us in your authorization bill is 
a big help, but we're not where we need to be in this area. 
We've initiated a comprehensive approach to prevent the tragedy 
of suicide among our soldiers, recognizing we have far to go to 
stem this growing challenge among our ranks, much to learn and 
much to do.
    Cooperation between the DOD, OSD, and our sister Services 
and the VA is strong and you will hear today about much of the 
progress that's been made.
    Senator Levin and Senator Sessions, thank you for 
acknowledging the extraordinary work of our Army's health care 
professionals. They are selfless men and women who are the very 
best at what they do.
    In stark contrast to the shortcomings identified in the 
Post article are the almost miraculous recent advances in 
battlefield medicine, trauma care, and rehabilitation, much of 
which has been accomplished by the medical professionals and 
staff at Walter Reed and elsewhere in the Army system. Survival 
rates for soldiers wounded in combat are unprecedented, 94 
percent, the highest in the history of warfare. Soldiers are 
surviving and recovering from wounds that would have been fatal 
in any other era and in any other health care system, thanks to 
the service men and women in military medicine, the Army, and 
our sister Services.
    Throughout the Army, we have leaders, officers, and NCOs, 
uniformed and civilian, committed to taking care of soldiers 
and families, demanding the best for our wounded, ill, and 
injured and their families. Because of that, our report today 
is one of progress, but it is not and probably never will be a 
report of mission accomplished.
    February 18, 2007, was a day our Army will not forget, a 
painful day, a shameful day for a proud institution, a band of 
brothers and sisters who look out for each other, who take care 
of each other, no matter the personal cost. The Washington Post 
helped us see something that we had overlooked and because of 
that Washington Post story we are a better Army today than we 
were a year ago, and we remain committed to continuing to 
improve our care and support of our wounded, our ill, and our 
injured soldiers and our families.
    Mr. Chairman, members of the committee, thank you all for 
the opportunity to appear today. I look forward to answering 
your questions.
    [The prepared statement of Secretary Geren follows:]

                 Prepared Statement by Hon. Pete Geren

    Chairman Levin, Senator McCain, and distinguished members of the 
Senate Armed Services Committee, I want to thank you for inviting LTG 
Eric Schoomaker and me to appear before you today. We are pleased to 
have the opportunity to discuss with you how we are transforming the 
way we care for our wounded, ill, and injured warriors.
    I'd also like to thank all of you for your unwavering support of 
our soldiers and families. I know they appreciate your ongoing efforts 
to provide them with the ways and means to accomplish their mission and 
to improve their quality of life. Congress has been a valued partner in 
creating the remarkable Army we have today. Thank you for the 
initiatives you included in National Defense Authorization Act (NDAA) 
2008 to improve health care for our wounded, ill, and injured soldiers.
    The problems identified by the Washington Post were centered in our 
medical hold and medical holdover populations, the outpatient care of 
our wounded, ill, and injured soldiers--they experienced poor 
facilities, leadership challenges, and an entrenched bureaucracy; 
however, the improvements we will discuss today go well beyond 
addressing the shortcomings identified in those articles.
    In stark contrast to the shortcomings identified in the Washington 
Post are the phenomenal advances in lifesaving battlefield medicine and 
overall trauma care, much of which has been accomplished through the 
efforts of the extraordinary medical professionals at Walter Reed. 
Survival rates for soldiers wounded in combat are unprecedented. In the 
Vietnam War, it took 21 days to evacuate a soldier from theater. In 
Iraq we routinely evacuate a soldier within 36 hours. Improvements such 
as the Joint Theater Trauma System, state-of-the-art evacuation system, 
improved body armor and battlefield equipment such as the one-handed 
tourniquet mean that, today, more than 90 percent of those wounded in 
Iraq and Afghanistan survive, making this the highest survival rate in 
the history of warfare. We have the best medical specialists, doctors, 
and nurses in the history of the Army, and many non-medical soldiers 
are skilled emergency medical technicians or combat lifesavers.
    The soldier outpatients at Walter Reed who were highlighted in the 
Washington Post were housed in inadequate facilities, experienced a 
failure of leadership, and were caught in an unresponsive bureaucracy. 
The Physical Disability Evaluation System (PDES) was cumbersome and did 
not allow this increasing number of patients to efficiently move 
through the system. This put a burden on Walter Reed that it was not 
prepared to handle.
    As an Army, we pledge never to leave a fallen comrade--that means 
on the battlefield, in the hospital, in the outpatient clinic, or over 
a lifetime of dependency. We broke that pledge, and we have paid a 
price for that. I am pleased to report, however, that the Army has made 
and continues to make significant improvements in the areas of 
infrastructure, leadership, and processes as part of our Army Medical 
Action Plan (AMAP).
    First, wounded, ill, and injured soldiers--Active, Guard, and 
Reserve--have been organized into 35 military units under the command 
and control of the medical treatment facility commander. The new 
Warrior Transition Units (WTUs) focus solely on the care of their 
soldiers. All 35 of our WTUs are now at full operational capability.
    Second, we've given the soldiers in the WTUs a mission that is 
codified in the Wounded Warrior Mission Statement:

          ``I am a Warrior in Transition. My job is to heal as I 
        transition back to duty or become a productive, responsible 
        citizen in society.''

    This is not a status, but a mission.

          ``I will succeed in this mission because I am a warrior.''

    Third, every soldier in the WTUs is supported by a triad of care, a 
primary care manager who is a physican, a nurse case manager, and a 
squad leader.
    We've assigned 1 squad leader for every 12 soldiers, 1 primary care 
manager for every 200 soldiers, and 1 nurse case manager for every 18 
or 36 soldiers depending on the medical complexity of the unit. Each 
unit also has a dedicated ombudsman who reaches out to soldiers and 
families as an extra resource and problem-solver.
    Fourth, we've established Soldier and Family Assistance Centers 
(SFACs) at medical centers and treatment facilities across the Army to 
replace the old system that had family services scattered across 
multiple locations. These are ``one-stop shops'' where soldiers and 
families can get information and help with services from help with 
entitlements, to benefits, to finances.
    Fifth, we created a 24/7 hotline that provides Warriors in 
Transition and their families 24-hour access to information and 
assistance. The Army has responded to over 7,000 calls on the hotline.
    Sixth, we created a new leadership position for warrior care, the 
Assistant Surgeon General for Warrior Care and Transition, currently 
held by BG Mike Tucker. He is our designated ``bureaucracy buster.'' 
His role is to facilitate immediate and sustained assistance to our 
wounded, ill, and injured soldiers and their families. Under BG 
Tucker's leadership, and with the active assistance of many other 
soldiers, leaders, and Army civilians, we have made substantial 
progress in cutting the red tape. Some of the many substantive changes 
we have made since February 2007 include:

         Continuing Combat-Related Injury Pay while soldiers 
        are assigned to the WTU or Community-Based Health Care 
        Organization.
         Created a special duty pay for our WTU noncommissioned 
        leaders (squad leaders and platoon sergeants).
         Preference for wounded soldiers for their location of 
        care within constraints of facility capabilities.
         Providing wounded soldiers top priority in housing.
         Authorized Permanent Changes of Station for Warrior in 
        Transition families.
         Reduced paper work for Army PDES processing.
         Expanded the 14-day window to 90 days for a soldiers 
        to transition to the Department of Veterans Affairs (VA) after 
        disability determination by the Army.
         Provided free internet, phone, and cable TV to WTU 
        barracks.
         Colocated VA Advisors at Army hospitals and 
        facilities.
         Expanded VA access to Army soldier medical records.

    We are developing Comprehensive Care Plans for each soldier in the 
WTU that set the conditions for the soldiers to achieve a successful 
return to duty or a successful transition to civilian life. We have 
worked with the National Rehabilitation Hospital on this effort to 
leverage best practices from the private sector.
    We've initiated a Post Traumatic Stress Disorder (PTSD) and 
Traumatic Brain Injury (TBI) education program for every soldier in the 
Army. This program is designed to not only educate and assist soldiers 
in recognizing, preventing, and treating these conditions, but also to 
erase the stigma associated with these injuries. We also provide 
similar training to family members. Over 800,000 soldiers have received 
training since August 2007. We have also completed specialized PTSD/TBI 
training for social work personnel, nurse case managers, and 
psychiatric nurse practitioners.
    To assist with the identification of TBI, we have initiated a 
baseline cognitive testing program. So far, 40,000 soldiers were tested 
predeployment. By July 2008, every soldier will receive a baseline test 
before deployment.
    An experimental helmet sensor has been developed that will record 
impacts to the head. Over 1,145 of these helmet sensors are in use in 
theater today.
    Behavioral health care is a critical area of emphasis for Army 
leaders at every level. I would like to highlight a number of mental 
health initiatives. We are:

         Hiring over 300 new mental health hiring actions, even 
        in the face of national shortages of health care providers.
         Expanding the ``Battlemind'' training program that 
        educates soldiers and families about deployment-related 
        behavioral health concerns.
         Providing access to confidential mental health 
        counseling for soldiers and their family members.

    I also want to highlight the U.S. Army Wounded Warrior (AW2) 
Program, which assists and advocates for severely wounded, ill, or 
injured soldiers and their families throughout their lifetimes, 
wherever they are located. AW2 currently serves more than 2,300 
soldiers, 600 on active duty, and 1,700 veterans. AW2 Program 
caseworkers work with soldiers and their families to proactively 
address and mitigate issues they encounter in their recovery. AW2 
provides unique services to the most severely disabled including:

         Helping wounded soldiers remain in the Army by 
        educating them on their options and assisting them in the 
        application process.
         Assisting soldiers with future career plans and 
        employment opportunities beyond their Army careers.
         Supporting soldiers and families with a staff of 
        subject matter experts proficient in non-medical benefits for 
        wounded soldiers.

    Finally, we have improved the ways we ``listen'' to the needs of 
our wounded soldiers and their families and monitor the quality of care 
and support we provide to our soldiers. We are using third party-
surveys and input from more than 18 internal and external sources.
    Our surveys show that soldiers and their families continue to have 
questions about the PDES, but they have seen improvements in soldiers' 
assessment of the care and leadership provided by the WTUs.
    We will continue to fine-tune feedback mechanisms that provide us 
with multiple perspectives from which to see ourselves. Examples of 
those things we measure are:

         Access to care
         Appointment ``no show'' rate
         ``Leader to led'' ratios
         Satisfaction survey results
         Medical Evaluation Board (MEB) processing timeliness
         Awards
         Uniform Code of Military Justice actions
         Status of cadre training
         Living conditions

    General Casey and I also recently directed the Surgeon General to 
establish a Tiger Team to examine the soldier deaths that have occurred 
in WTUs. The Tiger Team presented an interim report this week and will 
continue to work to address this issue.
    We are working to reform the current PDES. We have reduced the 
amount of paperwork soldiers are required to complete. The assignment 
of additional Staff Judge Advocates to provide legal advice to soldiers 
undergoing the PDES process has reduced formal Disability Evaluation 
board requests. We have also instituted standardized training and 
certification for the Physical Evaluation Board Liaison Officers that 
support our soldiers.
    We have provided soldiers and their families interactive access to 
their MEB and Physical Evaluation Board (PEB), eliminating the need for 
appointments to review the paperwork and reducing the uncertainty that 
can plague the process. MEB and PEB review can now be done via secure 
Internet on Army Knowledge Online. We have increased the MEB staff so 
that staff-to-case ratios have dropped from 1:80 to a more effective 
1:30 ratio. Finally, we are working with DOD on a PDES pilot study 
currently ongoing at Walter Reed.
    The events of the last year have led to a strengthened partnership 
between the DOD and the VA. The senior leaders of both departments meet 
regularly as part of the Senior Oversight Committee (SOC). We are 
working together to provide a seamless transition for our soldiers from 
the DOD disability system either back to service in the Army or to a 
productive life as a veteran.
    The SOC has directed the following:

         Establish a single, comprehensive, standardized 
        medical exam for all wounded soldiers;
         Update the VA rating disabilities schedule to include 
        TBI; and
         Establish a TBI/PTSD Center of Excellence.

    In close coordination with the VA, the Army has executed the 
following actions:

         Added 16 VA liaison officers at major medical 
        treatment facilities,
         Provided VA access to DOD medical records and 
        databases as needed,
         Instituted a Federal Recovery Coordinator at Walter 
        Reed and Brooke Army Medical Centers (a SOC initiative),
         Exchanged senior leaders with the VA, and
         Entered into an agreement with the VA governing 
        coordination between VA benefits advisors and personnel at Army 
        installations.

                               CONCLUSION

    President Lincoln pledged our Nation to care for those who shall 
have borne the battle, their widows,--and now, widowers--and orphans. 
Working together, we must maintain that pledge not with words, but with 
deeds.
    Before I close I want to note that two brigades' worth of wounded, 
ill, and injured soldiers are returning to the force every year. 
Greater than 65 percent of all wounded, injured, or ill soldiers return 
to duty. About 27,000 of our soldiers have returned to the force since 
2001, and 88 percent of these soldiers are noncommissioned officers, 
the backbone of your Army.
    I want to thank the committee for supporting the improvements that 
we have been able to make under the AMAP and for the flexibility built 
into the recently passed NDAA. The provisions you carried forward from 
the Dignified Treatment of Wounded Warriors Act will help soldiers in 
critical areas such as TBI/PTSD treatment and research, expanded mental 
health care, and DOD/VA disability reform. Working together, we have 
made significant progress but several steps remain incomplete. The 
Army's ability to process wounded warriors would be improved if it were 
allowed to focus on fitness for duty and let the VA focus on disability 
determination and compensation. This is a key and critical provision of 
the Dole/Shalala recommendations.
    Again, thank you for inviting me to testify. I look forward to your 
questions.

    Chairman Levin. Thank you, Secretary Geren. That was a very 
important statement and a very moving statement. Thank you for 
the preparation of it and for delivering it the way you did.
    General Schoomaker?

 STATEMENT OF LTG ERIC B. SCHOOMAKER, USA, SURGEON GENERAL OF 
       THE ARMY AND COMMANDER, U.S. ARMY MEDICAL COMMAND

    General Schoomaker. Chairman Levin, distinguished members 
of the committee: Thank you for the opportunity to discuss the 
total transformation that the Army is undergoing in the way we 
care for soldiers and their families. We are committed to 
getting this right and providing a level of care and support to 
our warriors and their families that is equal to the quality of 
their service.
    Secretary Geren has eloquently expressed this 
transformation in his testimony. The Secretary, the Chief of 
Staff of the Army, and the rest of the Army leadership are all 
actively involved with every stage of the AMAP, which you, sir, 
alluded to in your opening comments, and to the transformation 
it embodies. In less than 1 year, the Army has funded, staffed, 
and written doctrine for a fundamental change in warrior care, 
a truly remarkable achievement.
    For example, as Secretary Geren mentioned, we now have more 
than 2,500 soldier leaders assigned as cadre to 35 WTUs that 
did not exist this time last February. This contrasts with 
fewer than 400 cadre for the same group of patients last 
February.
    The most significant feature of these WTUs is this triad of 
care that has been alluded to, consisting of a primary care 
physician, a nurse case manager, and a squad leader working 
together to care for the needs of each individual. The regular 
meetings and the coordination between each leg of the triad 
serves to create a web of overlapping responsibility and 
accountability which embraces each warrior for the duration of 
the treatment and recovery.
    Our squad leaders, many of them combat arms soldiers and 
former patients--two of the officers that you were introduced 
to earlier have been patients at Walter Reed and have been 
combat injured--are trained and responsible for the well-being 
of a small group of warriors in transition, just as any Army 
unit. These soldiers that you met just a minute ago are four 
combat-tested leaders and they spend their days at Walter Reed 
looking out for the best interests of the wounded, ill, and 
injured soldiers. They really are the backbone of the AMAP.
    Sir, with your permission I'd like to introduce two of my 
battle buddies in putting together this plan. I'd ask Brigadier 
General Mike Tucker and Colonel Jimmie Keenan just to stand up. 
These are two of the principal architects of the AMAP. Mike is 
a career armor officer. We took him out of the armor school at 
Fort Knox. Jimmie Keenan is a career Nurse Corps officer, and 
they truly are the architects and executors of the AMAP. We 
couldn't have done it without them. [Applause.]
    Chairman Levin. Thank you for introducing them. Thank you 
for your service.
    General Schoomaker. Another example of the difference 
between today and last year: One year ago, our wounded, ill, 
and injured soldiers believed that their complaints were 
falling on deaf ears within the Army. Now we've established a 
MEDCOM-wide ombudsman program with ombudsmen at 26 of our 
installations and we're hiring more each week. Everyone at our 
medical treatment facilities knows who the ombudsman is and how 
to find him or her. Many are retired NCOs and officers with 
experience in medical care. They work outside of the local 
chain of command, but they have direct lines to the hospital 
commander, the installation commander, and the garrison 
commander to get problems fixed.
    We've also established a 1-800 wounded soldier and family 
hotline that's outlined on this card that every soldier and 
family carries, in order to offer wounded, ill, and injured 
soldiers and their family members a way to share concerns on 
any aspect of their care or administrative support. We respond 
to these inquiries within 24 hours of the call. So far we've 
received in excess of 7,000 calls.
    Another improvement in the care of soldiers over the last 
year is the development of multiple feedback mechanisms so that 
we can see ourselves from a variety of perspectives. I think 
this is a lesson that we learned last year. We monitor and 
evaluate our performance through 18 internal and external 
means, including the ombudsman and the hotline that I addressed 
earlier. But we also have a contracted industry leader in 
patient surveys that we look at very carefully.
    In addition, we host numerous visits from Members of 
Congress and your staffs. In January alone we opened our WTU 
doors to more than a dozen congressional visits. These visits 
give us a valued external perspective and allow us the 
opportunity to be as open and transparent in our operations as 
possible. Your feedback and the feedback of your staffs on 
these visits has been instrumental in our success.
    As you well know, despite these successes, there's much 
progress still to be made. We still need more research on 
psychological health and TBI. Congress jumpstarted us last year 
with supplemental funding, for which we are very grateful, but 
research must be a continuing priority effort.
    We need to continue to look at the disability, the physical 
disability evaluation system (PDES) and ways to make it less 
antagonistic, more user-friendly, and more understandable to 
the soldiers and their families. I believe the pilot program 
that started in the National Capital Region is a good start, 
but, as each one of the members of the panel have mentioned, 
we'd like to see changes made in the PDES made legislatively as 
aggressively as possible.
    We need your continued support so that we can move forward 
together in 2008 much as we did in 2007. This year's National 
Defense Authorization Act was very consistent with how the Army 
is approaching wounded warrior matters. I truly appreciate the 
flexibility you have provided us to develop policies and 
achieve solutions. Your bill not only helps warriors, it helps 
families, it helps the health care providers caring for them. 
Thank you for taking the time to listen to us and to work with 
us.
    The Army's unwavering commitment--a key element of the 
warrior ethos is that we never leave a soldier behind on a 
battlefield or lost in a bureaucracy here at home. We are doing 
a better job of honoring that commitment today than we were on 
this day last year. In February 2009 I want to report back to 
you that we've achieved a similar level of progress as we did 
over the last year. I'm proud of Army medicine's efforts over 
the past 232 years and especially over the last 12 months. I'm 
convinced that, in coordination with the DOD, VA, and Congress, 
we have turned the corner.
    Thank you for holding this hearing and thank you for your 
continued support of the warriors that we are so honored to 
serve. I truly look forward to your questions.
    [The prepared statement of General Schoomaker follows:]

           Prepared Statement by LTG Eric B. Schoomaker, USA

    Chairman Levin, Senator McCain, and distinguished members of the 
committee, thank you for the opportunity to discuss the total 
transformation the Army is undergoing in the way we care for soldiers 
and families. We are committed to getting this right and providing a 
level of care and support to our warriors and families that is equal to 
the quality of their service.
    Secretary Geren eloquently expresses this transformation in his 
testimony. The Secretary, the Chief of Staff of the Army, and the rest 
of the Army leadership are all actively involved with every stage of 
the Army Medical Action Plan (AMAP) and the transformation it embodies. 
Senior Army leadership has made it very clear that they are in lock 
step with the following statement by Secretary of Defense Gates, 
``Apart from the war itself, this department and I have no higher 
priority.''
    What I would like to highlight for you today are some of the 
tangible impacts of the transformed system explained by Secretary 
Geren. In doing this, I would first point out that, in some aspects, 
the concerns reported at Walter Reed Army Medical Center (WRAMC) were 
an unintended consequence of the extraordinary success of modern 
battlefield medicine. Thanks to improvements such as the Joint Theater 
Trauma System, state-of-the-art evacuation system and improved body 
armor, over 90 percent of those wounded in Iraq and Afghanistan 
survive, making this the highest survival rate in the history of 
warfare. As a result, there are many more wounded soldiers with complex 
injuries struggling to recover than in any previous war. In today's 
highly motivated All-Volunteer Army, this translates to an 
unprecedented number of soldiers determined to rejoin their units or to 
transition back to their communities as proud and productive veterans.
    At WRAMC, where soldiers are able to participate in the center's 
state-of-the-art rehabilitation programs, the result has been a 
population of outpatients six times greater than this premier medical 
center was designed to handle. To tap this extraordinary determination, 
the framers of the AMAP realized the need to provide injured soldiers a 
mission of their own: to heal fully enough to transition back to duty 
or become a productive, responsible citizen in society. As a result, 
WRAMC and Army medicine have been reorganized to better enable soldiers 
and their families to accomplish this goal.
    The changes have made a lasting imprint on wounded soldiers and 
their families throughout this Nation. According to Major Steven 
Gventer, a soldier wounded in Iraq by a rocket propelled grenade round 
who is currently commanding one of the companies that make up the 
Warrior Transition Brigade at Walter Reed, the changes brought about as 
part of the AMAP ``. . . did a great service to soldiers. We have done 
everything possible for these soldiers and are continuing to get better 
every day.''
    There are now more than 2,400 individuals assigned as cadre to the 
35 Warrior Transition Units compared to less than 400 as previously 
organized. These cadres are trained specifically for this mission and 
they truly know the wounded, ill, and injured soldiers and families for 
whom they provide care and support. They escort troops to meetings, act 
as their advocates, field their calls, and even pick up relatives at 
the airport. As Major Gventer puts it, ``It's a job that entails just 
about anything and everything that allows the Warrior in Transition to 
focus on his or her mission, which is to heal.''
    Most telling as to the progress we have made are observations like 
those of Army Captain Elvind Forseth, who suffered hand, arm, and eye 
damage when a roadside bomb hit his HMMWV in Mosul on January 4, 2005 
and has been recovering since at Walter Reed. Captain Forseth states he 
has seen great changes, ``It's fantastic. This is the first time in a 
long time that I didn't absolutely hate being in here.'' Captain 
Forseth, 34, has submitted his paperwork for medical retirement and 
says the process is running smoothly.
    Staff Sergeant Michael Thornton is assigned to the Warrior 
Transition Battalion at Fort Sam Houston, TX. While serving with the 
4th Infantry Division near Baghdad in September 2006, he sustained 
burns over 33 percent of his body when the vehicle he was traveling in 
hit a roadside bomb. He was transferred to what was then the Medical 
Hold Company to convalesce. In June 2007, the company to which he was 
assigned became a Warrior Transition Unit as the AMAP was implemented. 
Staff Sergeant Thornton states that, since then ``Things flow more 
efficiently. It seems more organized. It's good to have dedicated 
leadership who handle just our issues. In the past, some wounded 
soldiers were also serving as squad leaders at the Medical Hold 
Company. They had appointments too, so it's better to have dedicated 
leadership. This is the best place I've seen in the Army. We have great 
docs and so many people who care about us. I've seen issues like a pay 
problem I had that was resolved with their help the same day. They go 
out of their way to take care of you and they're good at it.''
    It has also been meaningful to see how the civilian health care 
community views the changes that we have made. One expert assessment 
was recently made by William H. Craig, a civilian health care executive 
with 17 years experience who currently serves as Vice-President of 
Clinical Support for Cook Children's Medical Center in Fort Worth, TX. 
Mr. Craig spent a week with the Warrior Transition Brigade at WRAMC, 
viewing firsthand how the Army has improved the transition process for 
outpatient soldiers and to see if the Army's way might have application 
in the civilian health care world. Mr. Craig's observations include:

          ``From a professional standpoint, I was most impressed with 
        the Army's organizational and leadership efforts through the 
        Warrior Transition Brigade. The Army has taken a process-based 
        approach to managing soldiers from the time they arrive at 
        Walter Reed until they leave to return to duty or to civilian 
        life. The Army developed a system through the Warrior 
        Transition Brigade that incorporates both daily people-
        management needs and medical care needs of the soldier into an 
        organizational structure that brings significant improvement to 
        the transition process. It is impressive to see an organization 
        like the Army, which I have always perceived to be very command 
        and control oriented in leadership style, actually be adaptive 
        in its leadership style and incorporate a flexible approach 
        based on the needs of this wounded soldier population.''

    Mr. Craig continues that, ``While my experience in the health care 
industry has shown we do a good job of case managing on the inpatient 
side, it seems to me our systems for outpatient case management are not 
as well developed as the Army's. When assessing the needs of their 
wounded soldier population, the Army developed a concept I believe 
complements the medical resources of an organization like Walter Reed 
and effectively meets the soldier's outpatient case management needs. 
This is referred to as the Triad of Care and incorporates three 
disciplines critical to managing the outpatient process once the 
soldier is discharged from inpatient status.''
    Mr. Craig concludes with, ``My week at Walter Reed with the Warrior 
Transition Brigade proved a point I have experienced many times in my 
career: if you give an organization the right level of resources 
combined with the right people to lead and execute, it can accomplish 
many great things.''
    I can think of no more fitting way to conclude my remarks than with 
this endorsement from such a respected member of the civilian health 
care community. The AMAP is the right response at the right time and in 
the right place for Army medicine and the United States Army. We see 
the positive impact of these changes every day as we encounter soldiers 
and families on the wards and in our clinics. It can be very rewarding 
to see the progress and growth.
    It can also be very frustrating when, despite all of our efforts, 
we have bad outcomes. We continue to face challenges that require blunt 
honesty, continuous self-assessment, humility, and the ability to 
listen to those in need. It is the Army's unwavering commitment to 
never leave a soldier behind on a battlefield nor lost in a 
bureaucracy. The changes initiated by the AMAP are transformational 
because they address the new requirements and costs of sustaining an 
All-Volunteer Force in an era of persistent conflict.
    I want to ensure Congress knows that the Army Medical Department's 
(AMEDD) highest priority is caring for our wounded, ill, and injured 
warriors and their families. I am proud of the AMEDD's efforts over the 
last 12 months and I am convinced that in coordination with the 
Department of Defense, the Department of Veterans Affairs, and 
Congress, we have ``turned the corner'' toward establishing an 
integrated, overlapping system of treatment, support, and leadership 
that is significantly enhancing the care of our warriors and families. 
Thank you for holding this hearing and thank you for your continued 
support of the AMEDD and the warriors that we are honored to serve. I 
look forward to your questions.

    Chairman Levin. Thank you, General. Thank you and all the 
witnesses for your testimony this morning.
    Let's try an 8-minute first round. We will try to work 
through that roll call vote that's coming up in 10 or 15 
minutes, which some of us can just go and vote and come back, 
so we can try to keep it seamless. As you folks are working on 
seamlessness, we'll try to do the same thing here this morning.
    Studies conducted by the Veterans Disability Benefits 
Commission concluded that the VA standard for assigning 
disability ratings for PTSD is inadequate. These studies showed 
a significant discrepancy between the disability ratings 
assigned by the DOD and the VA for servicemembers with PTSD. 
The commission found that of 1,400 servicemembers who were 
rated by both the DOD and the VA for PTSD, the DOD assigned 
disability ratings of 30 percent or higher to only 18 percent 
of that group of 1,400 servicemembers, while the VA assigned 
ratings of 30 percent or higher to 90 percent of that same 
group of individuals.
    Now, that is a stunning difference. That's not a few 
percentage points. The same people, the same 1,400, not 1,400 
people over here and 1,400 people over there. It's 1,400 people 
who were the same. The DOD gave disability ratings of 30 
percent or higher to 18 percent of that group and the VA gave 
ratings of 30 percent or higher to 90 percent of those same 
individuals.
    Now, even before we passed the Wounded Warrior Act the law 
required the DOD to use VA standards for rating disabilities, 
but in practice the Services deviated from those standards, in 
many cases resulting in lower disability ratings than assigned 
by the VA for the same disability for the same person.
    The Wounded Warrior Act specifically requires the DOD to 
use the VA standard. It authorizes deviation only when the 
deviation will result in a higher disability rating for the 
servicemember. Now, you've described this pilot project where 
we're going to have a single exam followed by hopefully a 
single rating, and we very much welcome that. I think you said 
there's 120 people in that pilot project.
    But in the mean time, while that project is going to take a 
year, we have a legal requirement now for the DOD to implement 
the requirement in law that restricts deviation from the VA 
standard to those circumstances where it benefits the 
servicemember. I think, let me ask you, Secretary Chu, how are 
you going to implement this requirement?
    Dr. Chu. Of course, Mr. Chairman, as you have pointed out, 
it has been longstanding policy of the Department that we're 
supposed to use the VA rating schedule. There are differences 
in outcomes. We're aware of that. That's why we are so excited 
about this pilot program, which the Secretary has asked that we 
proliferate across the Department as soon as it's practical to 
absorb its lessons about the administrative issues that need to 
be addressed.
    The ultimate safeguard--these are basically clinical 
judgments reaching different conclusions. The ultimate 
safeguard is just to have one agency come to the conclusion, 
and that is the central feature of the pilot program, which is 
we'll use VA's disability ratings.
    Now, there will still be an issue here, and this is where 
the Dole-Shalala proposal I think is important, because our 
fitness decision will be on those conditions that speak to that 
issue. It will not necessarily be all the conditions the 
individual has.
    Chairman Levin. My question is, you have a pilot program 
over there. You say the ultimate answer is to have one rating 
and you're right and that's why we put it into law. But in the 
mean time, we can't accept that kind of a deviation.
    Dr. Chu. I agree, sir.
    Chairman Levin. For the same people.
    Dr. Chu. I agree, sir, and we are trying to reinforce that 
it is one schedule. I do think that the solution, as we all 
agree, is a single examination system, and we are moving that 
way.
    Chairman Levin. We're going to need to know what are you 
doing in the mean time until that system is put in place to 
reduce that deviation. If this were a difference between 5 
percent deviation or 10 percent deviation, that would be one 
thing. But this is 90 percent versus 18 percent. That is 
totally unacceptable even as an interim differential.
    Dr. Chu. I would agree, sir. I do think I should emphasize 
for the record that an earlier study looked at a wider range of 
conditions; the average difference between the two agencies was 
8 percentage points.
    Chairman Levin. All right. On PTSD.
    Dr. Chu. PTSD is a particular issue, although it's also 
true that VA has recently revised PTSD ratings for many of the 
veterans involved in older conflicts, and that may be partly 
explaining the large differences that are reported. DOD does 
the rating at the time of discharge. VA may adjust that rating 
across the veteran's longer life history.
    Chairman Levin. Secretary, these are the same 1,400 people.
    It doesn't cover veterans from older conflicts. These are 
the same 1,400 people.
    We're going to give you 30 days on this one, to tell us 
what action's going to be taken to reduce that differential, 
for the reasons I gave.
    Now, there's another provision in the law that requires the 
establishment of a board to review the DOD disability ratings 
of 20 percent or less. I'm wondering, is that board--do you 
have plans now to appoint that?
    Dr. Chu. We intend to appoint that board, sir. It is not 
yet appointed. But we fully understand the requirement of the 
statute, which is to review all the older cases since the 
beginning of this conflict.
    Chairman Levin. Where there's 20 percent or less.
    Dr. Chu. Where there's 20 percent or less.
    Chairman Levin. That's a critical issue in terms of 
benefits and family coverage for medical care.
    Please give us an estimate: 30 days, you think?
    Dr. Chu. I think 1 to 2 months to get it established, yes, 
sir; I think that's fair.
    Chairman Levin. All right.
    [The information referred to follows:]
      
    
    
      
      
    
    
      
    Chairman Levin. Secretary Mansfield, has the VA updated the 
VA schedule for rating disabilities for PTSD?
    Secretary Mansfield. It's currently under way, sir. It has 
to go through the Federal review process.
    Chairman Levin. What's the timetable on that?
    Secretary Mansfield. The process itself requires 30 days 
for public comments and then a follow-up of 30 to 60 days to 
review the comments, prepare a final rule, and get Office of 
Management and Budget clearance to publish. Then we would act 
after that. So I would imagine 90 to 120 days. It has been a 
highlighted issue within the Department and within VBA, our 
benefits administration.
    Chairman Levin. There was a recent series of Denver Post 
articles that report that 79 soldiers who were determined to be 
medical no-gos have been knowingly deployed to Iraq. General 
Schoomaker, this question is for you. The most recent article 
describes a soldier being taken from a hospital where he was 
being treated for bipolar disorder and alcohol abuse so he 
could be deployed to Kuwait. 31 days later he was returned to 
Fort Carson because health care professionals in Kuwait 
determined that he should not have been sent there in the first 
place because of his medical condition.
    These articles quoted email from Fort Carson's Third 
Brigade Combat Team that says: ``We have been having issues 
reaching deployable strength and thus have been taking along 
some borderline soldiers who would otherwise have been left 
behind for continued treatment.''
    Are these reports accurate? What's the Army doing to 
address them? Maybe Secretary Geren and General Schoomaker. Let 
me start with you, Secretary, and then I'll go to the General.
    Secretary Geren. We are looking into those issues. Sir, 
before a soldier deploys they are evaluated and it's a 
subjective process to determine whether or not they are fit for 
deployment, and judgment is exercised. We've had this issue 
come up in a number of deployment platforms around the country, 
in fact one this time last year that was raised down at Fort 
Stewart.
    I guess the essential point is that the judgment is 
exercised at the point of deployment, and sometimes that 
judgment turns out to be wrong.
    Chairman Levin. Is there a shortage of deployable strength 
that is now causing some of these decisions to be made that 
otherwise would not be made?
    Secretary Geren. That should not be happening. I can't tell 
you that it's not, but it certainly should not be happening. 
But every soldier must be considered, whether or not he or she 
is fit for duty, and if not they should not be sent, and 
everyone understands that. I don't believe we found any 
evidence that the pressure has caused people to be sent that 
shouldn't have. Maybe cases where something was overlooked or 
where a mistake was made, but the commanders who evaluate these 
soldiers understand what the requirements are and should never 
send anybody that's unfit. But we look into every one of these 
cases.
    Chairman Levin. Are you familiar with that email, that 
article?
    Secretary Geren. Yes, sir, I am familiar with the article.
    Chairman Levin. Have you checked the person who wrote that 
email to say that that is not an acceptable reason for 
deploying somebody? Could you do that?
    Secretary Geren. Yes, sir, I certainly could.
    [Additional information supplied for the record.]
      
    
    
      
    
    
      
    
    
      
    Chairman Levin. Do you want to add anything to that, 
General?
    General Schoomaker. Sir, I have not seen the case myself. I 
am familiar with the story. My understanding at this point, 
because the soldiers who possess those profiles who were 
deployed, to include the soldier who is the centerpiece of the 
article, their profiles and the decision to deploy have been 
looked at carefully. In all the cases in which soldiers were 
deployed with profiles, they were placed in positions and in 
conditions which would be supported by their profile. The 
profile itself does not limit deployment. My understanding of 
the index soldier was that he was not hospitalized and that the 
opinion of outside consultants was that his condition should 
not limit his ability to be deployed. But I think it's still 
being looked at.
    Chairman Levin. The email itself, however, says that ``We 
have been having issues reaching deployable strength.'' I mean, 
that's a contemporaneous email and that should not be a factor. 
Would you both agree with that?
    General Schoomaker. Yes, sir.
    Secretary Geren. Yes.
    Chairman Levin. So whoever thought that was a factor has to 
be corrected, and that message has to be made clear across the 
board. Would you agree with that?
    General Schoomaker. I agree with that.
    Chairman Levin. Thank you.
    Senator Warner.
    Senator Warner. Thank you, Mr. Chairman.
    Gentlemen, those of us in the Senate who have had the 
opportunity to work on these issues have received a great deal 
of information, indeed support and learning, from the families 
of these various soldiers, sailors, airmen, and marines that 
have suffered these injuries. I've been particularly fortunate 
to have had access and brought to my attention the wives of a 
number of these individuals who have on their own initiative 
fought a very courageous battle. I'm pleased to say that in our 
audience this morning is Sarah Wade, whose husband in 2004, 
Sergeant Ted Wade, was severely injured. He's still in the 
process of rehabilitation, and she's accompanied by Meredith 
Beck, who is a very active member of an organization called 
Wounded Warrior Project, a nonprofit organization.
    I wonder, Mr. Chairman, if we'd invite those two to stand 
and be recognized here. They are examples of the families that 
stand by their man. [Applause.]
    Secretary Geren, you visited with me the other day. It's 
interesting how forthright you are with sharing the 
information, good news and not so good news, with our 
colleagues. I feel that in discharging your responsibilities, 
certainly with this Member of Congress, you've been absolutely 
forthcoming and factual.
    You showed me a series of charts about the things that were 
concerning you. Among them was the very alarming rate of 
suicide. It's particularly high in the Reserve and Guard 
components. I'd like to ask you to lead off what steps under 
your leadership the Department of the Army is taking, and then 
maybe we'll go to the other witnesses, who have a broader 
responsibility for the other departments, to the extent that 
the Navy, the Air Force, and the Marine Corps are suffering 
some from this problem.
    Secretary Geren. I'd be glad to lead off, but I'd also like 
to ask General Schoomaker to add as well because this is an 
area where the leadership of the Army has focused a great deal 
of attention, and not just over the last few months. We've 
recognized over the last few years an alarming growth in the 
rate of suicides. We last year experienced the highest level of 
suicides we've had since we started tracking suicides in 1980.
    Senator Warner. So that's a period of 28 years.
    Secretary Geren. Yes, sir. That's when we began tracking 
it. We can't tell how it compares to prior years. But we've 
seen a steady increase over the last 5 years, and it's 
something that everybody in Army leadership understands they're 
part of the solution to that effort.
    Every week we have a balcony briefing. We bring all the 
senior leadership in the Army together in the Pentagon 
Wednesday morning. One of the slides we look at is the suicide 
incidents over the preceding week. We want to make sure every 
leader in the Army recognizes that it's a part of his or her 
responsibility to help address this.
    We have a very comprehensive effort under way right now--
and General Schoomaker can provide you greater details, but we 
are looking at innovative ways to approach it through different 
types of training for soldiers, for leaders, working with the 
chaplains, working with families.
    I think one of the most important things we can do is 
overcome the stigma over getting help for mental health issues. 
We have soldiers that don't come forward and ask to be helped. 
Until we break down that stigma, until we break down that 
barrier, we're going to have soldiers that are in desperate 
need that don't get the help they need.
    This PTSD training that we're doing, it's not just PTSD and 
TBI, but I think it's going to break down the stigma across the 
whole range of mental health issues and help soldiers and 
family members to recognize, this soldier has a problem, come 
forward and do something with it.
    But we are looking at trying to understand the trends. We 
have seen some of these deaths associated with misuse of 
narcotics and other drugs that were lawfully prescribed and 
perhaps misused, a mix of alcohol and drugs. Most of them 
result from a failed relationship or some other type of 
traumatic event in their life, exacerbated by the stress that 
they're under and the pressures that they're under. Also, 
leaders in the Army, because the system is stressed, aren't 
able to put their arm around the soldier and understand what's 
going on with his life.
    But from the lowest ranks to the most senior ranks, this is 
a problem that we are working to address. I would like to ask 
Dr. Schoomaker--he's done a great deal of work in this area and 
I think that he has much to share with the committee.
    General Schoomaker. Thank you, sir.
    Thanks for the question. You're right, there are two trends 
right now that we are watching very carefully that the 
Secretary has alluded to. The first is suicides within the Army 
at large. I think Secretary Geren has really outlined the 
multidisciplinary approach that we have. It starts with small 
unit leaders and fellow soldiers and their ability to recognize 
a soldier who may be in trouble, that may have problems with 
coping with a lost relationship, which includes in some cases a 
loss of a relationship with the Army itself because of 
misconduct and the like.
    It's compounded by drug or alcohol use, and certainly the 
families play a very critical role. We are looking at this in a 
multidisciplinary way. We have looked carefully across the 
principle staff who are responsible, from the chaplains through 
the personnel community, through those that represent 
leadership at large, and then the medical community. We're 
prepared to come in front of the Secretary with some 
recommendations about how we will be approaching suicide 
prevention in the near future.
    The other trend that we're looking at very carefully is a 
trend in accidental deaths, especially within our WTUs. Now 
that we have concentrated approximately 9,500, almost two 
brigades worth, of soldiers who have illnesses or injuries, 
some combat-related, some other, within these WTUs under the 
care of cadre with a primary care provider and nurse case 
managers, we recognize now that a number of them have a 
constellation of drugs--drugs for anxiety, drugs for sleep, 
drugs for pain, which in combination, especially if used with 
alcohol, can be a lethal cocktail.
    We have, unfortunately, lost over the last few months 
several soldiers. We've brought together a team. The Secretary 
and the Chief of Staff of the Army charged me about 10 days ago 
with expeditiously bringing together a team of experts to look 
at the factors that lead to these accidental deaths. I contrast 
these with suicide. I don't believe these are suicides. We've 
looked very carefully to separate those that are suicides from 
those that are truly accidental, and those that we are seeing 
are accidental deaths. We've looked at the major factors and 
are trying to eliminate those factors.
    Senator Warner. Secretary Chu, to the broader aspects of 
it.
    Dr. Chu. Yes, sir. The Marine Corps is already beginning to 
emulate the Army's practice of the chain teaching of mental 
health indicators, responsibilities at every level of command. 
The Secretary of Defense, to deal with the stigma issue--a 
small but important step--has advocated and the administration, 
I believe, will soon decide to revise the instructions on 
security questionnaires so that we set aside a positive answer 
on have you sought mental health assistance if it has to do 
with PTSD or the various issues that relate to combat service.
    I do think there are two issues here. One is the trend, 
where we are all concerned with the Army's increase. Also the 
level, the Department, even with this adverse trend, is 
approximately where civilian rates are. That doesn't mean 
that's where we want to be. Within the Department we do have a 
Service that's at much lower level, absolute level of suicide, 
the Air Force. So one of the things we're doing is asking all 
the departments to look at what's successful about these Air 
Force programs that might be translatable to their 
circumstances.
    We are very excited with this Center for Psychological 
Health and Traumatic Brain Injury Congress has so generously 
funded. It's stood up in a provisional way, being led by an 
Army psychiatrist, Colonel--soon General, I guess--Dr. Loree 
Sutton. I've asked her to focus not just on prevention after 
the fact, but what can we do before the fact; and how can we 
help the resiliency of our people to deal with the stresses 
that military life does bring to them. Should we, for example, 
be asking questions all the way back at the enlistment point 
that we don't ask today or having screens that we don't use 
today?
    We do, of course, use one broad screen already that is a 
predictor of can you stick with a military career. That's the 
high school diploma. That's why they're so important in our 
recruiting standards.
    So we are trying to take a broad-based approach, ranging 
from the specific questions and examples to the strategic, how 
should we be recruiting people from American society so they 
can successfully serve in a very difficult environment?
    Senator Warner. I actually say to this distinguished panel, 
we have to have the infrastructure to carry forward all of 
these various initiatives, literally the bricks and the mortar 
and the roofs and the ceilings and so forth. Where are we with 
regard to, first, maintaining Walter Reed's physical plant such 
that it can continue to deliver that level of health care that 
these honorable, wonderful people are entitled? Second, the 
projections of a new facility at Fort Belvoir and the 
modifications to the infrastructure at the Bethesda center to 
take on the additional; are we on schedule? Is the budget 
adequate for these two construction projects?
    Dr. Chu. Yes, sir.
    Senator Warner. Is there anything that Congress needs to do 
to facilitate?
    Dr. Chu. Our most important request will, of course, be to 
support the fiscal year 2009 request in this regard, which does 
ask for a substantial tranche of money to support a more 
ambitious plan for the new Walter Reed campus than we had 
before, and a faster plan. That includes Walter Reed thought 
about in the large, not just the Bethesda campus, but also, 
importantly, the DeWitt Army Hospital modernization and the 
refurbishment at Fort Belvoir.
    In terms of the personnel at Walter Reed--that, I think, is 
always a challenge when you close a base, how you keep 
everything up at the top level all the way up to the last day. 
We have sought and gotten from the Office of Personnel 
Management additional direct hire authority to make sure we can 
staff Walter Reed correctly, including the ability to pay 
special retention bonuses to the personnel there.
    But I would defer to Secretary Geren on additional 
specifics.
    Secretary Geren. General Schoomaker just recently left the 
post as commander at Walter Reed, so I'd like to ask General 
Schoomaker to respond.
    General Schoomaker. Yes, sir. I think Congress and the 
leadership of the DOD and the Army sent me and my command when 
I commanded Walter Reed last year a very clear message that we 
were to restore Walter Reed to a world-class facility, despite 
the impending fusion of Walter Reed with the National Naval 
Medical Center in Bethesda and the formation of the new Walter 
Reed National Naval Medical Center that the Secretary alluded 
to.
    We've done just exactly that. We have given very clear 
orders and have had very robust support from the Department to 
fix all those things that need to be fixed and to maintain both 
the manpower as well as the clinical practices and the physical 
plant of the Walter Reed campus.
    Senator Warner. Thank you very much.
    Chairman Levin. Thank you, Senator Warner.
    Senator Ben Nelson.
    Senator Ben Nelson. Thank you, Mr. Chairman.
    I want to thank our military men and women and those who 
are on the civilian side who do such an outstanding job to 
protect our country. Of course, nothing is more important in 
dealing with their needs than to make sure that the health 
system we provide for them is the best possible health care 
system. So we were all chagrined and saddened with the 
revelations of a year ago.
    In terms of what we're working with toward public-private 
partnering, Secretary Mansfield and Secretary Chu, last year I 
met with a sergeant in Nebraska from the National Guard who 
suffered a TBI as a result of his service in Iraq in 2006. When 
I met with him, he indicated the many challenges he had in 
getting the care that he required. He was lost in the system on 
at least two occasions, and he was finally able to get care in 
Nebraska through a private facility, Madonna Rehabilitation 
Hospital.
    Receiving quality health care in rural States is obviously 
a challenge in many areas due to resources and geography alone. 
That's why I believe it's critical that we find partnership 
opportunities for our public institutions and private 
institutions to be able to make sure that we get that quality 
care and we integrate it.
    How do you provide for that integrative care for veterans 
as they transition back into their communities, so that we 
ensure their long-term care, not simply a short-term situation, 
but their long-term follow-up care across a wide geographic 
area? I've been told that local VA hospitals have authority to 
contract with civilian partners, but in many instances are just 
very reluctant to do so and we have to continue to press to get 
them to be able to forge a collaboration.
    But is this centralized or decentralized process from the 
standpoint of the VA? What are your thoughts about how we can 
make this system work? We talk about it being seamless. You'll 
have to pardon me if I find the word ``seamless'' between the 
VA and the DOD an oxymoron. Perhaps ``nearly seamless'' might 
be something more, that would be more likely achievable. 
``Seamless'' I think is beyond anyone's expectations, given a 
bureaucracy that is full of what I consider ``we-bes'': ``We be 
here when you come, we be here when you go.'' We're going to 
constantly find that very difficult to purge and converge those 
systems.
    But from the standpoint of the VA first and then the DOD 
second.
    Secretary Mansfield. Thank you for that question, Senator. 
First let me apologize to that individual. The idea that 
somebody gets lost in the system is something that we do not 
want, and we're doing everything we can to ensure that we take 
care of that. So I would apologize to that individual.
    Senator Ben Nelson. Sergeant Mac Richards.
    Secretary Mansfield. I'll get with you and we'll follow up 
on that.
    The idea of TBI care, serious TBI care, started with the 
fact that the VA since 1992 had four brain injury treatment 
centers that were doing treatment, care, research, and efforts, 
and those four centers in Palo Alto, Minneapolis, Richmond, and 
Tampa became our polytrauma centers. Each one of those brain 
treatment centers was also co-located with a spinal cord injury 
clinic, so we had a robust rehabilitation capacity in those 
hospitals. There's a fifth one on the way hopefully in the next 
budget.
    What we've done since then for the effort to have more 
geographic representation is had each one of our VSNs, or 17 
more VA medical centers, come on line as level two polytrauma 
treatment centers, so we can attempt to get the treatment more 
dispersed geographically around the country.
    The issue of the private treatment is one that we've dealt 
with in the past in sharing agreements in various locations to 
get specialty care that we needed that we didn't have on staff 
or just couldn't provide.
    Senator Ben Nelson. Excuse me. Can that be geography-
related as well, not close by, so that they don't have to drive 
250 or 500 miles round trip?
    Secretary Mansfield. Sir, I was going to say, what we are 
learning and dealing with and attempting to do is deal with the 
individuals in an effort to bring all the conditions that would 
apply to bear to make the decision to go forward. I know that 
Dr. Kussman, the head of our Veterans Health Administration, 
has made the point that if the people that we're treating don't 
feel that they're getting the care that they need then we need 
to work with them in an effort to get it right.
    I know that we've done that in many instances where folks 
are getting treatment that either VA is paying for or in some 
cases, TRICARE I think is also taking care of the individual. 
It's an effort that has started, is moving forward, needs the 
continued emphasis of the leadership, has had continued 
emphasis, and we will do more.
    Senator Ben Nelson. Dr. Chu?
    Dr. Chu. Sir, if I could just address the two issues you 
raise. One is the seamless transition; the other is the 
question of how we provide quality care to those on a 
geographically dispersed basis.
    On the seamless transition front, we are very excited by 
the appointment of the first Federal integrated recovery 
coordinators. Their ultimate responsibility is to make sure 
there is a plan for that person that is really lifelong in 
character and that the steps are in place--the mechanisms in 
place, to be sure that plan is being followed. I think that's a 
key ingredient in getting us at least to the nearly seamless 
condition that you set as an immediate goal.
    On the question of the geographically dispersed delivery of 
care, I do think this is where the central proposition of Dole-
Shalala is so important. It recommends, and the President's 
legislative proposal would propose to carry out, that if you're 
medically retired from the DOD we would end DOD deciding 
whether you got TRICARE coverage based on the percentage of 
disability. If you're medically retired you would get TRICARE 
coverage for you and your family.
    Now, I think that's important not only for the families, 
but also for the issue that you described, because that does 
give you the right to go to any place you want, essentially, in 
the United States, and it would end a good deal of this 
problem, because it's always been a problem for the VA. In many 
States there may be only two or three VA hospitals and it is 
going to be a distance for patients to come to that hospital 
for care, even though the quality reviews across the medical 
profession in the United States today give VA extraordinary 
high remarks for the quality of medical care that it delivers. 
It really is first class.
    Senator Ben Nelson. I don't think very often the question 
is about the quality of care or even recognizing that with the 
TBI situation, all the research that's going into that, that 
there's a general perception that we're improving the quality 
of care. It's availability and the seamless nature of it.
    General Schoomaker, this has probably happened to others as 
well, but I know last week you were interviewed by NPR and you 
were given the example that somebody allegedly--that Army 
officials told workers at the VA to stop helping injured 
soldiers fill out forms and so forth. So much for the idea, as 
I said, of seamless care and seamless relationships. Probably 
not the first example of embarrassment and probably not the 
last.
    But it does point to how important it is from the top down 
and from the bottom up to get it right so that there isn't 
stovepiping or resistance to this effort to make sure that 
those who have done it their own way for so long don't 
frustrate this process by wanting to continue to do it their 
own way or they know best what way it ought to be done.
    I wish you might comment on that. I know you did last week.
    General Schoomaker. Yes, sir, and I remain personally 
chagrined that an effort to really reach out and ensure that 
the best practices that we were observing, frankly, at Fort 
Drum were proliferated throughout the system--ironically, we 
found a system that was working extremely well and yet it was 
interpreted wrongly.
    I will say, first of all, it's very hard for me to say 
anything ill about the VA. I'm a product. I'm a physician, a 
product of the VA system. I was trained in two VA hospitals 
associated with major universities. This is a great system of 
care. This is a national treasure. They have set the standard 
on good, objective outcomes-based care within the country, and 
I think we're better positioned than we ever have been with 
leaders like Deputy Secretary Mansfield and the new Secretary 
of Defense, my former boss General Peake, and General Kussman 
and others throughout that VA system.
    Our response to what we saw at Fort Drum, sir, was that 
Secretary Peake and Secretary Geren promptly sat down, we 
hammered out an agreement, a memorandum of understanding with 
the VA, and we've put that aside. We now have a formal 
memorandum that empowers VBA counselors at each one of our Army 
MTFs to fully counsel any soldier or family and make it very 
clear that they're part of the solution and that we welcome 
that.
    Senator Ben Nelson. But it does point out that it's an 
ongoing process that you can't measure it simply in terms of 
time. It's a marathon, not a sprint.
    General Schoomaker. Yes, sir. I think your comments earlier 
about the seamlessness and Secretary Chu's comments--I think 
the fact is there are seams in the system. I think the earlier 
comment from the chairman about disability adjudication, which 
for the military is based upon fitness for duty and within the 
VA system is based upon the whole person concept, means that 
you can apply the earlier study to virtually any individual 
problem and you'll find the same issue there.
    We adjudicate disability in the military based upon that 
one major unfitting condition and we turn to the VA and allow 
the VA to take all of those conditions that we all jointly 
recognize are present and adjudicate disability on the basis of 
the whole person. That's a seam that has to be closed.
    Chairman Levin. Thank you, Senator.
    Senator Ben Nelson. Thank you.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Nelson.
    Senator Inhofe.
    Senator Inhofe. Thank you, Mr. Chairman.
    Chairman Levin. Senator Inhofe, I think the vote has either 
started or is about to start.
    Senator Inhofe. How about I go ahead and start and run 
through my time?
    Chairman Levin. Would you turn that over to the next person 
here, and if there's nobody here when you're here just recess 
until I get back?
    Senator Inhofe. Okay, I will do that.
    Chairman Levin. Thank you.
    Senator Inhofe. First of all, General Schoomaker, I 
appreciate what you said and let me just drive it home, because 
as long as I can remember, even back when I was in the United 
States Army, there were complaints about the kind of treatment 
in the VA centers. Then when I was elected here, oh, about 22 
years ago, we had just some real crises. Now, maybe this is 
unique in our State of Oklahoma, but the treatment was not 
good.
    I can't tell you how that's changed. I had a group in my 
office yesterday of the veterans and they just rave about it. I 
have gone to all the centers, including some of the retirement 
centers and others. I don't know what's accounted for it, but 
whatever you're doing, keep doing it that way. It's been great.
    Maybe because I'm the only veteran in the Oklahoma 
delegation, I seem to get more calls and complaints than any of 
the rest of them do. They're in three areas that have been 
addressed somewhat in this meeting and by your committee. One 
is in the disparity between the disability evaluation systems 
that we've had. Senator Levin talked about that. You've 
responded to that.
    The other two are in transition areas that we've been 
talking about with Senator Nelson, that is transition into 
civilian life or into another service of our country. Many of 
these people who become disabled, they want to continue serving 
in this transition. Then the transition, of course, that we 
talked about from DOD to VA.
    Now, I understand, from whoever wants to respond to this, 
that this disparity between the evaluations has been corrected 
now or is in the process of being corrected in terms of 
disability evaluations between the various levels.
    General Schoomaker. Sir, I think that's a recommendation of 
the Dole-Shalala Commission that's going to require legislative 
changes. We can smooth over the bureaucratic steps required 
between the military system of adjudication and the finding of 
fitness for duty and the VA system of adjudication of 
disability, but we currently are not empowered to make this a 
single system without further legislation.
    Senator Inhofe. Are you going to be helping us in drafting 
the legislation?
    General Schoomaker. Oh, absolutely.
    Senator Inhofe. Making recommendations?
    Dr. Chu. Yes, sir, we'd be delighted to. General Schoomaker 
is absolutely correct. Until there is a change in the 
fundamental statute, you will always--even if we each rate each 
condition with the same percentage, which is the first issue, 
which we can deal with and we are dealing with, the Department 
only rules on fitness to serve based on those conditions that 
affect your military career. You may have other conditions.
    Senator Inhofe. In terms of the evaluations, if any of the 
five of you don't believe it's a problem just call our office 
and we can provide you with some cases.
    Now, in terms of the transition into civilian life or other 
government services, any further comments any of you want to 
make about that, because this has been another source of 
complaints?
    Dr. Chu. Sir, one of the things we've done, particularly 
with this conflict, is organize a series of job fairs, 
particularly at medical centers, where we especially emphasize 
the importance of Federal agencies stepping forward, including 
our own, the DOD.
    Senator Inhofe. When did they start? When did you start 
doing that?
    Dr. Chu. About 2 years ago we started these, and we've done 
about a dozen of these altogether. They are intended to both 
bring civil employers as well as government agencies together 
to the military community, not restricted to those who've been 
recently wounded necessarily, but that's the focus. We have 
worked very hard in a proactive way through the Military 
Severely Injured Center to help the newly injured think about 
the possibilities for them, what would make sense from their 
perspective, and how do we link them up with these agencies so 
they can be successful.
    Senator Inhofe. Secretary Mansfield, you touched slightly 
on this, the transition between the DOD and VA. Could you just 
address this electronic transfer of data, and are we making 
progress there?
    Secretary Mansfield. We're definitely making progress, sir. 
We've come further than the JEC had. We're in the process now 
where we can actually exchange information. The issue, though, 
is that we're working in an effort to make it interoperational. 
Right now you can read the information, but you can't 
manipulate it. So we are exchanging information from imaging, 
from clinics, from pharmacy, and from testing. We're further 
along the line, but we still have a long way to go.
    Of course, part of the issue is that you have an Army 
record, a Navy record, and an Air Force record that needs to be 
consolidated, then get access to that through a single data 
access point. We're working on that.
    Senator Inhofe. Secretary Geren, this is more Army 
sensitive than anything else. The chairman talked about some of 
them who were deployed who perhaps should not be deployed. But 
on the other end of that, there are a lot of them who want to 
be deployed who are not. It seems like there is a greater 
problem in the Army. Our 45th out of Oklahoma, that's over 
2,600, they're over there in Iraq right now. I went down to 
Camp Gruber when they were preparing for it and while they--the 
National Guard members--receive TRICARE, they don't have the 
dental benefits. This seems to be where the problem is. I was 
surprised to see this, that the DOD has set a Service-wide goal 
of greater than 75 percent for fully ready to deploy 
servicemembers and greater than 90 percent for partially ready 
servicemembers.
    Currently, five of the seven Reserve components are below 
the 75 percent. Now, I have from your report on page 194 those 
seven and the two that have the great problem are the Army 
National Guard and the Army Reserves. Everybody else, frankly, 
is over the 75 percent. But these are not. These are, in the 
case of the Army National Guard, 45 percent; and the Air Guard, 
51 percent.
    Now, of those, that's just dental only problems. That seems 
to be the greatest problem in terms of having these people not 
ready for a deployment for medical purposes.
    It would seem to me that--and I talked to some of them down 
there at Camp Gruber before they were going--you can't put a 
bridge in or do the root canal; there's not time during this 
transition period. Once they get over in the field of combat, 
they're not going to be able to do those things.
    Now, wouldn't one solution that perhaps you might want to 
consider or you are considering is to somehow have dental 
benefits? There was a time when the Guard and Reserve really 
didn't have these overseas deployments and maybe it wasn't 
necessary then. But it is now, and it seems to be, of the 
medical--again, I'll repeat that--the 38 percent, is 45 percent 
is dental only. So that seems to be the biggest problem.
    What do you think, Pete?
    Secretary Geren. The experience in Oklahoma is not unique. 
The dental issue is something that we are looking at very 
carefully. One of the initiatives that the Chief and I are 
working on is how to do a better job of fully operationalizing 
the Guard and Reserve, and medical preparedness for deployment 
is one of the issues and the dental is always at the top of the 
list.
    So I don't have an answer for you today, but it's something 
that we are looking at.
    Senator Inhofe. If your goal is to reach 75 percent, from 
the figures I have here pulling the dental problem would put 
you at 75 percent.
    Dr. Chu. Senator, I do know that some units in Oklahoma 
have adopted a best practice we'd like to see more of them use, 
which is to use operations and maintenance funds during periods 
of premobilization drill to bring mobile dental vans to the 
unit.
    Prior to mobilization, and the standard that you've 
described is what we want all units to be at all the time, so 
that we don't have to deal with these medical issues post-
mobilization.
    Senator Inhofe. I appreciate that, because I think--and Mr. 
Chairman, during your absence I made comments that you talked 
about how there are some who didn't want to be deployed but 
were found deployable, but there's probably more who want to be 
deployed who for some reason or other can't. Or maybe that's 
unique to Oklahoma, but I sure have heard from a lot of people.
    Dr. Chu. Again, I want to praise those units in Oklahoma 
that use this practice. It is a great solution. It is 
reasonable in terms of its cost.
    Senator Inhofe. Thank you.
    Secretary Geren. Real quickly, Senator, we have a group of 
guardsmen and reservists that advise the Chief and Army 
leadership on Guard and Reserve issues. They meet with us 
regularly, and that has been one of the issues that they've 
been examining and putting together recommendations in that 
area. We recognize that challenge. It is expensive, and there's 
also just some logistical issues associated with it. But we 
recognize the importance of it and are working through it now.
    Senator Inhofe. Thank you.
    Chairman Levin. Thank you, Senator Inhofe.
    Senator Bill Nelson.
    Senator Bill Nelson. Gentlemen, thank you for trying to 
correct this problem and make it right.
    Secretary Chu, has Secretary Gates designated a lead agent 
to implement the TBI-PTSD mental health plan?
    Dr. Chu. Yes, we have our Center for Psychological Health 
and Traumatic Brain Injury. It is the agency that will be 
executing the generous addition to the budget Congress provided 
last year.
    Senator Bill Nelson. The question was has he designated a 
person to implement it?
    Dr. Chu. The commander is now Colonel, soon General, Dr. 
Loree Sutton, Army psychiatrist.
    Senator Bill Nelson. You all know the problem here and 
thank you for trying to correct this problem. We have excellent 
care, for example, for TBI once we can get them into the 
centers, and one of those centers is in my State, in Tampa. The 
problem has been getting them identified and getting them in 
those centers. As the other Senator Nelson pointed out in a 
case in his State of Nebraska, I could point out to you many 
cases in my State of Florida where the military person gets 
lost between being released from DOD and coming into the VA 
health care system. So thank you for working on that.
    Secretary Geren, I want to go over with you what I had 
talked to you on the telephone about. I think it needs to come 
to the attention of the committee: A World War II veteran who 
was wrongly accused and incarcerated, an African American, 
during a POW camp revolt in Italy and in the hysteria is swept 
up and incarcerated for a year. Just this year--so that's some 
60 years later--a review of the records, the DOD realizes that 
it made a mistake. They reversed his dishonorable discharge. 
They made it an honorable discharge, acknowledged that the U.S. 
Army was wrong, and 60 years later returns to him the back pay 
that he would have earned during the 1 year of incarceration, 
$720.
    Now, that's just plain wrong, that someone is denied that 
and is given 1944 dollars without compensation for at least the 
cost of living adjustments, which would only be $8,000 in 
today's dollars.
    Chairman Levin. Senator Nelson, excuse me for interrupting. 
I'm going to run and vote and come back. If no one's here when 
you need to go, just recess.
    Senator Bill Nelson. I'll do that, Mr. Chairman.
    Chairman Levin. Thank you for raising this issue, however.
    Senator Bill Nelson. Yes, sir.
    Chairman Levin. It's of importance to the committee.
    Senator Bill Nelson [presiding]. Of course, I appealed to 
you as Secretary of the Army and then you said you did not have 
the legal authority. I appealed to the Secretary of Defense and 
he said he did not have the legal authority. As a result of 
that, I filed a bill to correct it.
    But it seems to me that under equity and fairness an issue 
that we are addressing here about health care for wounded 
warriors, that under equity and fairness, a warrior has been 
wounded by taking away his most prized possession, which is his 
honor and his liberty, and 60 years later that the U.S. Army 
and the DOD is saying that they don't have somewhere in the 
bowels of the Pentagon the ability through equity and fairness 
to adjust $720 back pay.
    Can you share with me, Mr. Secretary, what you think we 
ought to do to right this wrong?
    Secretary Geren. Yes, sir, I'm glad to. I reacted exactly 
the same way you did when I learned of this. I'd go so far as 
to say it's a travesty of justice. $720 today is nothing 
compared to what that soldier went through and what he 
suffered, and certainly what $720 would buy you in 1944 and 
what it would buy you today, it's no comparison at all.
    When I learned of this I asked our lawyers to figure out 
some way to fix this, some way to address this. They kept 
coming back and saying there's no way to do it. We looked at a 
couple of different ways and, unfortunately, they kept coming 
to the same conclusion, and the OSD lawyers agreed with the 
Army lawyers, that under the current statutory framework we're 
prohibited from deviating from that schedule.
    So I'm glad that you've introduced a bill and I hope 
there's speedy consideration of it so that we can right this 
wrong and try to do what we can to compensate this soldier for 
what he suffered.
    Secretary Mansfield. Senator, if I could raise an issue. If 
he was a dishonorable discharge he would not have been eligible 
for VA benefits back then. So why don't we check it and see if 
there's some way that we can look at that situation now that 
it's been corrected and the VA may be able to assist him.
    Senator Bill Nelson. Okay, Secretary Mansfield, we'll do 
that, and thank you for that suggestion.
    Samuel Snow naturally is getting up there in years. He 
lives in Leesburg, FL. I would pursue this with great vigor 
because this is somebody who has been wronged. But the reason 
I'm bringing it up to you is that again it's another indicator 
of the cold, hard, impersonal rules and regulation on something 
that is obviously wrong. We've seen this in Samuel Snow's case. 
We've seen it in how some of these veterans have been handled. 
We've seen it, for example, in that veteran from Winter Haven, 
FL, that was lost in the system, the military discharged him, 
had no indication that he had TBI because they didn't ask, they 
didn't probe. So he's out there on his own, and he knows 
something's wrong, and he goes and gets an appointment after 
waiting, over at one of the VA hospitals at Bay Pines. Then he 
finally gets there after waiting a couple of months and then 
they say: Well, we can't handle this; you have to go to the 
Tampa Haley Hospital, and of course, that's another waiting 
period.
    Somehow, this veteran knew to call me. Of course, the 
minute we found out what happened he had appointments in the 
Haley Hospital in the TBI center the next day.
    There's something cold and hard and impersonal that we have 
to break through not only the subject of this hearing, on 
wounded warriors, but on the treatment of people like Samuel 
Snow 60 years ago, that his country didn't treat him right and 
60 years later is giving him a check and saying, go away. It's 
wrong. It ought to be corrected.
    Secretary Mansfield. Sir, I would tell you that we've been 
working hard to correct that. I would agree with you that it's 
wrong. We, as I stated in my opening statement, need to ensure 
that each one of these individuals that steps up, raises their 
right hand, puts themselves in a position to defend this 
country and puts themselves at risk, deserves timely access to 
every benefit that this Nation has promised them. We're working 
together as hard as we can to make that happen.
    I would make the point, in regard to the person you 
mentioned, with that situation and others, we have changed the 
rules and regulations to make sure that people with these 
issues get taken in sooner and quicker and are seen.
    I would tell you also that everybody that comes to us is 
screened for TBI and PTSD, and we're working with DOD on 
follow-up issues to do that.
    But I would agree with you, sir: You have two of the 
biggest bureaucracies in the world that need a little shaking 
to make sure that they know that they're dealing with people.
    Dr. Chu. Sir, let me also emphasize, as you and Secretary 
Geren agreed, ultimately the issue with Mr. Snow is statutory. 
If Congress were willing to give the Secretary of Defense 
discretion in cases like this, as it has given him discretion 
in waiving repayments, which we have used extensively, we would 
be able to avoid the situation.
    But it is ultimately not a rule or regulation in the Snow 
case; it is the law, and we are stuck.
    Senator Bill Nelson. If it is the law, we will change it.
    Dr. Chu. My plea, sir, is for broad discretion as opposed 
to the rifle shot, because then you can deal with the 
unanticipated situation just as you have advocated, and we 
would like to be in that position.
    Senator Bill Nelson. Now, it's hard for me to believe that 
the DOD in the enormity of its resources and rules and 
regulations, that there is not discretion somewhere to correct 
this wrong. As Secretary Mansfield has said already, there's 
another avenue we might explore with regard to maybe he hasn't 
been advised of veterans benefits that would be available to 
him since he had been wrongly, dishonorably discharged, and we 
will pursue that. I wonder why we had to come to a United 
States Senate hearing to get to that.
    But in the mean time, since I have to recess this hearing 
so that I can go vote, I wish you in the recess would confer 
with your assistants and see if there might be any other little 
angle that we haven't figured out.
    Secretary Geren. Sir, I can assure you we have pushed this 
within our legal system as hard as we can. I know you get two 
lawyers together, you get two opinions, but unfortunately we 
continue to run into the same statutory interpretation. If 
someone could help us see it differently, we'd be glad. I can 
assure you we all feel the same about that case and want to 
help, and appreciate your advocacy and your interest in 
addressing it statutorily. We believe that's where we are, and 
we sent it back and sent it back and sent it back and kept 
getting the same answer. We want to see it fixed as well.
    Senator Bill Nelson. The committee will stand in recess 
subject to the call of the Chair. [Recessed.]
    Chairman Levin [presiding]. The committee will come back to 
order. Yes?
    Secretary Mansfield. Could I have the privilege of 
speaking, please?
    Chairman Levin. Sure, Secretary Mansfield.
    Secretary Mansfield. Sir, in reference to the last 
discussion about the individual wronged and the ability to deal 
with that and the need for legislation, I would refer you to 
Title 38 U.S. Code 503: ``Administrative error, equitable 
relief. If the Secretary determines that benefits administered 
by the Department have not been provided by reason of 
administrative error on the part of the Federal Government or 
any of its employees, the Secretary may provide such relief on 
account of such error as the Secretary determines equitable, 
including the payment of moneys to any person whom the 
Secretary determines is equitably entitled to such monies.''
    That's what the DOD needs. That's the VA section and I 
think that's what DOD needs. It would allow us to go back and 
look at the situation by virtue of the fact that, with that 
dishonorable discharge, he was not eligible for a lot of VA 
benefits and we could not make an adjustment based on that.
    Chairman Levin. Does the mistake have to have been made 
under that law by the VA?
    Secretary Mansfield. No, sir. It says ``on the part of the 
Federal Government or any of its employees.'' ``The Federal 
Government.''
    Chairman Levin. So if there was a mistake made, which there 
seems to have been, by the DOD, the VA can act now under 
existing law?
    Secretary Mansfield. Yes, sir, for VA benefits.
    Chairman Levin. For VA benefits. That's part of the deal, 
as I understand it.
    Secretary Mansfield. That would be one way to make him 
whole, to look at what he would have been eligible for: home 
loan or education or compensation.
    Chairman Levin. I'm sure Senator Nelson will pursue that. 
But what you're doing is opening up the avenue that, even 
though you don't think the DOD has that power--we'll check that 
in a second--the VA has power if there's a mistake made by any 
governmental agency that affected the benefits of the VA, that 
you may not be able to make that soldier whole, but you'll be 
able at least to take care of the VA part of doing it under 
that law.
    I'm sure Senator Nelson, I assume he's aware of that and 
will pursue that. But if not, thank you for bringing that to 
our attention.
    Secretary Mansfield. We'll notify him. But DOD needs 
legislation.
    Chairman Levin. Let me follow that up now. Do you know, 
Secretary Chu, if DOD has that same power?
    Dr. Chu. I don't believe so, sir, but obviously we'd want 
to doublecheck.
    Chairman Levin. We'll raise it in the National Defense 
Authorization bill this year, then. There's no reason why the 
DOD should not have the same power that VA has to correct 
mistakes. So my staff I know is following this and we will 
pursue that, unless, Secretary Geren, do you know whether the 
DOD has that power?
    Secretary Geren. We looked as hard as we could to figure 
out a way to address this situation and Army--we looked at it, 
looked at everything that we had that was discretionary. We 
could not find a way for it to fit. We went to OSD's lawyers to 
see if there would be a way to do it at the OSD level. They 
could not find a way. We kept coming to the same conclusion, 
that there was a statutory block that kept us from doing it, 
and we certainly would support an effort to provide the 
flexibility to redress it.
    Chairman Levin. Secretary Mansfield, thank you for bringing 
that to our attention.
    Secretary Mansfield. Thank my excellent staff here, sir.
    Chairman Levin. We thank your excellent staff. We 
appreciate that. We all rely on our staff, more than we like to 
admit.
    There's nobody here who hasn't had a first round, so let me 
start a second round here. The Senior Oversight Committee has 
been working diligently on a number of these issues, as we've 
heard here this morning and were aware of even before this 
morning. But the question is whether or not the issues that we 
are discussing will remain a priority over time, talking about 
transitions and seamless transitions, since there will be a 
change of administrations in January. What steps are you taking 
to ensure that these issues will remain a priority during the 
transition period from this administration to the next?
    Secretary Chu, why don't I ask you first and then Secretary 
Mansfield.
    Dr. Chu. We are planning to use--and Secretary Mansfield 
and I have already begun discussing that issue--the now 
statutorily chartered JEC, which is a similar partnership 
between DOD and VA, to make sure that there is no backsliding, 
no ground lost, no lessening of commitment to these 
initiatives. We are determined to see them through past the 
transition using that already existing mechanism.
    I think it's already produced, as Secretary Mansfield 
indicated, important successes in other areas. I point to North 
Chicago as a prime example of that agenda succeeding, and I'm 
confident it can carry forward into the next administration.
    Chairman Levin. Secretary Mansfield?
    Secretary Mansfield. Sir, one point I would make is that 
everything that we've discussed that we're putting into action 
are becoming VA directives that will be on the books as we 
leave. The other point I would make is in the course of a 
transition there is normally a discussion with the incoming and 
the outgoing of the highlights of what the outgoing 
administration looks at and wants to put in--give their 
attention to the folks coming in, I'm sure would be a part of 
this effort.
    Chairman Levin. Is there a permanent structure, a joint 
structure that's now in place, to evaluate these changes that 
we've talked about and to monitor systems and to make further 
recommendations for process improvement? Is there that 
structure and if so what is it?
    Secretary Mansfield. Sir, I would say that, again, the 
statutorily mandated JEC with its benefits subgroup and its 
health care subgroup have been working for 5 years now, in an 
effort to put processes in place that we can measure what is 
required and be able to make a decision at the end of each year 
what we've done, what we need to do.
    Chairman Levin. Now, who are the members of the JEC?
    Secretary Mansfield. Currently it's myself and Dr. Chu. 
Secretary Chao from Labor has asked us to include a member from 
the Veterans Employment and Training Service, which is 
responsible for veterans employment, and we've agreed to bring 
somebody from there on board. Then, in the benefits arena, you 
have the Under Secretary for Benefits from the VA and the 
equivalent OSD and DOD folks. In the health arena you have the 
Under Secretary for Veterans Health and the equivalent folks 
from the Services in DOD.
    Chairman Levin. Now, you two are political appointees.
    Secretary Mansfield. Yes, sir.
    Chairman Levin. Those under secretaries--are they political 
appointees as well?
    Dr. Chu. They are political appointees.
    Secretary Mansfield. Yes.
    Dr. Chu. But the council, the JEC, is, thanks to your 
efforts, a statutory body. So whoever succeeds, either acting 
for or confirmed by the Senate, will succeed to that 
responsibility. The career staff understands that this agenda 
has to go forward using this mechanism.
    Secretary Mansfield. Under secretaries in the VA are 
political appointees.
    Chairman Levin. Would you make sure that the career staff 
not just tells your successors, assuming that you're not 
reappointed, about this, but that somehow or other, can they be 
acting during a period that there is a gap?
    Secretary Mansfield. Sir, the career staff, the leading 
senior career staff in each agency, are heavily involved in 
this and understand very well the need for them to be included.
    Chairman Levin. Are they authorized to meet during a 
transition period without you?
    Secretary Mansfield. As part of the JEC?
    Chairman Levin. Yes.
    Dr. Chu. I see no reason why they could not. I don't want 
to get in the general counsel's way here on the Vacancies Act 
issue, but I see no reason that those performing the duties of 
these officials, which would be the last resort, could not in 
fact convene a meeting.
    Chairman Levin. Will you let us know whether that can 
happen?
    Dr. Chu. I will do that, sir.
    Chairman Levin. If it can't happen, let us know what would 
be required to make that happen legislatively?
    Secretary Mansfield. We will provide that information, sir.
    Chairman Levin. That would be great. Thank you.
    Secretary Geren, last week you announced a program called 
the Wounded Warrior Education Initiative. Could you tell us 
what that's about?
    Secretary Geren. Yes, sir. We announced it at Leavenworth, 
KS. In September, the chancellor of the University of Kansas 
came to meet with me and with Dr. Gates to propose an 
initiative where Leavenworth would partner with Kansas 
University in developing a graduate degree program for wounded 
warriors, for specifically wounded warriors. It's a program 
where the wounded warriors would either stay on Active Duty or, 
if they have left Active Duty, be supported in some type of an 
internship role, attend a 2 years master's program at Kansas 
University, then return to the military and serve in either a 
teaching capacity or a support capacity at our colleges at 
Leavenworth.
    It is a very innovative program, and we were able to work 
with Kansas over a period of just several months and pull it 
together, and last week we announced that we have eight 
soldiers accepted into the program; we hope to build on it. I 
think it's a model that could be used elsewhere.
    Chairman Levin. Yes, if it works I assume you will expand 
it.
    Secretary Geren. Yes, sir.
    Chairman Levin. Now, some have proposed giving veterans a 
plastic card that they could take to any health care provider 
to pay for their health care. Can you give us your view on that 
proposal, Secretary Mansfield?
    Secretary Mansfield. I don't think it's a good idea.
    Chairman Levin. Why is that?
    Secretary Mansfield. The VA is set up to be able to be the 
primary care provider for the individuals in the system and 
keep track of what their needs are and follow them throughout 
the system. Part of what you're looking at is taking us away 
from that, where we wouldn't know what's going on with the 
care, what the quality is, what they need, what they don't 
need.
    The other part of it is it would make us in effect a 
insurer, a Medicare-type payor for the system, and I don't know 
what kind of a requirement we would have for the back office, 
that we'd have to replicate the Medicare system to get the 
bills; figure out what the bills are; whether they were 
reasonable or not; whether the treatment was reasonable; and 
then make a payment.
    Chairman Levin. Do veterans groups generally favor this 
kind of approach, do you know, or not?
    Secretary Mansfield. I don't think they do favor it, sir. I 
think they would look at it as starting to unravel the VA. As 
was mentioned here earlier, we now have reached a point where 
we are regarded as providing pretty good care and taking pretty 
good care of these individuals that are in our system.
    Chairman Levin. One of you mentioned the electronic health 
record system which we're trying to develop between the two 
entities. I've forgotten, was it Dr. Chu? Were you doing it? 
You made that reference? What's the timetable for that?
    Dr. Chu. Sir, we anticipate by the end of this year having 
all existing electronic information interchangeable--viewable, 
as I understand the computer community phrase it--between the 
two institutions, so if you are a VA doctor you can see the DOD 
record and vice versa. We already have the pharmacy data at 
that stage. We have the laboratory data to that stage, the 
first discharge summaries to that stage, et cetera.
    It's a very significant project. It's been ongoing for a 
number of years. The recent Senior Oversight Committee effort 
has given extra energy to it and I think we'll get to that goal 
by the end of this year.
    It doesn't necessarily make the data, as the computer 
community would phrase it, computable. In other words, you 
can't manipulate it inside the program. I can look at it. For 
that, eventually what we need to do is have a common electronic 
health record between the two Cabinet agencies, and we are 
committed to doing that. That is a multi-year project. That's 
not going to be overnight. It allows us to replace our aging 
existing inpatient electronic records.
    We do have in DOD a worldwide, essentially web-based, 
although that's not actually the vehicle used; it's on servers 
that we control, the outpatient electronic record now, which is 
part of what we're making available to the VA physicians for 
outpatient treatment. But we need to modernize our inpatient 
software, replace it basically. The VA eventually will have the 
same need. So we are committed jointly. The first exploratory 
effort has begun getting to that common, essentially identical, 
electronic health record for the future. But that is a multi-
year project.
    Chairman Levin. If it's an identical record, then each 
agency would be able to add to that record?
    Dr. Chu. Exactly.
    Chairman Levin. Manipulate the information.
    Dr. Chu. Manipulate the information, and DOD's ambition is 
to mirror for that what we can now already for ourselves do for 
outpatients, which is wherever you are, at least in theory, I 
can call up what's been done to you as an outpatient, on an 
outpatient basis. That's important because our people move 
around the world so much. So we don't want something that's 
site specific in character. These data are now on servers that 
allow worldwide access.
    Chairman Levin. Did we require that by law?
    Dr. Chu. You required in statute that we make it 
interoperable.
    Chairman Levin. But not the second step?
    Dr. Chu. Not the second step. It's a multi-year project. We 
will be coming to you in this and future budgets.
    Chairman Levin. But we haven't already mandated it?
    Dr. Chu. I don't believe so, sir.
    Chairman Levin. You and I both used the word ``manipulate'' 
and I think we have to find a different verb.
    Dr. Chu. Yes, sir. They like to say ``computable.''
    Chairman Levin. Yes. I shouldn't use that word because some 
people would understand that to be a pejorative word, that we 
are somehow or another manipulating data for some nefarious 
purpose.
    Dr. Chu. No nefarious purpose intended.
    Chairman Levin. No, no. I used the word, too. But I don't 
know what the new verb is. ``Computable,'' is that it?
    Dr. Chu. ``Computable'' is my understanding.
    Chairman Levin. Make it computable.
    Okay. I think Senator Chambliss, yes, Senator Chambliss, 
you are next.
    Senator Chambliss. Thank you very much, Mr. Chairman.
    Gentlemen, thank you, first of all for being here, and for 
your excellent testimony this morning. But thank you for what 
you do. Thank you for being concerned about our brave men and 
women who wear the uniform.
    Also please convey our thoughts and prayers to the 
Secretary. Gee, Pete--what did you do to him over there? Rough 
morning at the Pentagon. Actually, it was pretty slippery in my 
neighborhood, too. Tell him we're thinking about him.
    Let me thank all of you for your efforts over the last year 
to improve health care and transition programs for our wounded 
warriors. I've personally seen how the WTUs and our health care 
professionals have made great strides in caring for and 
treating our wounded servicemembers. I have been to both Fort 
Gordon and Fort Benning, where I've seen firsthand what is 
happening with respect to our men and women who are coming back 
with injuries.
    We are doing a great job of helping them reintegrate into 
the military and the community, and I appreciate the hard work 
each of you has done to get us to this point.
    I note in Secretary England's statement that he focuses on 
the recovery coordination program. This program is designed to 
identify and integrate care and services for wounded 
servicemembers, veterans, and their families. Establishing 
recovery coordinators to serve as the patient and family single 
point of contact during their recovery and transition period 
was discussed in the number one recommendation of the Dole-
Shalala Commission, and I'm pleased to see that the Department 
is taking steps to implement this very important 
recommendation.
    Training for the recovery coordinators is obviously very 
important if they are going to perform their jobs effectively. 
Augusta, GA, has developed a very unique collaboration in the 
area of wounded warrior care. The City of Augusta is home to 
the Eisenhower Medical Center at Fort Gordon, formerly operated 
under the great leadership of General Schoomaker. We miss you 
there, but your successor General Bradshaw is certainly doing a 
great job.
    What I am going to talk about here and ask you about is 
something that began under your leadership, and we thank you 
for your continued attention to the care for our wounded 
warriors.
    It is also home to the Charlie Norwood VA Medical Center 
and the Medical College of Georgia, particularly the school of 
nursing. These three institutions are already collaborating in 
the treatment of wounded warriors and the Charlie Norwood VA 
Center hosts the only Active Duty rehab facility for military 
personnel in a VA medical center. The Medical College of 
Georgia School of Nursing has an existing program for training 
and certifying clinical nurse leaders. These clinical nurse 
leaders are basically the civilian equivalent of DOD's wounded 
warrior recovery coordinators and perform many of the same 
tasks.
    As a means of extending the collaboration and treatment of 
wounded warriors in the Augusta area, the Medical College of 
Georgia School of Nursing has proposed a short certificate 
program which would take advantage of classes and faculty 
already available in their clinical nurse leader program to 
help train and certify DOD's recovery coordinators. I 
understand from the statements of several of you that DOD is 
conducting some training, including web-based training, for 
your recovery coordinators. But I'm wondering if you would 
consider taking advantage of this proposal that the Medical 
College of Georgia is offering, to determine if it could be an 
effective means of helping to train your recovery coordinators 
and if it would provide a value-added addition to the 
Department's establishment of a wounded warrior recovery 
program.
    I'll direct that to whoever wants to respond first, but Dr. 
Chu, Mr. Secretary.
    Dr. Chu. Yes, sir. We always value new ideas. We'd be 
delighted to look at this one.
    Secretary Mansfield. Sir, I would add that it's interesting 
you mentioned Fort Gordon, because we have at the present time 
a program with VA and DOD that goes back I think to 2004, where 
the VA is actually doing rehab for Active Duty soldiers down 
there. So that cooperative effort is already in place down 
there, and we can look at going forward and, as Dr. Chu 
mentioned, doing something new and better.
    Senator Chambliss. Anyone else have a comment? [No 
response.]
    I know that the personnel at the Medical College of Georgia 
School of Nursing would be willing to modify their proposal in 
order to meet any specific training requirements, as well as 
the necessary timeframe that DOD might require for training 
their recovery coordinators, and whatever will be helpful to 
the Department and the college from a discussion standpoint. 
These folks are ready and willing to offer any services 
necessary.
    General Schoomaker, you know firsthand the great job that 
Dr. Romm and the folks over at the Medical College do, as well 
as the folks at the VA Medical Center. I've had the pleasure of 
visiting many of our patients there at the VA Center over the 
last several years. The work that we are doing, particularly 
with our severely injured soldiers, is truly amazing there. 
Thanks again, General Schoomaker, for your leadership and role 
at Eisenhower in establishing it as certainly the premier in my 
opinion recovery unit for our wounded warriors out there.
    General Schoomaker. Thank you, sir. Frankly, I get the 
credit for the terrific work of a team at the Augusta VA 
Medical Center and at Eisenhower. We had a very farsighted 
group in both communities who recognized very early in the war 
the nature of the injuries that our soldiers, sailors, airmen, 
and marines were suffering. The long experience that the 
Augusta VA Medical Center and many VAs throughout the system 
have in rehabilitative medicine, especially with blind and deaf 
and TBI and PTSD, which Secretary Mansfield has talked about 
already, I think was resident within those communities, and 
they reached out to us, just as we reached to them, and we 
continue to have a very collegial and cooperative relationship.
    It's important to note that this was built on a 
relationship of cooperative agreements that go back in 
neurosurgery, that go back in cardiothoracic surgery between 
the two organizations, which set the framework for what you 
have there today.
    We really truly appreciate the support that you have given 
to this, that Senator Isakson has given, that Congressman 
Norwood, the late Charlie Norwood, gave to it, and now 
Congressman Broun gives to it.
    Senator Inhofe said something earlier that I think is very 
important and that is that his own--the revelation, the 
epiphany that he has experienced in going back into the VA 
system and seeing that this is such a high quality system. That 
insight, frankly, is one that all of our soldiers and their 
families need to recognize. Relationships such as we have at 
the Augusta VA Medical Center, but all our polytrauma units, if 
you've been to see them, tell us every day as well--it allows 
our soldiers and families, even if they come back into uniform, 
fully recovered and rehabilitated, it gives them an insight 
into what the VA medical system provides for them and much 
greater confidence through working knowledge of the VA. So 
these kinds of relationships are just absolutely fundamental.
    Thank you, sir.
    Senator Chambliss. Thank you, Mr. Chairman.
    Chairman Levin. Senator Chambliss, thank you.
    Senator Warner.
    Senator Warner. Thank you, Mr. Chairman.
    The Army really has on its own initiative established this 
warrior transition brigade. As I understand it, this fine 
officer was introduced as the brigade commander, is that 
correct?
    General Schoomaker. Yes, sir. He's the first brigade 
commander for the WTU. Colonel McKendrick is the commander of 
the only brigade within the WTUs. We have 34 other WTUs at the 
battalion and company level.
    Senator Warner. They're staffed accordingly to the need in 
that geographic jurisdiction?
    General Schoomaker. Exactly, sir, on a standard Army 
document that provides staff in accordance with the number of 
patients and the severity of patients.
    Senator Warner. Then, General, do you find it desirable if 
Congress were to recognize this in legislation at all? Or do 
you prefer to just leave it as it is right now?
    General Schoomaker. I guess, sir, I need a little 
clarification as to how Congress wants to recognize it.
    Senator Warner. Well, now, wait a minute. I'm not 
suggesting that Congress move in. This is an Army initiative.
    General Schoomaker. Yes, sir.
    Senator Warner. It's working. You may not need anything in 
there by Congress. But every now and then organizations need a 
little structural recognition in the law to stay alive after 
passage of time and other priorities begin to encroach on Army 
needs and so forth.
    General Schoomaker. Yes, sir. I believe in the National 
Defense Authorization Act for Fiscal Year 2008 you gave us the 
right structure and the right imperative, without giving us 
such directive ratios of soldiers and patients, that we have 
the latitude to really make the judgments that we need to make, 
sir.
    Senator Warner. Now, what about your staffing? Are you 
looking for volunteers to take this on? Is it career-enhancing? 
As you well know, that has to be somewhere in the residual 
recesses of every Army mind as he or she is moving up: Is this 
assignment going to help me move on to my next goal in the 
Army?
    General Schoomaker. Yes, sir. What we have done is, first 
of all we have codified the units in Army doctrine so that they 
have all of the necessary administrative tools to have an 
enduring presence within the Army. We have funded them. The 
Army has stepped forward very aggressively and put manpower 
against them. Despite a war and the challenges of deploying 
soldiers, they have placed 2,500 soldiers against them and 
these are not traditional medics.
    What we see happening is that these positions represent for 
the cadre that fill those roles an opportunity for them to take 
a knee from constant deployment or recruiting duties or 
training duties and other things. We've also put special pays 
in for the NCO leadership. These are all signs that these are 
important jobs for the Army, and I think the visibility it's 
given for the senior Army leadership and the emphasis that the 
Chief of Staff and the Secretary have given to this I think are 
all signs of the importance.
    Senator Warner. What about Reserve and Guard members? They 
will be on equal par?
    General Schoomaker. They are, sir.
    Senator Warner. Do you have a quota for so many regular 
Army and so many who are Army reservists and so forth?
    General Schoomaker. Absolutely, sir, to mirror the 
composition of the WTUs, so guardsmen and reservists are also 
present there, especially because of the special needs of the 
Guard and Reserve with respect to administrative and pay and 
travel issues and the like.
    Senator Warner. Let's go back to the family support, the 
parents, the spouses, and so forth. Do they have access to this 
organization to help get support?
    General Schoomaker. Oh, yes, sir. Of course, the Army 
family is one of the cornerstones of the Army. We feel very 
strongly about the need to support our families. We have 
created Soldier and Family Assistance Centers at every one of 
our sites.
    Senator Warner. But is this brigade also part of that 
infrastructure that the families can access?
    General Schoomaker. Oh, absolutely, sir.
    Senator Warner. The wife, parent, can walk right in and 
say, look, my soldier husband or son is just not able to get 
here today; I want to try to get this for him, and so forth?
    General Schoomaker. Yes, sir. The nurse case managers that 
are providing administrative oversight of the needs of that 
soldier I think also provide ingress for that.
    Have I depicted that correctly there?
    Secretary Geren. Yes, sir.
    Senator Warner. You're satisfied that the budget and 
everything else is adequate to help the family members as they 
try to continue their roles of support for their spouses or 
sons as the case may be?
    General Schoomaker. Yes, sir. As we've identified 
challenges to these families to travel, for example, or to be 
there, be present and provide support for a wounded son or 
daughter or husband or wife, even non-marriage, non-medical 
attendance, we have reached out to them and have found the 
necessary funds to support their travel and presence.
    Senator Warner. To our distinguished Secretary of Veterans 
Affairs, indeed I look back over your personal record of 
achievements. You've certainly served this Nation well. Thank 
you for continuing, Secretary Mansfield, in your role today.
    Secretary Mansfield. Thank you.
    Senator Warner. Have we covered here this morning--some of 
us in the course of votes missed some testimony--the disability 
rating for servicemembers, the pilot program? Have you 
testified about that this morning?
    Secretary Mansfield. We talked about it generally, sir. The 
pilot started. It's up and running. We've had the first case 
run through the system. It'll be running until November and 
we'll be taking periodic looks at it.
    Senator Warner. So that the record this morning has 
adequate testimony with regard to that very important program?
    Secretary Mansfield. I believe so, sir.
    Dr. Chu. Yes, sir, I agree.
    Senator Warner. Thank you very much.
    How about the improvements in the DOD disability evaluation 
system? Have we covered that adequately this morning?
    Dr. Chu. Yes. That's part and parcel of the same effort.
    Senator Warner. All right. Mr. Chairman, I think you've 
conducted a very good hearing this morning. I have seen part of 
it.
    Secretary Geren. Mr. Chairman, could I just make one point 
in response to Senator Warner?
    Chairman Levin. Please, Secretary Geren.
    Secretary Geren. When the legislation was being developed 
for the Wounded Warrior Act there were those, many of them who 
were in the other body, that did advocate a fairly prescriptive 
approach to setting ratios and using statutes to set up these 
WTUs or systems to meet the needs of wounded warriors. We 
worked with this committee and you gave us the kind of 
flexibility that we felt was very important for us to be able 
to shape these units so that they were able to adjust to the 
dynamic situation that they're asked to work in. We appreciate 
very much how this committee worked with us and provided us 
that kind of flexibility.
    We think that's one of the success stories in this 
legislation that you passed--it gives these Army leaders the 
opportunity to be somewhat entrepreneurial. They did create 
this in a very short time out of whole cloth, a totally 
different approach, and they continue to adjust it. They 
continue to make improvements.
    General Schoomaker talked about this task force that he's 
heading up to look at how we start accommodating the needs of 
some of these soldiers who are particularly vulnerable, that 
have all been brought together in these WTUs. He will continue 
to fine-tune this, as well as General Tucker and the others 
that are working in the area. So the flexibility that you gave 
us, I think, is very important as we shape this over the coming 
years, and we appreciate very much how you've given these great 
Army leaders the opportunity to be entrepreneurial, to do 
something that has not been done before. It's a work in 
progress today, great progress, but a work in progress.
    Senator Warner. The group of Army veterans--actually 
they're Active Duty--is almost 10,000; is that correct?
    Secretary Geren. Yes, sir. In the WTUs?
    Senator Warner. Yes.
    Secretary Geren. That's Active, Guard, and Reserve, but 
they're all currently on Active Duty. It's about 9,600 right 
now.
    Senator Warner. These, they go all the way from where 
they're still getting treatment to this transition group, 
trying to integrate them back into the U.S. Army and find an 
MOS and a responsibility that they can fulfill the Army 
commensurate with such limitations as they might have as a 
consequence of their wounds; is that correct?
    Secretary Geren. Yes, both to give them the opportunity and 
prepare them to return to duty or, if they're going to 
transition to civilian life, to make sure that they are well-
equipped to be productive citizens and anything we can do to 
prepare them for that.
    Senator Warner. A number of these are accessing health care 
both within the regular Army and accessing it within the 
veterans organization; is that correct?
    Secretary Mansfield. That's correct, sir.
    Senator Warner. You've worked out a system where that can 
be done.
    These are really dramatic changes, Mr. Chairman, in the 
small period of a year's time. You're to be commended, each and 
every one of you.
    Dr. Chu, in the old Navy we used to get a red hash mark for 
every couple of years of service. How many years of service 
have you been coming before this committee?
    Dr. Chu. If I include my prior service, with my break in 
service here, it's getting close to 20 years.
    Senator Warner. 20 years.
    Chairman Levin. How many Purple Hearts have you been 
awarded--[Laughter.]
    Senator Warner. For wounds inflicted by Congress. 
[Laughter.]
    Chairman Levin. I hadn't finished the sentence, but he got 
it.
    Senator Warner. That's quite a record, Dr. Chu.
    Dr. Chu. Thank you, sir.
    Senator Warner. That's quite a record.
    Give your Secretary our best. Tell him you stood in very 
well for both the Deputy and Secretary Gates. All of us went 
home on that ice last night. It's an experience. It could 
happen to anybody.
    Chairman Levin. Give our best to Secretary Gates. Tell 
Secretary England we didn't miss him, you did fine. That will 
make his day, I'm sure.
    Secretary Geren, you made reference to flexibility. We did 
work with you very closely to give you flexibility and I think 
you and the others understand that that flexibility goes to how 
you accomplish the requirements, not whether the goal is 
achieved. I think it was the right thing to do and we're more 
than happy to work with you, because we think you and the other 
witnesses and the Department are as determined as we are to get 
these changes made. So that's what we're relying on. That's 
what our troops are relying on, and their families.
    We thank you for your testimony. We thank the soldiers for 
their service, for coming here this morning, and their families 
for the kind of support that they give, which is so essential 
to these programs working.
    With that, we will stand adjourned.
    [Questions for the record with answers supplied follow:]

             Questions Submitted by Senator Robert C. Byrd

                      MEDICAL TREATMENT FACILITIES

    1. Senator Byrd. Secretary Chu, Public Law 110-28 requires the 
Department of Defense (DOD) to inspect and develop standards for 
medical treatment facilities (MTFs), and for medical hold and medical 
holdover personnel housing. Secretary England's prepared testimony 
suggests that these standards were developed and the facilities were 
inspected. When can Congress expect to see a copy of the standards 
developed by the DOD?
    Dr. Chu. The Department already maintains standards for MTFs, and 
established standards for medical hold/holdover housing in September 
2007. The inspections are complete, and the first Department 
consolidated summary inspection report, which includes a summary of the 
DOD standards for MTFs and medical hold/holdover housing, will soon be 
transmitted.

    2. Senator Byrd. Secretary Chu, the same legislation required that 
not later than 180 days after the date of the enactment, which was May 
25, 2007, and annually thereafter, the Secretary of Defense shall 
inspect each facility of the DOD as follows: Each military MTF; each 
military quarters housing medical hold personnel; and each military 
quarters housing medical holdover personnel. Secretary England's 
prepared testimony states that each facility already has been 
inspected. Has each facility been inspected to the standards developed 
by the DOD?
    Dr. Chu. Yes. Each of the military Services has completed its 
inspections to the DOD standards.

    3. Senator Byrd. Secretary Chu, were deficiencies noted during 
these inspections?
    Dr. Chu. Due to a substantial commitment of resources over the last 
year, urgent deficiencies have been corrected; and the inspections 
found that all MTFs providing care to wounded servicemembers and 
quarters housing medical hold and medical holdover personnel meet the 
DOD standards for maintenance and operation.

    4. Senator Byrd. Secretary Chu, what were the principal types of 
deficiencies noted?
    Dr. Chu. The primary type of deficiencies noted and corrected 
concerned accessibility requirements.

    5. Senator Byrd. Secretary Chu, when can we expect to begin seeing 
these reports as required by the law?
    Dr. Chu. The DOD's first consolidated summary inspection will soon 
be transmitted.

    6. Senator Byrd. Secretary Chu, given the deficiencies reported 
last year, has the cost of correcting deficiencies identified during 
the standards inspections been included in the fiscal year 2009 DOD 
budget request?
    Dr. Chu. With regard to housing for medical hold and holdover 
personnel, the correction of urgent deficiencies has been funded with 
the fiscal year 2007 and fiscal year 2008 operations and maintenance 
(O&M) appropriations. However, the military Services consider much of 
the current housing for medical hold and holdover personnel to be an 
interim solution. Accordingly, the President's fiscal year 2008 
military construction budget request included two new wounded 
servicemember barracks for the Marine Corps at Camp Pendleton, CA, and 
Camp Lejeune, NC. The Department is grateful for congressional support 
and approval of these important projects. The President's fiscal year 
2008 global war on terror military construction budget request included 
seven Army Medical Action Plan (AMAP) projects, two of which had 
Warrior in Transition (WT) barracks: Fort Riley, KS, and Fort Drum, NY. 
The Department is assessing the need for additional AMAP military 
construction projects in future budget requests.
    Regarding MTFs, the correction of urgent deficiencies has been 
funded with fiscal year 2007 and fiscal year 2008 O&M appropriations. 
The inspections did not include a comprehensive assessment of the aging 
environments at these MTFs and how they compare to those of civilian 
world class facilities. The Department is assessing the need for 
additional medical military construction projects in future budget 
requests to provide world class healing environments in a new era of 
health facilities that improve clinical outcomes, patient and staff 
safety, and operational efficiencies. The President's fiscal year 2008 
global war on terror budget request did include funding to accelerate 
construction and enhance clinical capabilities in support of our 
wounded servicemembers at the new Walter Reed National Military Medical 
Center, Bethesda, MD, and new Fort Belvoir Community Hospital, VA. It 
also included a Burn Rehabilitation Center project for our wounded 
servicemembers at the new San Antonio Military Medical Center, TX.

    7. Senator Byrd. Secretary Chu, in the development of standards for 
the maintenance and operation of military medical facilities, Congress 
intended to ensure that military medical facilities meet generally 
acceptable standards for the maintenance and operation of such 
facilities or quarters, as the case may be; and, where appropriate, 
standards under the Americans with Disabilities Act of 1990; and that 
they be developed at the earliest date practicable to ensure that our 
service men and women receive the care they have earned.
    Please explain the nature of concrete progress made in meeting 
these requirements, and, again, when can Congress begin to see the 
routine flow of reports from the medical services of the DOD detailing 
deficiencies as well as steps that the DOD is taking to correct them?
    Dr. Chu. The DOD already maintains standards for MTFs, and DOD 
established standards for medical hold/holdover housing in September 
2007. The inspections are complete, and the Department's first 
consolidated summary inspection report, which includes a summary of DOD 
standards for MTFs and medical hold/holdover housing, will be submitted 
to Congress shortly.
    The Department made a substantial commitment of resources over the 
last year to correct urgent deficiencies (mostly to meet accessibility 
requirements). The inspections found that all MTFs providing care to 
wounded servicemembers, and quarters housing medical hold and medical 
holdover personnel meet DOD standards for maintenance and operation. If 
further inspections reveal any major deficiencies, the reports will be 
submitted in accordance with the National Defense Authorization Act for 
Fiscal Year 2008 (Public Law 110-181), sections 1648 and 1662.
                                 ______
                                 
           Questions Submitted by Senator Joseph I. Lieberman

                      BEHAVIORAL HEALTH PROVIDERS

    8. Senator Lieberman. Secretary Geren, the shortage of behavioral 
health care providers in the United States is well-documented, in both 
the military and civilian sectors. However, the acute mental health 
needs of many servicemembers are exacerbating the shortages of 
uniformed behavioral health providers within the DOD. In turn, this 
shortage poses a significant barrier to adequately addressing problems 
with identification of mental health problems, such as Post-Traumatic 
Stress Disorder (PTSD), and access to appropriate Services. I am 
currently working with Senator Boxer to introduce legislation that 
ensures that each of the Services has the necessary financial 
incentives to recruit and retain uniformed behavioral health providers, 
which are especially critical given our current deployment and 
stateside behavioral health needs. Are there specific authorizations 
that the Department currently does not have, but that would assist, in 
recruiting and retaining uniformed behavioral health professionals?
    Secretary Geren. The passage of the National Defense Authorization 
Act for Fiscal Year 2008, specifically section 661 (Consolidation of 
Special Pay, Incentive Pay and Bonus authorities of the Uniformed 
Services), provides a degree of flexibility which will be helpful. 
Section 661 appears to provide sufficient authority to institute the 
recruitment and retention programs, and we will work with the DOD to 
implement them. We will need to evaluate these programs as they 
progress. If our analysis indicates that the new legislative 
authorities are not effective, we will work with Congress to develop 
additional solutions.

    9. Senator Lieberman. Secretary Geren, what steps has the 
Department taken to retain uniformed behavioral health providers in 
each Service and what analyses have been conducted to determine how 
many additional uniformed Service providers are needed?
    Secretary Geren. The Army has received authorization for and 
implemented the Critical Skills Retention Bonus (CSRB) for Clinical 
Psychologists at a rate of $13,000/year for 2 years or $25,000/year for 
3 years. Additionally, the Health Professions Loan Repayment Program is 
available for the retention of 20 Clinical Psychologists and 20 Social 
Workers at the current rate of $38,437 per year. Social Workers in the 
grade of captain are eligible for the Army CSRB at the rate of $25,000 
for a 3-year Active Duty service obligation. Psychiatrists who execute 
a multi-year special pay contract (extending their Active Duty service 
obligation) are paid at the rates of $17,000/year for a 2-year 
contract, $25,000/year for a 3-year contract and $33,000/year for a 4-
year contract.
    The Army performs regular force management analyses of operational 
forces as part of the Total Army Analysis. In Theater, the Army has 
taken the additional step of reviewing the quantity and distribution of 
mental health assets as part of the annual Mental Health Advisory Team 
(MHAT) assessments. The Army uses the Automated Staffing Assessment 
Model (ASAM) to determine appropriate staffing requirements in our 
military treatment facilities (MTFs). Our manpower experts 
significantly revised the ASAM 2 years ago to reflect the additional 
psychological stresses on soldiers and their families as a result of 
the war. This revision led to increased requirements for behavioral 
health providers. Additionally, in the spring of 2007 the Army Medical 
Command queried each MTF to identify shortfalls in behavioral 
healthcare staffing requirements. This afforded hospital commanders the 
opportunity to validate ASAM-recommended levels or identify additional 
needs.

    10. Senator Lieberman. Secretary Geren, given deployment needs, to 
what extent is the Army focused on recruiting and retaining uniformed 
behavioral health professionals rather than civilian providers?
    Secretary Geren. We are equally focused on recruiting and retaining 
both uniformed and civilian providers. The military and civilian mix 
within the Army's behavioral health community is the result of many 
deliberate processes. The military authorizations present in our 
deploying units are carefully developed, reviewed, and codified in our 
Tables of Organization and Equipment. The military authorizations in 
our fixed facilities are also derived by a deliberate process. To focus 
on military or civilian providers to the detriment of the other is 
unhealthy for our total team. We continue to pursue all actions to 
recruit and retain to 100 percent of our military authorizations while 
at the same time recruiting and retaining civilians.

                     MILITARY TREATMENT FACILITIES

    11. Senator Lieberman. Secretary Chu, my staff has been traveling 
to military installations across the country to assess medical and 
behavioral health needs and resources in the system. It is evident from 
their visits that there is a growing strain on our military health care 
system. In particular, the reduction in uniformed health care providers 
appears to be placing a distinct strain on the military health care 
system because of the dual deployment and stateside staffing 
requirements within MTFs of personnel. This appears to have created an 
overreliance in many specialties on contracted providers.
    What models has DOD and each of the Services used in determining 
uniformed, government service, and contractor staffing requirements for 
MTFs? Have these models been adjusted for peacetime and wartime 
requirements, and for the demographic changes in the forces?
    Dr. Chu. Service and local level medical administrators apply 
models that work best for their settings, mission requirements, and 
available military and local assets.
    A recent DOD-level initiative developed a specific model for 
staffing of mental health providers across the Services that is 
currently being validated by the Center for Naval Analyses. This 
population- and risk-based model accounted for multiple factors in 
making recommendations for the number and types of mental health 
providers at MTFs. The specific factors included:

         number of Active Duty (AD) members
         number of family members and percentage that use military 
        providers
         number of other eligible beneficiaries
         number of individuals at an MTF with a diagnosis of PTSD
         average number of mental health (MH) visits per year of those 
        with PTSD diagnoses
         number of AD members to be deployed in the next year
         number of accredited psychology training programs in MTFs in 
        the area
         number of accredited psychiatry training programs located in 
        MTFs in the area
         number of MH techs assigned to inpatient psychiatric units
         number of MH nurses assigned to inpatient psychiatric units
         number of social workers primarily assigned to inpatient 
        psychiatric units
         number of psychologists assigned to inpatient psychiatric 
        units
         number of psychiatrists primarily assigned to inpatient 
        psychiatric units

    12. Senator Lieberman. Secretary Chu, what proportion, Department-
wide and for each of the Services, of the health care work force is 
comprised of General Schedule employees, contractors, and uniformed 
providers? How do the proportions differ from previous years?
    Dr. Chu. We have sound data on government civil servants and 
uniformed personnel. Contractors are locally controlled and based on 
budget so, although we suspect an increase of contractor full-time 
equivalents (FTEs) we do not have reliable centralized numbers. The 
proportion of government civil servants has increased from 26 percent 
to 30 percent. At the same time, the combined numbers have gone from 
156,609 to 156,409.
       
    
    
      
    13. Senator Lieberman. Secretary Chu, how has core funding to staff 
MTFs been allocated, Department-wide and for each of the Services, to 
support uniformed providers, General Schedule employees, and 
contractors?
       
    
    
       
    
    
      
    14. Senator Lieberman. Secretary Chu, to what extent has the 
medical system utilized recalled retirees?
    Dr. Chu. The Services medical systems are all utilizing voluntary 
retiree recall but none have used involuntary retiree recall. Voluntary 
retiree recall has been used predominantly for senior individuals who 
are in key positions, clinical or administrative, and facing mandatory 
retirement. The numbers are small with the Army using the most, 165 
since 2004.

    15. Senator Lieberman. Secretary Chu, would it be beneficial to 
extend the period of time for which they could voluntarily serve after 
being recalled to alleviate health care workforce shortages?
    Dr. Chu. Individuals under voluntary retiree recall serve to 
support contingency operations in which the Secretary of the Service 
authorizes the recall. Retired soldiers are only mobilized for Active 
Duty to support a national emergency and the build-up of forces when 
personnel requirements cannot be met using Active personnel, National 
Guard, or Reserve Forces. The mobilization and recall of retired 
soldiers normally requires the approval of the Secretary of the 
military department. When the campaign ends, the recall will be ended. 
Most retiree recalls during this contingency have committed to serving 
for 2 years. At the end of that tour, some have extended. We have not 
had problems related to tour lengths being too short.

                        WARRIOR TRANSITION UNITS

    16. Senator Lieberman. General Schoomaker, I recently learned about 
your efforts to investigate a series of deaths that have occurred in 
warrior transition units (WTUs), which you believe may be related to 
drug and/or alcohol overdoses. Many of the young men and women assigned 
to WTUs are convalescing after serious physical and psychological 
injuries, and are not only using prescription drugs, but also abusing 
them in conjunction with other substances, such as illegal drugs and 
alcohol. The WTUs are already playing a critical role in efficiently 
addressing the needs of servicemembers with significant injuries. 
However, their work is especially complicated because, in many cases, 
they serve a high-risk population because of the nature and complexity 
of the injuries; therefore, I applaud your efforts to examine this 
issue further and then to put into place necessary safeguards to 
address any problems that may be uncovered. How will the investigation 
be conducted?
    General Schoomaker. The Army established a cross-functional Tiger 
Team consisting of psychologists, psychiatrists, physicians, 
pharmacists, nurses, safety experts, criminal investigation agents, WTU 
commanders, first sergeants, and sergeants major to examine the soldier 
deaths that have occurred in WTUs. First, the team reviewed every 
Serious Incident Report since June 2007 and catalogued all WT deaths 
and serious incidents. The team identified 12 deaths and 29 incidents 
that merited further review through root cause analysis and a four-step 
risk management process.

          Step One--Risk Identification--analyzed and identified 
        sources of risk.
          Step Two--Risk Assessment--assessed risk in terms of severity 
        of impact, likelihood of occurring, and controllability.
          Step Three--Risk Response Development--developed strategies 
        to reduce possible damage and developed contingency plans.
          Step Four--Risk Response Control--implemented risk 
        strategies, monitored and adjusted the plan for new risks, and 
        instituted changes.

    Team members aggregated findings and recommendations from the risk 
management review and assembled a list of recommendations designed to 
protect soldiers and further reduce the likelihood of serious incident. 
I received an interim report on February 12, 2008, from the Tiger Team, 
with recommendations for 71 initiatives. The team is already 
implementing 18 of the initiatives and is continuing to address 
concerns related to deaths and serious incidents in our WTUs.

    17. Senator Lieberman. General Schoomaker, what safeguards do you 
anticipate may need to be put in place?
    General Schoomaker. The Tiger Team recommended 71 initiatives in 
their interim report, including 18 that could be implemented on or 
about March 3, 2008. Some of these actions include the following:

         Create an alcohol-free zone around WTU billets and on-post 
        lodging facilities to ensure that WTs do not consume alcohol 
        within their barracks rooms.
         Conduct a risk assessment for each WT to determine those at 
        high risk. Each assessment is individualized and considers 
        input received from the primary care manager (PCM), nurse case 
        manager, squad leader, as well as other WTU staff and health 
        care professionals.
         Annotate a ``no alcohol'' order on a soldier's physical 
        profile when the PCM determines that consumption of alcohol 
        poses unacceptable risk to a soldier due to a particular 
        medical condition and/or medication regimen. The soldier's WTU 
        commander counsels the WT in writing that he or she is 
        prohibited from consuming alcohol.
         Link pharmacy support to each WTU for consultation and 
        training on the dangers of abuse.
         Conduct family and social support assessments during in-
        processing and during weekly nurse case manager contacts in 
        order to determine and document in each WT's medical record 
        potential broken relationships.
         Coordinate and identify a location to store privately-owned 
        weapons.
         Review each WT's pay to determine if there are any indicators 
        of financial stress or similar issues.
         Ensure that each WT and their family received a reintegration 
        briefing as part of the soldier and family orientation.
         Educate all VIP escorts, family, and staff on the risks 
        associated with providing alcohol to WTs who are on 
        medications.
         Train all platoon sergeants and squad leaders, as well as 
        other WTU staff as directed by the WTU commander, in Cardio-
        Pulmonary Resuscitation (CPR) and provide pocket masks and 
        gloves.

    Additional initiatives are being developed and will be implemented 
in a phased manner by May 15, 2008, and August 15, 2008, to create the 
most secure environment possible to protect WTs and their families.

    18. Senator Lieberman. General Schoomaker, are substance abuse 
services working closely in conjunction with WTUs in all locations?
    General Schoomaker. The Army is currently evaluating ways to 
improve the communication capabilities between Army OneSource and MTFs 
and WTUs in order to better serve WTs and their families. The AMAP 
addresses substance abuse services as a primary responsibility of the 
Soldier Family Assistance Centers operated by the Army's Installation 
Management Command (IMCOM). IMCOM also operates the Army OneSource 
website where soldiers can seek and obtain assistance and referral for 
substance abuse.

    19. Senator Lieberman. General Schoomaker, can you describe how 
WTUs work in concert with the substance abuse programs?
    General Schoomaker. Key to the success of managing care and support 
for WTs and their families is the Comprehensive Care Plan which is 
developed for each WT and managed by the members of the care triad. The 
Comprehensive Care Plan includes critical care functions of 
psychosocial assessment, addiction therapy, and behavioral health 
treatment for WTs. Additionally, WTU staff includes social workers who 
provide further support for soldiers and their families. Resources are 
also available through the local MTF and the Army Medical Command to 
address any substance abuse needs.

    20. Senator Lieberman. General Schoomaker, what other challenges 
can you identify in standing up the WTUs?
    General Schoomaker. The most significant challenge in establishing 
WTUs is the recruitment, assignment, and development of a fully-trained 
and committed staff for all 35 WTUs. It has taken a great deal of 
effort over a short timeline to ensure that each and every member of 
the WTU staff understands the unique demands and challenges caring for 
wounded, ill, and injured soldiers requires, as well as possessing the 
courage, commitment, compassion, and dedication required to meet these 
challenges. The Army Medical Department remains committed to meeting 
these challenges by providing the resources, facilities, and training 
that WTU staff, WTs, and their family members require to recover, 
rehabilitate, and reintegrate either to continued military Service, or 
as veterans prepared to be productive and successful citizens. In 
addition to the ongoing challenge of sustaining and improving this 
program, there remains a requirement to fund and complete necessary 
construction of accessible housing, adequate administrative facilities, 
and Soldier Family Assistance Centers, all developed in close proximity 
to each other and to the MTF to create Warrior Transition Complexes. 
These complexes will provide WTs and their families ease of access to 
the care and support they require.
                                 ______
                                 
             Questions Submitted by Senator Daniel K. Akaka

                        VETERANS AFFAIRS CLAIMS

    21. Senator Akaka. Secretary Mansfield, I recently introduced 
legislation which would establish a presumption in the Veterans Affairs 
(VA) claims adjudication process for combat experience. Among other 
things, this bill is designed to reduce delays in the disability 
adjudication process. I understand that VA currently has an ongoing 
process to address this issue. Please provide details on what the VA is 
already doing.
    Secretary Mansfield. 38 U.S.C.  1154(b) currently enables ``any 
veteran who engaged in combat with the enemy'' to show service 
connection for an injury or disease using only lay evidence. The United 
States Court of Appeals for the Federal Circuit has held that ''[t]he 
statute does not provide a relaxed standard of proof for determining 
whether a veteran engaged in combat.'' Rather, according to the Court, 
a veteran must first establish that he or she engaged in combat with 
the enemy in order for a veteran to be able to show service connection 
for an injury using only lay evidence under 38 U.S.C. Sec. 1154(b). The 
VA therefore does not have an ongoing process, other than case-by-case 
adjudications, to address proof of combat for purposes of section 
1154(b).
    With regard to claims for service connection for PTSD, the 
veteran's testimony alone establishes the occurrence of the claimed in-
service stressor if the evidence of record confirms the veteran engaged 
in combat or was a prisoner of war. VA considers the receipt of certain 
individual decorations as evidence of exposure to combat-related 
stressors. In addition, on January 23, 2008, the Compensation and 
Pension Service instructed field offices that, if a veteran was 
diagnosed with PTSD while on Active Duty, that diagnosis is sufficient 
to warrant an examination for the condition without additional 
preliminary development.

    22. Senator Akaka. Secretary Mansfield, in 1998, VA and DOD signed 
a memorandum of agreement (MOA) to implement a common physical 
examination. In 2003, the President's Task Force for Improving Health 
Care Delivery recommended that all servicemembers upon separation 
receive a physical accepted by both VA and DOD. Where are DOD and VA on 
this matter?
    Secretary Mansfield. The 1998 MOA between VA and the DOD was for a 
cooperative single separation exam at VA benefits delivery at discharge 
sites. If a servicemember decides to file a claim for VA disability and 
is also required to undergo a military separation physical, then only 
one exam is performed and VA's protocols are used.
    In November 2004, VA and DOD signed another memorandum of 
understanding (MOU) to implement the single cooperative exam. To date, 
130 military installations are covered by this agreement. A new pilot 
program that began on November 26, 2007, in the National Capital Region 
further uses the single cooperative examination in the disability 
evaluation system (DES), for servicemembers undergoing the medical 
evaluation board/physical evaluation board (MEB/PEB) process. DOD will 
use this program to determine fitness for continued military Service, 
and VA will use the program to determine Service-connected disabilities 
and their severity for purposes of compensation. In the pilot, DOD 
accepts the tentative VA assigned evaluations for purposes of 
determining entitlement to severance pay or disability retirement.

                   NATIONAL GUARD AND RESERVE MEMBERS

    23. Senator Akaka. Secretary Chu, the recent report of the 
Commission on the National Guard and Reserves discussed how best to 
provide transition assistance to members of the Guard and Reserves 
during the demobilization process. The Commission's report embraced the 
Yellow Ribbon Reintegration program pioneer by the Minnesota National 
Guard. The 2008 National Defense Authorization Act (NDAA) authorized 
DOD to administer this program for all National Guard and Reserve 
members and their families. I understand the timeline for this program 
is in conflict with current policy for when returning Guard and Reserve 
have their first drill. What is being done to eliminate this conflict, 
implement this program, and to improve the transition process for 
members of the Guard and Reserve?
    Dr. Chu. The Department is committed to supporting National Guard 
and Reserve members and their families throughout the deployment cycle. 
The DOD already has pilot programs in 15 States that provide services 
and support to Reserve component members and their families, and plans 
to expand the program to all 54 States and territories. The Department 
plans to establish the Office for Reintegration Programs within the 
near future, and has already begun establishing the Advisory Board, and 
identifying key staff for this office and the Center for Excellence.
    Regarding the policy restriction on performing inactive duty 
training immediately following demobilization, the Department is 
revising the policy to allow the Services to require demobilized 
members to participate in reintegration training and activities.

                      SCREENING FOR SERVICEMEMBERS

    24. Senator Akaka. Secretary Chu, VA is currently screening all 
returning veterans who seek treatment with VA to see if they may have 
experienced a traumatic brain injury (TBI). Shouldn't such a screening 
be done for all returning servicemembers during the demobilization 
process?
    Dr. Chu. All servicemembers, including the Guard and Reserve 
component, complete assessments when returning from deployments. The 
Post-Deployment Health Assessment (PDHA) is required within 30 days of 
returning from deployment and the servicemembers complete the Post-
Deployment Health Reassessment (PDHRA) 90-180 days after returning from 
deployment. During these assessments, servicemembers answer questions 
where they can identify possible TBI experiences and discuss the 
experiences with a health care provider.
    The DOD and VA jointly developed the set of TBI screening 
questions. The DOD/VA Joint Executive Committee mandated that the same 
set of questions be used by both agencies. DOD developed new PDHA and 
PDHRA forms with these TBI screening questions. The new forms were 
officially published on September 11, 2007. Since then, the Services 
have worked hard to modify their respective electronic data collection 
systems. They finished this work in late December. In addition, the 
Armed Forces Health Surveillance Center (AFHSC), which is the 
repository for the electronic forms, has successfully tested data feeds 
from the Army, Air Force, and Navy systems. No problems were 
identified.
    Now that the technical solutions are operational, the Services will 
start using the new forms for health assessments. The exact starting 
dates will vary with each Service. To ensure a smooth and timely start, 
a policy memorandum establishes a 60-day implementation phase during 
which AFHSC will accept both the old and new versions of the forms.
    Meanwhile, the Services have been encouraged to start using the new 
versions of the forms immediately rather than wait for the formal 
announcement of what they already know is necessary. The Army plans to 
start selected pilot tests of the new forms before April 1, 2008. The 
Navy, Air Force, and Coast Guard will all start using the forms in 
March 2008.

    25. Senator Akaka. Secretary Chu, during a recent Senate Veterans' 
Affairs Committee hearing, testimony was heard that servicemembers 
returning from Operation Iraqi Freedom (OIF)/Operation Enduring Freedom 
(OEF) who answer questions on the PDHA related to PTSD or TBI in the 
affirmative run the risk of being denied post-deployment leave.
    How do we get servicemembers to answer these questionnaires 
honestly, without being concerned about the inability to go on leave?
    Dr. Chu. Any time we ask people questions about their health, there 
is always a chance that they may need an urgent evaluation. However, 
delays such as you describe are exceedingly uncommon. Most of the PDHAs 
are accomplished before the servicemembers leave the theater of 
operations. A health care provider determines whether any urgent 
evaluation is necessary. Urgent referrals are highly unusual, unless 
the individual expresses a serious intent to hurt themselves or someone 
else. The examples you mention, PTSD and TBI, would not fit in this 
category. Those diagnoses merit prompt follow-up, which can be 
accomplished after the servicemember returns home. The large units 
returning from the theater are normally busy with various demobilizing 
tasks for several days before the individual members disperse to their 
homes. This allows plenty of time for urgent referrals to be handled 
on-site, or for education and reassurance to be provided to those who 
can safely follow up later on. There will always be some people who 
choose to answer these questions inaccurately, despite all the evidence 
to the contrary and the reassurances given during the assessment 
itself. It is clear that most people do not fall into this category 
based on the number of positive responses we see on the PDHA forms, 
both those accomplished in theater and those completed at the 
demobilization sites.

                         WOUNDED SERVICEMEMBERS

    26. Senator Akaka. Secretary Mansfield and Secretary Chu, I remain 
concerned that VA and DOD do not have a common definition for which 
servicemembers are seriously injured, wounded, and ill. What is the 
operational definition that is being applied in deciding which 
servicemembers will be considered for assignment to a VA Federal 
Recovery Care Coordinator?
    Secretary Mansfield. Within 3 days of admission to a MTF, a 
multidisciplinary team reviews the servicemember's case using the 
following criteria to determine if assignment to the Federal recovery 
care program is in order:

         In acute care at MTF
         Diagnosis of spinal cord injury, burn, amputation, visual 
        impairment and/or TBI/PTSD
         At risk because of psychological complications (psychological 
        and family assessment)
         Patient self-referral based on ability to benefit
         Command referral based on ability to benefit

    These criteria are applied without regard to Active component/
Reserve component status. No one will be denied entry into the Federal 
recovery care program.
    Dr. Chu. Eligibility criteria for wounded, ill, or injured 
enrollment into the Federal Recovery Coordinator Program for Active and 
Reserve personnel serving on Active Duty includes the following 
conditions: (1) being treated in an acute care setting within a MTF and 
expected to receive greater than or equal to 30 percent military 
Service disability rating; (2) diagnosed or referred with one or more 
of the following conditions: spinal cord injury, burns, amputation, 
visual impairment, TBI, and/or PTSD; (3) considered at risk for 
psychosocial complications (identified through psychosocial and family 
assessment); (4) self-referral based on perceived ability to benefit 
from a Federal Individual Recovery Plan (FIRP), or Command referral 
based on ability to benefit from a FIRP. The basis of the origin of a 
wound, illness, or injury is not a discriminator for enrollment in the 
FIRP.

                  POST-DEPLOYMENT HEALTH REASSESSMENT

    27. Senator Akaka. Secretary Mansfield and Secretary Chu, the 
Government Accountability Office (GAO) recently released a report on 
the effectiveness of the Post-Deployment Health Reassessment (PDHRA) 
for members of the Guard and Reserve. I am concerned that those who are 
in units of less than 60 personnel or who are individually deployed may 
not be getting appropriate attention. What steps are being taken to 
ensure that any identified medical needs of this population are being 
met through either DOD or VA?
    Secretary Mansfield. The VA has been an active partner in working 
with Reserve and National Guard Units on the PDHRA initiative since the 
pilot began in November 2005. All Reserve and National Guard 
servicemembers returning from deployment are required to participate in 
the PDHRA screening 90-180 days post-deployment. VA medical centers and 
veteran centers provide either on-site staff support or PDHRA event 
assistance for all Reserve and National Guard servicemembers referred 
from a PDHRA screening event. This includes those referred from remote/
rural areas. VA and veteran center staff have participated in PDHRA 
events held in Guam, American Samoa, Virgin Islands, and Puerto Rico, 
along with rural areas across the continental United States.
    The VA has had a strong partnership alliance since late 2005 with 
the National Guard Bureau's transition assistance advisors (TAAs) based 
at all National Guard Headquarters. VA has been involved in training 
and ongoing coordination activities for the TAAs, who are based in all 
50 States as well as Puerto Rico, Virgin Islands, Guam, and the 
District of Columbia. The TAAs work closely with local VA medical 
centers and vet centers to assure that referral linkages are in place 
between VA and National Guard Units to include those located in remote/
rural areas.
    Readjustment Counseling Service has robust outreach initiatives in 
place covering remote/rural settings. Coverage of Reserve and National 
Guard units are critical components of their outreach efforts.
    Dr. Chu. The DOD carefully designed the PDHRA program to include a 
variety of options just for the reason you mentioned. The Department 
always recognized that it would be much more difficult to reach out to 
smaller units or individuals. This is precisely why we established a 
call center, so that it would be available for anybody, anywhere, 
anytime. The attention provided by the call center is the equal of what 
occurs during on-site visits in all respects. The only difference is 
that the servicemember speaks to a health care provider on the phone 
rather than across a desktop. The Department recognizes that some 
people are critical of this lack of a face-to-face interaction. 
However, there are many people who are more comfortable and honest, 
discussing sensitive topics like mental health concerns, over a phone 
with someone who is far away and who cannot be seen. This is simply 
another variation of telemedicine, which has been shown to be very 
effective in several health fields. The call center has been highly 
successful and a desired method, assessing more than 7,000 
servicemembers in January 2008 alone.
    The call center also makes follow-up calls to see if the 
servicemembers who received referrals from either an on-site or 
telephonic assessment obtained an appointment. If not, the call center 
staff offers to help the servicemember. In addition, DOD has contracted 
with Vanderbilt University to perform a formal process evaluation of 
the various ways we accomplish PDHRAs, such as comparing the success of 
the call center compared to on-site team visits.
    The Department has decreased the threshold for the number of 
servicemembers required to qualify for an on-site team from 60 to 40. 
This was possible through thoughtful reengineering of the traveling 
team members' skill sets and other process revisions that increased 
scheduling flexibility and allows us to send teams to smaller units 
than before. This combination approach allows us to reach most units 
with on-site teams, if that is what the commander would prefer, with 
the call center available as an effective alternative for the rest of 
the units.

                         TRANSITION ASSISTANCE

    28. Senator Akaka. Secretary Chu, I understand last August DOD 
released a memo to the Services expressing Secretary Gates' commitment 
to increase participation by demobilizing Guard and Reserve personnel 
in the Transition Assistance Program (TAP) and Disabled Transition 
Assistance Program (DTAP) to 85 percent. Where is DOD on implementing 
the Secretary's guidance?
    Dr. Chu. The Department is working aggressively to ensure that the 
Active and Reserve components are prepared and equipped to meet the 85 
percent target to which the Secretary has committed. The Department is 
reviewing current transition assistance materials and delivery 
techniques by the Services, the Department of Labor (DOL) and the VA to 
determine where technology and the latest learning methodologies can 
enhance the learning experience. Through technology, the support 
material for transition assistance can be more accessible globally to 
the servicemembers, their families, the Service providers, and the 
commands.
    As a result of the memo noted above (attachment 1), meetings were 
held with the Service Assistant Secretaries for Manpower and Reserve 
Affairs to survey what each of the Services was already doing to meet 
this goal and to address how they would ensure each of their Services 
did fully comply.
    As an outcome of that session, the Department established the TAP 
Executive Steering Committee (attachment 2), which consists of a senior 
DOD, DOL, and VA panel that includes the Department's Deputy Under 
Secretary for Military Community and Family Policy, the Deputy 
Assistant Secretaries of each of the Services, as well as the Guard and 
Reserves, and senior officers who have had field operational 
experience. The Steering Committee's charter is to determine what needs 
to be done, and then establish an overarching plan to support and 
implement the programs and procedures determined by the Executive 
Steering Committee needed to attain the 85 percent commitment.
    To ensure Reserve component involvement is a part of this effort, 
the Department released a memo (attachment 3) to the Services and to 
senior Guard and Reserve Commanders, to encourage their subordinate 
commanders to strongly support and aggressively market this effort 
through Guard and Reserve family support networks and service 
organizations to all Guard and Reserve members and their families.
    So that Guard and Reserve commanders are successful in this effort, 
DOD is prepared to send mobile training teams to premobilization and 
demobilization sites, or to State and local Guard and Reserve units 
that request assistance in training their personnel on how to access 
programs and information applicable to benefits and support functions. 
The mission and scope of the Guard- and Reserve-centric Mobile Training 
Teams is provided in attachment 4.
    The Army has linked the Turbo Transition Assistance Program 
(TurboTAP.org) Web site to their Army Career and Alumni Program (ACAP) 
On-Line Home page. ACAP counselors inform servicemembers during 
preseparation counseling about TurboTAP and encourage them to register 
with the Web site. Mobilized Reserve component servicemembers who are 
severely wounded or injured while on Active Duty are reassigned to the 
wounded WTU.
    In a February 26, 2008, memo to all wing commanders, the Air Force 
Reserve Command strongly encouraged eligible reservists and their 
families to use the TAP and DTAP. The memo provides primary points-of-
contact for TAP and DTAP, which are the Airman and Family Readiness 
Directors or Liaisons. Family Readiness personnel are maximizing their 
marketing efforts of this extremely important program to all reservists 
and their families.
       
    
    
       
    
    
       
    
    
       
    
    

    29. Senator Akaka. Secretary Mansfield, what is VA doing to improve 
the transition process for the Guard and Reserve?
    Secretary Mansfield. Increasing the number of demobilizing Guard 
and Reserve personnel who attend TAP and DTAP is a high priority for 
VA. DOD recently proposed establishing a TAP Executive Steering 
Committee to ensure that TAP and DTAP participation is increased to 85 
percent. VA will work closely with DOD in establishing the committee to 
formulate plans to reach this goal.
    With the activation and deployment of large numbers of Reserve/
National Guard members to Afghanistan and Iraq, VA is working with DOD 
to expand outreach to returning Reserve/National Guard members and 
their families. When units of Reserves or National Guard members are 
returning home, VA provides briefings and assists with filing claims.
    An MOA was signed in 2005 between VA and the National Guard Bureau 
to institutionalize this partnership and to support better 
communication between the two.
    VA is encouraging State National Guard coalitions to improve local 
communication and coordination of benefits briefings to assure that 
National Guard and Reserve members are fully aware of benefits. In 33 
States, MOUs have been signed between VA, the State National Guard 
offices, and the State VA to promote the relationship and cooperation 
to provide services and benefits to their members.
    VA has an MOA with the Army Reserve in the concurrence process that 
will formalize this relationship as we did with the National Guard. We 
are also working on MOUs with the other Reserve components to formalize 
those relationships.
    The National Guard Bureau employs 57 transition assistance advisors 
(TAAs) for the 50 States and four territories. Their primary function 
is to serve as the statewide point of contact and coordinator, 
providing advice to Guard members and their families on VA benefits and 
services and assisting in resolving problems with VA health care, 
benefits, and TRICARE. VA and the National Guard Bureau teamed up at 
the beginning of the program in February 2006 to provide training to 
the TAAs on VA services and benefits and help define their role as VA 
advocates. VA participates in annual refresher training for the TAAs, 
as well as the monthly TAA conference calls.
    Each regional office has an OEF/OIF manager who is responsible for 
overseeing the OEF/OIF workload and outreach initiatives. These 
responsibilities include working closely with the National Guard and 
Reserve units to obtain service treatment records. OEF/OIF managers 
work with military medical facilities to ensure timely notification of 
casualty arrivals and to develop procedures for scheduling ward visits. 
Managers also work closely with Reserve/Guard Units to coordinate and 
provide benefits briefings.
                                 ______
                                 
                Questions Submitted by Senator Evan Bayh

                     HEALTH CARE FOR SERVICEMEMBERS

    30. Senator Bayh. Secretaries England, Mansfield, Geren, Chu, and 
General Schoomaker, I've been told that one of the immediate hurdles in 
increasing the pool of private mental health and other medical 
professionals available for our soldiers outside of the DOD or VA 
systems is current law. As I understand, in order for psychiatrists, 
neurologists, or other medical professionals to provide TRICARE 
services, they must also accept the Medicare reimbursement. Is that the 
most significant hurdle we face as a Nation in providing more private 
health care providers to wounded soldiers or veterans?
    Secretary England and Dr. Chu. Even though we have not seen 
persistent access problems, in those locations where certain health 
care specialties are limited, we would like a larger pool of providers. 
To help ensure continued access to quality private sector care, our 
managed care support contractors have added nearly 2,800 behavioral 
health providers to the network since May 2007. In addition, in 
December 2007, we instituted a behavioral health care appointment 
assistance service to aid Active Duty personnel and their enrolled 
family members in obtaining timely mental health care.
    While TRICARE's reimbursement of professional providers is based 
upon the methodology used by Medicare, a provider does not have to 
accept Medicare reimbursement in order to provide TRICARE services. A 
TRICARE provider has the option of becoming a network provider where 
negotiated discounts are expected, provide services by participating on 
a claim by claim basis and accepting the TRICARE payment as payment in 
full, or provide services as a non-participating provider and bill up 
to 115 percent of TRICARE maximum allowable amount.
    Legislative initiatives to link the DOD and Medicare payment rates 
for health care began in the early 1980s and the NDAA for Fiscal Year 
1996 codified the linkage to Medicare payment amounts. Based upon prior 
concerns involving the adequacy of TRICARE physician payment rates, a 
GAO review was conducted in 1998 that found that the professional 
provider methodology was sound and that DOD was saving about $770 
million annually as a result of these maximum allowable charges. In 
2001 GAO conducted another study to determine whether increases in 
professional payment rates would be beneficial. That report concluded 
that changing the reimbursement rate would be costly, inflationary, and 
largely unnecessary. Due to concerns about payment rates in those 
localities where access was a problem, the NDAA for Fiscal Year 2001 
granted new flexibility to increase TRICARE reimbursement rates in 
areas where access to health care services is severely impaired. The 
Department has implemented that authority; for example, we recently 
granted a waiver for child psychiatry services in Key West, FL. The 
Department will continue to use this authority to raise reimbursement 
rates where access to care is a demonstrated issue.
    Secretary Mansfield. For eligible veterans, VA facilities are 
permitted to use qualified and licensed private health care providers 
to provide medical services through our fee basis program. VA has the 
ability to enter into contracts with qualified health care providers 
through several statutory authorities (38 U.S.C. 1703, 7409, 8153).
    As a Federal health care payer, VA finds many community health care 
providers expect assignment of payment at Medicare rates. When VA 
authorizes medical care in the community, in advance of treatment, 
payment for professional services is generally at the 100 percent 
Medicare allowable reimbursement rate for most geographic areas.
    VA has authority to exceed the 100 percent Medicare allowable 
reimbursement for services purchased in Alaska.
    The reimbursement methodology and payment terms for fee-basis care 
are set out in VA's regulations at 38 CFR 17.55 and 17.56.
    Secretary Geren and General Schoomaker. Reimbursement rates are not 
the most significant hurdle we face in providing more private health 
care providers to wounded soldiers and veterans. Title 10 requires 
TRICARE reimbursement, often referred to as the CHAMPUS Maximum 
Allowable Charge (CMAC), for civilian healthcare providers to match 
MEDICARE reimbursement rates. Generally, TRICARE and MEDICARE 
reimbursement rates are the same. This provision provides TRICARE with 
an industry accepted reimbursement system. Title 10 does authorize the 
Secretary of Defense to approve exceptions to this rule. Higher 
reimbursement amounts may be authorized if it is necessary to assure 
that covered beneficiaries retain adequate access to healthcare 
services. An example of this exception is the Alaska demonstration 
project. The Alaska demonstration project increases State-wide 
reimbursement rates by 35 percent across all Services. Additionally, 
the TRICARE Management Activity has approved other targeted rate 
increases in selected localities across the country.

    31. Senator Bayh. Secretaries England, Mansfield, Geren, Chu, and 
General Schoomaker, how would you recommend to Congress that we amend 
this law?
    Secretary England and Dr. Chu. When access to mental health 
services is related to professional reimbursement rates, the Department 
will continue to use the existing waiver authority. Rate increases 
targeted to those localities where access to care is severely impaired 
may improve access, but will not address other problems such as 
scarcity of mental health providers. The law already provides the 
flexibility needed to increase payment rates when access to care is an 
issue and states that payment for services by an individual health care 
professional shall be equal to the amount determined to be appropriate 
to the extent practicable in accordance with the same reimbursement 
rules for services under title XVIII of the Social Security Act.
    Secretary Mansfield. VA has yet to experience difficulty in 
locating providers willing to accept Medicare reimbursement for the 
treatment of veterans, except in the State of Alaska. However, in the 
State of Alaska, VA has regulatory authority to exceed the Medicare fee 
schedule. VA also has the authority in certain circumstances, to 
negotiate payment rates exceeding Medicare fee schedules with providers 
by contract or other legal agreement. VA does not see a need for any 
change in the legislation at this time.
    Secretary Geren and General Schoomaker. We do not recommend 
amending this law. The law provides the Secretary of Defense the 
necessary flexibility to grant exceptions.

    32. Senator Bayh. Secretaries England, Mansfield, Geren, Chu, and 
General Schoomaker, how would that enable you to provide better care?
    Secretary England and Dr. Chu. There may not be a direct 
correlation between paying more and obtaining better care. When 
justified, paying more to obtain needed health care services and 
treatment may benefit the patient under specific circumstances. We 
believe TRICARE already has the necessary authority to pay more, when 
access problems are demonstrated.
    Better care is the focus of the Department's larger effort on 
psychological health. We have charged the new Center for Psychological 
Health with identifying best practices.
    Secretary Mansfield. VA does not see a need for any change in the 
legislation at this time.
    Secretary Geren and General Schoomaker. We do not feel the law 
needs to be amended.

    33. Senator Bayh. Secretaries England, Mansfield, Geren, Chu, and 
General Schoomaker, can you please describe the extent to which non-
government experts or institutions have been used in assessments of DOD 
and VA mental health care? If that outside input is limited, please 
provide the reasoning behind it. If it is not, please describe the 
instances when it has been used within the past 5 years.
    Secretary England and Dr. Chu. The members of the DOD Mental Health 
Task Force that examined the state of mental health care around the 
globe in DOD were civilians, with five of seven being non-governmental 
subject matter experts. While they identified a number of areas for 
potential improvement, they concluded in their final report that, ``In 
the history of warfare, no other nation or its leadership has invested 
such an intensive or sophisticated effort across all echelons to 
support the psychological health of its military servicemembers and 
families as the DOD has invested during the global war on terrorism.''
    Subject matter experts from non-governmental academic sectors 
continuously collaborate with DOD clinicians, whether it be through 
shared research or established training programs around the country, in 
which civilian staff rotate to military sites and military staff rotate 
to civilian sites. These programs are of such rigor as to consistently 
result in highly competitive scores of military residents in a variety 
of medical specialty programs.
    DOD programs, such as those in suicide prevention, are widely 
respected, and supported through multiple collaborations with leading 
world experts. Such experts are integrally involved in both formally 
evaluating and shaping our programs through collegial workshops and 
conferences. The most respected non-governmental mental health 
morbidity experts are involved in assessing the effectiveness of our 
population-based screening programs, and our online mental health 
screening programs are rooted in the finest non-governmental programs 
in existence.
    Secretary Mansfield. The Under Secretary for Health's Committee on 
Care of Seriously Mentally Ill Veterans (SMI Committee) has, from its 
inception in the 1990s, been associated with a Consumer Liaison Council 
which meets in conjunction with the SMI Committee which is composed of 
VA mental health experts and field leaders. The Consumer Liaison 
Council has members from several of the mental health advocacy groups 
(e.g. National Alliance for the Mentally Ill), veterans service 
organizations (e.g. American Legion, Vietnam Veterans of America) and 
professional organizations (e.g. American Psychological Association). 
The Consumer Council hears reports from VA on progress of programs and 
makes comments to the SMI Committee.
    VA entities such as the National Center for PTSD (NCPTSD) and the 
mental illness research education clinical centers all have advisory 
boards which are composed of VA and non-VA experts in mental health 
issues. For example, the Chair of the Board on the NCPTSD scientific 
and educational advisory boards is a non-VA expert. The advisory boards 
hear about progress on VA projects and make suggestions for further 
activities.
    In addition, during the past several years, VA has contracted with 
RAND Corporation to carry out a comprehensive assessment of VA mental 
health care that is ongoing.
    The outside organization with the greatest impact on assessing 
mental health services in the Veterans Health Administration (VHA) is 
the Joint Commission. Every VA medical center and clinic must receive 
ongoing accreditation by the Joint Commission and meet its continually 
updated standards.
    In addition, VHA has asked the Commission on Accreditation of 
Rehabilitation Facilities (CARF) to review increasing numbers of mental 
health rehabilitation programs. VHA programs required to achieve and 
maintain CARF accreditation include:

          a. Mental health residential rehabilitation and treatment 
        services, which include, but are not limited to:

                  (1) Domiciliary residential rehabilitation and 
                treatment programs;
                  (2) Psychosocial residential rehabilitation treatment 
                programs;
                  (3) Substance abuse residential rehabilitation 
                treatment programs; and
                  (4) PTSD residential rehabilitation treatment 
                programs.

          b. Employment and community services which include, but are 
        not limited to:

                  (1) Comprehensive homeless veterans centers;
                  (2) Intermediate health care for homeless veterans 
                programs with four or more fulltime employees; and
                  (3) Compensated work therapy, and compensated work 
                therapy-transitional residence with four or more full-
                time employees combined, or incentive therapy programs 
                with four or more full-time employees.

          c. Starting in fiscal year 2008, VHA's new psychosocial 
        rehabilitation and recovery centers and day treatment centers 
        that transition to psychosocial rehabilitation and recovery 
        centers will also be required to achieve CARF accreditation.
          d. The recent Institute of Medicine (IOM) reports on 
        assessment of PTSD and treatment of PTSD are examples of non-VA 
        input. However, the task for IOM was not to evaluate VA mental 
        health care, but to evaluate the published research literature 
        on assessment and treatment in order to inform VA on best 
        practices. In response to the recently released report on PTSD 
        treatment, OMHS and the Office of Research and Development 
        (ORD) have held a planning meeting to develop guidance on 
        design and evaluation of clinical trials. That meeting included 
        a number of non-VA academic experts in PTSD and research 
        design.

    Secretary Geren and General Schoomaker. The Army has used internal 
and external resources to review existing behavioral health service 
delivery and quality in both garrison and operational environments. 
Over the past 5 years, the Army has executed five MHAT assessments of 
operational behavioral health. This has resulted in significant 
adjustments to the deployed behavioral health footprint and has shaped 
deployment preparation training for uniformed behavioral health assets. 
MHAT recommendations also led to the establishment of the Battlemind 
Training System, a comprehensive training program for soldiers and 
family members. The latest MHAT report will be released shortly.
    The Army also conducted an external review of garrison based mental 
health activities. Over the course of a 19-week project (October 2006 
through January 2007), BearingPoint conducted a review of the Army 
Medical Command's (MEDCOM) Behavioral Health service line with the 
overall objective of assessing the effectiveness and efficiency of the 
system and developing recommendations to improve services. For this 
assessment, the research team visited 22 MTFs conducting behavioral 
health operations, both CONUS and OCONUS. BearingPoint implemented a 
comprehensive multi-method approach, seeking not only to address 
factual observations, such as workload and cost metrics, but also to 
understand how the various constituencies in each community perceive 
the quality and value of behavioral health services. Their research 
included an on-line survey for soldiers, in-depth interviews with 
behavioral health staff and providers, a combination of in-depth 
interviews and an on-line survey with military leaders, and focus group 
discussions with soldiers and family members. The team also reviewed 
each MTF's organizational structure, operations, and cost and workload 
data. A final report was released on February 13, 2007, and resulted in 
38 key findings which were further refined to 9 actionable issues. 
MEDCOM has approved a pilot program to incorporate these findings.
    The DOD Mental Health Task Force consisted of military, Federal, 
and non-Federal behavioral health experts. The Task Force's findings 
and recommendations have informed many of the Army's current efforts to 
increase access to care and decrease stigma. Finally, soldiers in every 
component of the Army were directed to participate in mandatory 
training on mild TBI and PTSD. This chain-teaching program was intended 
to provide leaders and soldiers information and resources on 
concussions, Post Combat Stress, and Operational Stress. It was 
developed in consultation with 11 external subject matter experts.
    The Army Provider Level Satisfaction Survey (APLSS) was developed 
by Synovate, a third party industry leader in health care survey 
research who also developed the survey model used by Kaiser Permanente 
to measure patient satisfaction with the medical care they receive. 
Patient responses on the APLSS are aggregated at the individual 
provider level. Data are evaluated monthly and posted electronically by 
provider, clinic, MTF, regional medical command, and MEDCOM levels. 
These results are available via a password-protected Office of the 
Surgeon General survey website that can be accessed by MTF leadership 
and providers. The aggregated results are compared to a civilian 
benchmark which was developed by having a panel of civilian households 
complete the same survey.

    34. Senator Bayh. Secretaries England, Mansfield, Geren, Chu, and 
General Schoomaker, last April, I introduced S. 1113. Included in that 
legislation was a plan to ensure that servicemembers who incur a 
covered TBI while on Active Duty be retained on Active Duty for 1 year 
after the medical assessment of their ability to perform their 
activities of daily living. Further, the bill would have provided for 
the limitation of physical evaluation boards for such members for 1 
year. In my legislation, these options would have been waiverable by 
the servicemember or their legal representative. Please comment on 
these proposals. How would the DOD view them? How would the VA view 
them?
    Secretary England and Dr. Chu. While we are learning valuable 
information about TBIs, and expect to learn even more with the research 
being funded, there is a wide range of TBI severity and there currently 
exists other administrative options to handle these cases in a similar 
fashion, such as being placed on the Temporary Duty Restriction List 
(TDRL), which allows for medical reassessment in a designated time. 
Medical assessment occurs frequently during the continuum of care in 
the servicemember's treatment and convalescence. Once it is determined 
that it is likely the servicemember will not be able to return to full 
duty, in a year the servicemember is entered into the Disability 
Evaluation System. Fitness for continued retention is not a medical 
decision, but rather a Service-specific determination based on the 
Service's mission requirements, which may be hindered by legislation of 
medical conditions. Until more information is gained on TBI as well as 
other conditions, to aid DOD in accession and retention decision-
making, we are concerned that creating legislation now may not be 
beneficial or equitable to all servicemembers.
    Secretary Mansfield. Legislative plan S. 1113 might be appropriate 
for a servicemember with milder TBI and who has a good prognosis to 
return to military service, ready access to early rehabilitation 
interventions that will identify, target, and achieve community reentry 
goals. VA does not support blanket retention of all military 
servicemembers with TBI on Active Duty for a year after medical 
assessment. Active Duty members who will not likely return to duty 
(e.g., moderate to severe head injury) have the greatest potential to 
benefit from comprehensive rehabilitation services that are initiated 
as soon as possible, together with early community re-entry 
rehabilitation interventions.
    Retaining servicemembers on Active Duty for 1 year could be 
counterproductive for the patient by delaying initiation of veterans 
benefits or impeding their continuity of rehabilitative care management 
across multiple systems of care (e.g., referrals back and forth between 
DOD, VA, and civilian facilities).
    Secretary Geren and General Schoomaker. Decisions related to 
retention on Active Duty are made on an individual basis by trained 
clinicians. A tool now available to assist clinicians with these 
decisions is the Clinical Management Guidance for Mild TBI in non-
deployed environments. The Army developed this tool and coordinated 
with the Office of the Assistant Secretary of Defense for Health 
Affairs to have it published. The tool provides guidance in the 
management of servicemembers with persistent symptoms that interfere 
with their performance of duty.

    35. Senator Bayh. General Schoomaker, the reality is that our 
Nation and the military's medical system face significant shortages of 
mental health professionals. In fact, as I understand, the Army is 
trying to hire 272 new mental health professionals this year. 
Unfortunately, the Army has estimated that it will have only 150 by 
March. As a result, our system today is hard-pressed and strained, at 
best, to provide the essential care that so many of our soldiers who 
suffer from TBI and PTSD need. With that in mind, should we instead be 
focusing our efforts on taking the needed steps to increase access to 
quality, community-based and private care for our wounded soldiers?
    General Schoomaker. To provide optimal care for our soldiers, we 
must make full use of the Military Health System (MHS), the VAs, and 
private sector care. Currently the MHS makes extensive use of private 
sector care through the TRICARE Network. The Office of the Assistant 
Secretary of Defense for Health Affairs (HA) recently issued a new 
policy to ensure beneficiaries have appropriate access to mental health 
services by aligning mental health access standards with existing 
primary care access standards. This policy directs two new business 
practices. First, military mental health clinics must provide more 
self-referral capabilities, much like a primary care clinic. Mental 
health clinics traditionally operated as specialty referral clinics 
with limited self-referral capabilities. Second, the policy establishes 
a 7-day routine standard for newly onset, non-urgent behavioral health 
conditions or exacerbation of a previously diagnosed condition. MTFs 
closely track access standards for our wounded soldiers. If access to 
care standards cannot be met at a military facility, the soldier is 
referred to the private sector for care. In addition, it is essential 
to partner with civilian health care providers to ensure that they have 
the education and training to care for our soldiers and veterans.

    36. Senator Bayh. Secretary Chu, because of advances in force 
protection measures and field medicine, wounded servicemembers are 
fortunately surviving at a much higher rate than in previous wars. 
Unfortunately, due to the nature of the blasts causing injuries, many 
are left with a TBI. While still on Active Duty, wounded servicemembers 
can be treated for almost any ailment at MTFs, VA, or private 
facilities at little or no expense to the patient or family. However, 
once a servicemember has retired, TRICARE is limited to its legally 
defined coverage and does not include the cognitive therapies necessary 
for TBI rehabilitation. While the VA can provide TBI care in many 
cases, it may not be appropriate for every individual, and these 
injured heroes have earned the access to all available options. Do you 
agree that injured servicemember/veterans' care should based on their 
medical condition, not on their status as Active Duty or retired? If 
so, what are you doing to address this situation?
    Dr. Chu. Injured servicemembers/veterans' care should be based on 
their medical condition. However, until recent changes in the law under 
the NDAA for Fiscal Year 2008, the DOD was statutorily limited in the 
Services it could cost share for members who had separated from Active 
Duty or retired.
    Active Duty servicemembers are authorized cognitive rehabilitation 
services under the law. The benefits authorized in section 1631 of the 
NDAA for Fiscal Year 2008 allows the Secretary, through regulations, to 
authorize any former member of the Armed Forces with a serious injury 
or illness to receive the same medical and dental care as a member of 
the Armed Forces on Active Duty for such care not readily available in 
the VA.
    Rehabilitation therapy covered under the TRICARE Basic Program is 
available to both servicemembers and retirees, and includes physician-
prescribed therapy to improve, restore, or maintain function, or to 
minimize or prevent deterioration of patient function. Prior to the 
enactment of section 1631, rehabilitation therapy under the TRICARE 
Basic Program for members who retired, medically or otherwise, had to 
be medically necessary and appropriate care keeping with accepted norms 
for medical practice in the United States, rendered by an authorized 
provider, necessary to the establishment of a safe and effective 
maintenance program, and could not be custodial, or otherwise excluded 
from coverage.
    Covered rehabilitation services for TBI patients may include 
physical, speech, occupational, and behavioral services. Cognitive 
rehabilitation strategies may be integrated into these components of a 
rehabilitation program and may be covered under the TRICARE Basic 
Program when cognitive rehabilitation is not billed as a distinct and 
separate service except for Active Duty servicemembers and those that 
may be covered under section 1631. For all others under the TRICARE 
Basic Program, cognitive rehabilitation defined as ``services that are 
prescribed specifically and uniquely to teach compensatory methods to 
accomplish tasks which rely upon cognitive processes'' are considered 
unproven and are not covered when separately billed as distinct and 
defined services.
    For other than Active Duty servicemembers and those that may be 
covered under section 1631, in determining whether a medical treatment 
has moved from unproven to proven, TRICARE reviews reliable evidence, 
as defined in 32 Code of Federal Regulations Part 199. Research study 
of cognitive rehabilitation in neurological conditions including TBI is 
limited by differences between patients, and by variation in the type, 
frequency, duration, and focus of cognitive rehabilitation 
interventions. The TRICARE determination that cognitive rehabilitation 
for TBI is unproven is supported by a 2002 Technical Assessment 
performed by Blue Cross/Blue Shield (updated in 2006), and by a 2004 
Technical Assessment by Hayes Incorporated also updated in 2006. Our 
own commissioned Technical Assessment in 2007 further supported the 
TRICARE determination as the literature available is inconclusive on 
cognitive rehabilitation therapy's role in the treatment of TBI.
    Medical evidence is dynamic and evolving, however, we know that 
some care that is considered unproven today will in the future achieve 
the required evidence threshold and become covered under the TRICARE 
Basic Program. Care that is likely to become proven is periodically 
reevaluated to ensure that TRICARE coverage is current and consistent 
with the latest evidence.
    Beneficiaries, including Active Duty servicemembers, may receive 
rehabilitation services in direct or purchased care facilities. Active 
Duty servicemembers may also receive TBI rehabilitation in specialized 
VA treatment centers. In most cases, patients will be referred to a 
rehabilitation facility that has agreed to participate in the TRICARE 
network. Both Active Duty and non-Active Duty beneficiaries may be 
referred for care in a non-network facility when there are no available 
network facilities able to meet the identified medical needs of the 
patient in the area where the patient lives or needs to receive care.

----------------------------------------------------------------------------------------------------------------
                                                  Supplemental
                                                Care  Program--    TRICARE Basic Program (retired     Veterans
                    Service                       Active Duty                 members)                 Affairs

----------------------------------------------------------------------------------------------------------------
Occupational, speech, or physical therapy.....             Yes   Yes..............................          Yes
Behavioral health services....................             Yes   Yes..............................          Yes
Cognitive rehabilitation......................             Yes   Yes, if part of a comprehensive            Yes
                                                                  rehabilitation program and not
                                                                  billed as a separate service.
Vocational rehabilitation.....................             Yes   No...............................          Yes
Skilled nursing facilities-Prospective Payment             Yes   Yes, SNF-PPS methodology, no time          Yes
 System (SNF-PPS).                                                limit.
Comprehensive post-acute brain injury                      Yes   No...............................          Yes
 rehabilitation programs.
Community integration rehabilitation..........             Yes   No...............................          Yes
Educational rehabilitation....................             Yes   No...............................          Yes
Transitional living programs..................             Yes   No...............................          Yes
Nursing home care.............................             Yes   No...............................          Yes
Home health care (skilled)....................             Yes   Yes, partial intermittent up to            Yes
                                                                  28 hours/week.
Non medical aides and attendants..............             Yes   No...............................          Yes
Respite care..................................             Yes   No...............................          Yes
Advanced prosthetic care......................             Yes   Yes, if medically necessary......          Yes
Driving assessment and training...............             Yes   No...............................          Yes
----------------------------------------------------------------------------------------------------------------


    37. Senator Bayh. Secretary Chu, can you assure me that the overlap 
of benefits authorized in the recent NDAA will include access to the 
Active Duty cognitive therapy coverage?
    Dr. Chu. Clarification on Cognitive Therapy vs. Cognitive 
Rehabilitation:
    Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy 
emphasizing the important role of thinking in how we feel and what we 
do. It does not exist as a distinct therapeutic technique. The term 
``cognitive-behavioral'' is a general term for a classification of 
related therapies, based on the idea that thoughts are the cause of 
feelings and behaviors, rather than external things, like people, 
situations, and events. Patients are helped to change the way they 
think in order to feel and act better even if the situation does not 
change.
    CBT is covered under the TRICARE program, for both active 
servicemembers and retirees, as psychotherapy. Psychotherapy must be 
medically or psychologically necessary.
    Cognitive Rehabilitation is defined as systematic goal-oriented 
treatment designed to improve cognitive functions and functional 
abilities (including memory, language, concentration, attention, 
perception, learning, planning, sequencing and/or judgment) which may 
be recommended for patients with acquired brain injury.
    Active Duty servicemembers are authorized cognitive rehabilitation 
services under the law. The benefits authorized in section 1631 of the 
National Defense Authorization Act for Fiscal Year 2008 allows the 
Secretary through regulations to authorize any former member of the 
Armed Forces with a serious injury or illness to receive the same 
medical and dental care as a member of the Armed Forces on Active Duty 
for such care not readily available in the VA.
    Rehabilitation therapy covered under the TRICARE Basic Program is 
available to both Active Duty servicemembers and retirees, and includes 
physician-prescribed therapy to improve, restore, or maintain function, 
or to minimize or prevent deterioration of patient function. Prior to 
the enactment of section 1631, rehabilitation therapy under the TRICARE 
Basic Program for members who retired, medically or otherwise, had to 
be medically necessary and appropriate care keeping with accepted norms 
for medical practice in the United States, rendered by an authorized 
provider, necessary to the establishment of a safe and effective 
maintenance program, and could not be custodial, or otherwise excluded 
from coverage. Covered rehabilitation services for TRICARE patients may 
include physical, speech, occupational, and behavioral services. 
Cognitive rehabilitation strategies may be integrated into these 
components of a rehabilitation program and may be covered under the 
TRICARE Basic Program when cognitive rehabilitation is not billed as a 
distinct and separate service. Under the TRICARE Basic Program, 
cognitive rehabilitation defined as ``services that are prescribed 
specifically and uniquely to teach compensatory methods to accomplish 
tasks which rely upon cognitive processes'' are considered unproven and 
are not covered when separately billed as distinct and defined 
services, except under the authority of section 1631. This section has 
a sunset provision of December 31, 2012.
    In our experience, the VA health benefit is intentionally 
structured to provide robust care to disabled veterans with long-term 
rehabilitation and other care needs.

    38. Senator Bayh. Secretary Chu, in her testimony before the Dole-
Shalala Commission this past summer, Colonel Joyce Grissom, the medical 
director for TRICARE Management Activity, told Commission members that 
TRICARE was at work reexamining the evidence to determine ``if some of 
the cognitive rehabilitation modalities can be brought in to the 
benefit for all [TRICARE] beneficiaries,'' and that a technical report 
would be provided to TRICARE officials this past August. Was this 
report provided to TRICARE officials, and if so, what were the results 
of this reexamination?
    Dr. Chu. The Emergency Care Research Institute (ECRI) completed the 
Cognitive Rehabilitation for the Treatment of Traumatic Brain Injury 
report and submitted it to the Department in July 2007. ECRI Institute 
is an independent, nonprofit health services research agency and a 
Collaborating Center for Health Technology Assessment of the World 
Health Organization.
    In its summary of findings, ECRI concluded that there was 
insufficient, evidence-based research available to conclude that 
Cognitive Rehabilitation Therapy (CRT) is beneficial in treating TBIs. 
The Department acknowledges that there is expert opinion recommending 
CRT in the treatment of TBI; however, expert opinion is the weakest 
support in the hierarchy of evidence used to determine coverage. The 
DOD will continue to look for future evidence-based research that 
objectively supports the efficacy of CRT in the treatment of TBI.
                                 ______
                                 
               Questions Submitted by Senator Mark Pryor

                            PRIVATE DOCTORS

    39. Senator Pryor. Secretary Mansfield, how many cases referred to 
private doctors for specialized care on a fee basis have not been paid?
    Secretary Mansfield. VA does not track its fee claims processing by 
the types of specialized care. Only aggregate data is available. The 
most recent claims processing data available are for January 2008.
    During the month of January 2008, a total of 797,247 claims were 
received for processing, including claims carried over from the month 
of December 2007. Of this total, 544,816 claims were processed and 
252,431 claims remained pending at the end of the month. The number of 
pending claims aged greater than 30 days at the end of the month was 
118,166 claims, or 14.8 percent of the total claims received.

    40. Senator Pryor. Secretary Mansfield, what is the problem?
    Secretary Mansfield. During fiscal year 2007, VHA has placed 
considerable focus upon timely processing of fee claims. This includes 
standardized reporting to assess outliers as well as determining 
necessary technology needs to meet significant program growth. 
Identified problems in achieving improved performance include the 
following:

         Receipt of incomplete claims from vendors lacking sufficient 
        supporting documentation necessary to adjudicate the claim;
         Significant growth in the use of the fee program to meet 
        access needs; and
         Improvements in information technology necessary to enhance 
        automation of claims processing, currently a significant 
        portion of claims processing is manual in nature.

    41. Senator Pryor. Secretary Mansfield, what are the solutions?
    Secretary Mansfield. The solution will combine additional staffing 
along with technology enhancements. During fiscal year 2008, VHA 
received additional funding support for this staffing requirement and 
facilities have been able to increase staffing levels in claims 
processing units to meet our targets. The President's budget includes 
resources that will help meet the growth in this program. An improved 
technology solution is being actively pursued, with a recent request to 
transfer dollars to the IT appropriation to meet this critical need. It 
is our intent to implement these changes in fiscal year 2009.

                             MENTAL HEALTH

    42. Senator Pryor. Secretary Geren and General Schoomaker, how are 
pre- and post-deployment mental health assessments being improved to 
adequately evaluate a soldier returning from combat overseas for the 
variable and unpredictable onset of PTSD?
    Secretary Geren and General Schoomaker. The Army continues to use 
existing medical surveillance systems to screen for a range of 
behavioral health issues, including PTSD. There have been no recent 
formal changes to the current screening process or questionnaires.
    Soldiers are screened in accordance with DOD Instruction 6490.03 
and the Deployment Cycle Support System. Soldiers are screened for both 
physical and mental/ behavioral health conditions prior to deployment, 
upon redeployment, and within 90-180 days after redeploying. The 
screenings consist of a self reporting section and an interview with a 
health care provider. Completed screenings are reported through the 
Medical Protection System to the Armed Forces Health Surveillance 
Center (AFHSC). The AFHSC staff performs analyses on the data stored in 
the Defense Medical Surveillance System to identify trends. The 
analysis and findings will be used to improve future pre and post 
mental health assessment tools.

    43. Senator Pryor. Secretary Geren and General Schoomaker, what 
type of reintegration programs is the military pursuing that helps our 
wounded warriors and their families not only heal both physically and 
emotionally, but instill confidence in their ability to tackle the 
challenges of life after the military as an injured veteran?
    Secretary Geren and General Schoomaker. The events of the last year 
have led to a strengthened partnership between the DOD and the VA. In 
close coordination with the VA, the Army has added 16 VA advisors at 
major MTFs to facilitate the process of applying for benefits and 
finalizing arrangements for follow-on care and services for a smooth 
transition to civilian status.
    The Army recently partnered with the University of Kansas to create 
the Wounded Warrior Education Initiative which will allow participants 
to complete a Master's degree, then return to the Army either in Active 
Duty status or as a civilian. The Combined Arms Center at Fort 
Leavenworth, KS, will benefit from these wounded warriors' education 
and personal experiences. In addition, the Army is currently piloting 
at Fort Bragg, NC, the Warrior Transition Employment Reintegration and 
Training Program which enables wounded warriors, working with the staff 
of the Soldier Family Assistance Centers, to receive education and 
training on how to create a resume, network, and develop job hunting 
skills. Through this program, WTs are assisted by counselors from the 
Army Wounded Warrior Program, Veterans Affairs advisors, and the staff 
of the Army Career and Alumni Program to develop a winning approach to 
obtaining employment when they leave the Army.
    Integral to the Army Medical Action Plan is the Comprehensive Care 
Plan (CCP). The CCP is a holistic approach to facilitate healing of the 
body, mind, heart, and spirit by having WTs follow the principles of 
being responsible for their own future, gaining more control over their 
lives, promoting health and a sense of well-being, maintaining a 
positive self identity, shaping satisfying social relationships, and 
overcoming social and cultural barriers. The CCP ensures attention is 
given to all these areas. Family members, caregivers, and others who 
are significant in each WT's life also play an integral role in the 
success WTs have in rehabilitating and becoming prepared to be 
productive when they are either able to return to duty or separate from 
service and become engaged and productive civilians.
    Additionally, the Army Wounded Warrior Program (AW2) was 
established to assist the most severely wounded soldiers and their 
families, throughout their lifetimes, regardless of location. AW2 is 
vital in helping the wounded warrior become self-sufficient, 
contributing members of our communities. AW2 provides unique services 
to the most severely wounded and their families by:

         Helping wounded soldiers remain in the Army by educating them 
        on their options and assisting them in the application process;
         Helping with future career plans and employment opportunities 
        beyond their Army careers;
         Supporting them with a staff of subject matter experts 
        proficient in non-medical benefits for wounded soldiers;
         Helping a soldier obtain full VA and Army benefits;
         Helping a soldier and their family get health care after 
        retiring from the Army; and
         Helping a soldier get financial counseling.

    Soldier Family Management Specialists located throughout the 
country at major MTFs and VA Medical Centers provide on the ground 
support to soldiers and their families from the time they arrive. 
Soldier Family Management Specialists act as career and education 
guides, benefits advisors, military transition specialists, local 
resource experts, family assistants, and life coaches.
    Companies have the opportunity to support those who sacrificed for 
our country by hiring soldiers severely wounded in the global war on 
terror. An important element in rebuilding the lives of severely 
wounded soldiers is gained through meaningful employment with companies 
throughout the world. AW2 links severely wounded, injured, or ill 
soldiers and companies together by providing personalized employment 
counseling and services. AW2 is vital in helping them become self-
sufficient, contributing members of our communities. AW2 coordinators 
work closely with the Army Career and Alumni Program to connect 
prospective employers with AW2 soldiers seeking work.
    Consistent with the objectives of the Army Medical Action Plan, the 
Army will continue to work with public and private entities to provide 
WTs the skills and assistance they require in their recovery to keep 
alive the ``can do'' attitude that characterizes these great men and 
women.

    44. Senator Pryor. Secretary Geren and General Schoomaker, many 
times soldiers do not want to admit to mental health problems. What 
assurances or instructions has the DOD provided to its military 
personnel who fear that identifying a mental health issue would 
adversely affect or jeopardize their careers?
    Secretary Geren and General Schoomaker. It is critically important 
that soldiers are able to seek help without worrying about the effects 
on their career. Soldiers and civilians alike are traditionally 
concerned about jeopardizing their security clearances. The Army is 
working with the DOD to revise the medical question on the security 
clearance form and eliminate that concern. During a soldier's service 
it is very likely that he or she can be called to deploy to a remote 
location away from family for sometimes extended lengths of time. The 
Army has recognized that building soldier and family resiliency is key 
to maintaining health and welfare. We developed ``Battlemind'' training 
products to increase this resiliency and have different training 
programs available for pre-, during, and post-deployment. These 
programs are designed for soldiers and their families, including 
children as young as pre-school aged, and they are distributed 
throughout the force. These programs are also available online anytime 
at www.behavioralhealth.army.mil.
    In a bold effort to both raise awareness and reduce the stigma 
associated with seeking mental health care, the Secretary of the Army 
and Chief of Staff of the Army initiated a leader chain teaching 
program to educate all soldiers and leaders about post-traumatic stress 
and signs and symptoms of concussive brain injury. This was intended to 
help us all recognize symptoms and encourage seeking treatment for 
these conditions. All soldiers were mandated to receive this training 
between July and October 2007, during which time we trained over 
800,000 soldiers. We are now institutionalizing this training within 
our Army education and training systems to continue to share the 
information with our new soldiers and leaders and to continue to 
emphasize that these signs and symptoms are a normal reaction to a 
stressful situation and it is absolutely acceptable to seek assistance 
to cope with these issues.
    Our efforts to decrease stigma appear to be having an impact. 
Findings from the most recent MHAT report show small but significant 
decreases in stigma. Rates of stigma are significantly lower in 2007 as 
compared to 2006 as reflected by responses to four of six survey 
questions related to stigma. Although we cannot draw a direct 
connection, this may be related to the leader chain teaching program 
and other Battlemind educational products.
                                 ______
                                 
             Questions Submitted by Senator Saxby Chambliss

                     NATIONAL INSTITUTES OF HEALTH

    45. Senator Chambliss. Secretary Chu, 2 years ago, a research group 
funded by the National Institutes of Health (NIH) reported very 
promising results with the use of progesterone, a hormone that appears 
to protect damaged brain tissue, in the treatment of civilian trauma 
patients with moderate to severe brain injury. The NIH moved forward 
with a planning grant and is expected to decide in March whether it 
will fund a major national clinical trial of this treatment in civilian 
trauma centers. If the NIH moves forward with this research, would DOD 
want to participate?
    Dr. Chu. The Department would consider offering some Military 
Health System sites and those of the Clinical Consortium being put in 
place under the Traumatic Brain Injury Broad Area Announcement by the 
Congressionally Directed Medical Research Program.

    46. Senator Chambliss. Secretary Chu, given the slow NIH funding 
process, do you believe DOD should support promising treatments (either 
by partnering with NIH or by a parallel process) in order to accelerate 
their validation?
    Dr. Chu. The Department partners routinely with the NIH, as well as 
engaging in its own extramural research program that supports early 
detection, diagnosis, and treatment of TBI.

    47. Senator Chambliss. Secretary Chu, would DOD consider providing 
additional funding to increase the number of civilian centers involved 
in testing a new treatment in order to find an answer more quickly?
    Dr. Chu. The Department is using funding from the Fiscal Year 2007-
2008 Supplemental Appropriations for psychological health and TBI, and 
is already investing in a clinical consortium to support that 
objective.

    48. Senator Chambliss. Secretary Chu, if this treatment is deemed 
to be promising enough by the NIH to warrant a major study to determine 
if it is effective, would DOD want to conduct its own study?
    Dr. Chu. That should not be necessary.

    49. Senator Chambliss. Secretary Chu, what type of partnership 
between DOD and NIH is appropriate to advance this type of research?
    Dr. Chu. The NIH already participates in the Department's research 
management process. If agreements that are more formal or transfer of 
funds for cooperative efforts are required, Interagency Agreements will 
be sufficient.

                         TRAUMATIC BRAIN INJURY

    50. Senator Chambliss. Secretary Geren and General Schoomaker, do 
you have the tools you need to make objective pre- and post-injury 
assessments of personnel with mild to moderate TBI?
    Secretary Geren and General Schoomaker. The diagnosis of mild TBI, 
also known as concussion, relies on the clinical interview. Throughout 
medicine there are no current gold-standard objective tests for the 
diagnosis of concussion. This is a very active area of investigation.
    For pre-injury assessment, in order to facilitate the evaluation 
and management of concussion, the Army has implemented a program to 
collect baseline neurocognitive data on Active and Reserve Forces prior 
to their deployment to combat theaters. The Automated 
Neuropsychological Assessment Metrics (ANAM) has thus far been 
performed on 40,000 soldiers predeployment. The Army has recently been 
funded to expand our neurocognitive assessment program to include all 
deploying personnel. We are actively coordinating with the Air Force, 
Navy, and Marines to test all deploying military personnel.
    Post-injury, all assessments are used in conjunction with the 
clinical evaluation. The Military Acute Concussion Evaluation (MACE) is 
a tool to standardize the clinical evaluation of those soldiers 
suspected of having a concussion. The application of the ANAM in 
Theater will give front-line providers another critical piece of 
information for the evaluation and management of injured 
servicemembers. The ANAM does not diagnose TBI, but importantly is able 
to measure the unseen, subtle effects of injury. Other post-injury 
assessments tests for concussion, including serologic biomarkers and 
the Brain Acoustic Monitor, are undergoing critical and necessary 
evaluation as post-injury objective tests.
    Moderate TBI is easier to detect since individuals have a loss of 
consciousness greater than 30 minutes and difficulty laying down new 
memories for greater than a day.

    51. Senator Chambliss. Secretary Geren and General Schoomaker, how 
much training is required for individuals to conduct these assessments?
    Secretary Geren and General Schoomaker. Training is a very 
important aspect of making objective post-injury assessments of mild 
TBI. Depending on the individual's background and experience with mild 
TBI, the amount of training required varies. We provide training and 
education to our providers prior to deployment, and while in Theater, 
to enhance their skills in this area. We are implementing a mandatory 
standardized web-based TBI training program for all healthcare 
professionals to include clinical support personnel. Training on 
administration of the ANAM is in progress for primary care providers 
and all deploying neuropsychologists. Additionally, we will soon be 
issuing guidance for implementing the revised 2008 PDHA and PDHRA forms 
that contain improved questions to more accurately screen for TBI.

    52. Senator Chambliss. Secretary Geren and General Schoomaker, how 
do you currently determine when a soldier or marine with a concussion 
or mild TBI is healthy enough to return to combat, and what technology 
is available to you to assist in these determinations?
    Secretary Geren and General Schoomaker. The Army's policy is to 
ensure the safety of the soldier first. When a servicemember has a 
concussion, healthcare providers use the MACE to standardize the 
appropriate evaluation and decisionmaking for diagnosis. Theater 
providers use a Clinical Practice Guideline that incorporates the MACE 
to delineate the pathways of care for concussion. These guidelines--
originally published in December 2006--have recently been updated by an 
in-theater TBI working group. After a concussion is diagnosed, soldiers 
receive appropriate step-wise care in accordance with the Theater 
guidelines. As an additional check to see if the servicemember has 
recovered completely, he or she is tested under conditions of physical 
activity. Furthermore, the ANAM can be utilized to provide an 
additional check to ensure that a servicemember does not have any 
undetected residual effects of concussion.

    53. Senator Chambliss. Secretary Geren and General Schoomaker, is 
it currently feasible to screen for mild TBI rapidly and accurately at 
MASH/CASH units in the field?
    Secretary Geren and General Schoomaker. Yes, the MACE is an 
effective and feasible method of acute TBI evaluation. To facilitate 
the evaluation and management of TBI, DOD is implementing a program to 
collect baseline neurocognitive data on Active and Reserve component 
prior to their deployment to combat theaters. Over 40,000 soldiers have 
been assessed to date. The Army has recently been funded to expand our 
neurocognitive assessment program to all deploying personnel and we are 
actively coordinating with the Air Force, Navy, and Marines to test all 
deploying military personnel.
    Initially, the Services will use the DOD-developed/DOD-owned ANAM 
tool to obtain baseline data. The ANAM is a computer-based instrument 
that measures reaction time, short-term memory, pattern matching, and 
mathematical processing. The ANAM takes approximately 15 minutes to 
complete and is being administered as part of the predeployment 
readiness processing.
    The application of this instrument in Theater will give front-line 
providers another critical piece of information for the evaluation and 
management of injured servicemembers. The ANAM does not diagnose TBI, 
but is able to measure the unseen, subtle effects of injury. DOD's 
expansion of the testing process will be guided by the ANAM tool, while 
data is collected to validate accurate clinical decisionmaking.
    The Defense Health Board is establishing a scientific advisory 
subcommittee to perform an ongoing review of the DOD neurocognitive 
assessment program.

    54. Senator Chambliss. Secretary Geren and General Schoomaker, have 
you evaluated novel assessment devices (e.g. DETECT) and would you be 
interested in validating and testing these new technologies?
    Secretary Geren and General Schoomaker. Yes, the Theater Medical 
Information Program is conducting an analysis of neurocognitive 
assessment tool alternatives. Also, the Defense and Veterans Brain 
Injury Center is planning a head-to-head evaluation of similar tools.

    55. Senator Chambliss. Secretaries Mansfield, Geren, Chu, and 
General Schoomaker, are you satisfied with the technology available to 
treat and diagnose TBI?
    Secretary Mansfield. I am satisfied that VA is leveraging the most 
advanced technologies and medical practices available to diagnose and 
treat veterans and servicemembers with TBI. Over the past 2 years, VA 
has provided more than $33 million to facilities across its polytrauma 
system of care for state-of-the-science technology and equipment, to 
provide the greatest potential for rehabilitation and recovery to 
injured veterans and Active Duty servicemembers. Additionally, the VA 
polytrauma tele-health network (PTN) provides a reliable and easily 
accessible tool to further coordinate and manage care.
    In fiscal year 2007, the PTN was expanded to include all polytrauma 
rehabilitation centers (PRC), polytrauma network sites, and several DOD 
MTFs. This ensures that the highest level of expertise for TBI 
available at the PRCs is readily accessible at locations nearer the 
veteran's home, through this state-of-the-art videoconferencing 
network.
    VA is leading this effort through its robust research and 
development programs, and will continue to integrate technology in its 
health care system as it emerges.
    Secretary Geren and General Schoomaker. We always seek to improve 
our health care and expect current research in TBI enabled by 
investment inside and outside government will help us improve our 
ability to diagnose and care for TBI. For moderate, severe, and 
penetrating TBI there are many technological advances in treatment and 
the Army is adding several neurosurgical care tools to the inventory. 
For mild TBI (mTBI) or concussion, military medicine is actively 
seeking answers to the diagnostic and therapeutic challenges. We, along 
with the VA and civilian medical systems, still have much to learn 
about the nature of the injury, objective tests, and optimal treatment 
of mTBI/concussion. Our medical professionals collaborate and partner 
with the Defense and Veterans Brain Injury Center and the DOD Medical 
Research Program for the prevention, mitigation, and treatment of blast 
injury, including mTBI/PTSD. There are several initiatives underway, to 
include an automated medication management tool, a web portal, and 
tele-medicine and tele-rehabilitation tools. Throughout this effort, we 
have received extraordinary support from the entire Army, the senior 
leadership of the DOD and the VA, as well as Congress. Together we are 
improving the way we protect our soldiers and the way we treat and 
rehabilitate injured warriors.
    The funds Congress provided will allow the Army Medical Department 
to research, develop, plan, and execute initiatives relevant to 
providing our patients and their families the highest quality and 
highest value of psychological healthcare and concussive injury 
treatment. We will continue to identify worthwhile investments to 
address the needs and gaps in care as we continue to focus on serving 
our soldiers and their families.
    Dr. Chu. The DOD continues to advance current technology in the 
prevention, detection, and management of TBIs through a robust research 
and development program. DOD has made gains since the start of the war 
in developing instruments and algorithms to assist in detection and 
management, but there is room for further improvement as we learn more 
about TBI sustained in an austere environment. We hope to continue the 
many collaborations we have with the academic and civilian community to 
determine where technology can further improve our assessment and 
management of TBI.

    56. Senator Chambliss. Secretaries Mansfield, Geren, Chu, and 
General Schoomaker, what are your acquisition and research priorities 
in this area?
    Secretary Mansfield. As TBI has emerged as a leading injury among 
U.S. Forces serving in military operations in Afghanistan and Iraq, 
VA's Office of Research and Development has adapted its existing 
neuroscience, trauma, and rehabilitative portfolios to the setting of 
polytrauma. VA-sponsored TBI and neurotrauma research priorities 
include projects aimed at the pathogenesis of injury, epidemiology 
(incidence and prevalence), cognitive and behavioral consequences, and 
the best means of treatment. The spectrum of VA-funded projects aligns 
itself with the characteristics of mild, moderate, and severe TBI. A 
challenging research priority has been that of augmenting the post-
deployment health questionnaire through improved tools that reliably 
diagnose TBI. In the case of mild TBI, physical symptoms such as 
headache or dizziness, emotional symptoms such as anxiety or 
irritability, cognitive deficits such as difficulty concentrating and 
even sleep disturbances, have provided clues that VA researchers are 
exploring in an attempt to refine screening instruments. Examples 
include:

         The Cognition and Stroke Risk Project: Gender and Cognitive 
        Decline (Brockton, NA)
         Functional Anatomy of Rapid Eye Movement Sleep, Brainstem 
        Control (Dallas, TX)
         Examining the Effectiveness of Cognitive Rehabilitation in 
        Veterans with Early Dementia and TBI (Decatur, GA)
         Demand Sensitive Rehabilitation for Executive Dysfunction 
        (Durham, NC)
         Attentional Disorders in Patients with Brain Injury 
        (Sacramento, CA)
         Diagnosing Combat-Related Mild TBI Using 
        Magnetoencephalography (San Diego, CA)
         Hypothalamic and Basal Forebrain Regulation of Sleep and 
        Arousal (Sepulveda, CA)

    Other VA-sponsored research seeks an improved understanding of 
neuroplasticity that may suggest improved pharmacologic as well as 
physical means of altering TBI outcomes. An emerging area of emphasis 
is that that of regenerative medicine which includes using somatic stem 
cell approaches to replace damaged neurons, and various approaches to 
stimulate axonal regrowth. Examples include:

         Regulation of Neuroglial Injury and Regeneration (Ann Arbor, 
        MI)
         Brain From Blood: Bone Marrow Derived Neurons Induced by 
        Stroke (Augusta, GA)
         Magnetic Resonance (MR) Tracking of Stem Cells for 
        Replacement Therapy in Amyotrophic Lateral Sclerosis (ALS) 
        (Baltimore, MD)
         Multimechanistic Spinal Cord Repair: Role of Stem Cells and 
        Scaffold (Brockton, MA)
         Central Nervous System (CNS) Plasticity Induced by Motor 
        Learning Technologies following Stroke (Cleveland, OH)
         Plasticity of Micturition-Related Neurons Following Spinal 
        Cord Injury (SCI) (Durham, NC)
         Grafting Neural Stem Cells for SCI: Analysis of Allodynia 
        (Milwaukee, WI)
         Plasticity-Based Motor Recovery after SCI (Philadelphia, PA)
         Axonal Regeneration in the Chronically Injured Spinal Cord 
        (San Diego, CA)

    Still other arms of the portfolio aim to improve outcomes by 
studying PTSD occurring so commonly among veterans affected by TBI. 
Visual and auditory changes have suggested additional research projects 
useful in understanding cranial nerve-mediated changes. Examples 
include:

         Center for Innovative Visual Rehabilitation (Boston, MA)
         Artificial Silicon Retinal (ASR) Retinal Prosthesis Efficacy 
        Evaluation (Decatur, GA)
         Early Detection of Noise-Induced Hearing Loss (Loma Linda, 
        CA)
         Preventing Jet Fuel and Noise-Induced Hearing Loss (Loma 
        Linda, CA)
         Auditory and Vestibular Dysfunction Research Enhancement 
        Award Program (Mountain Home, TN)
         Cognitive-Behavioral Treatments for PTSD Sleep Disturbance 
        (Philadelphia, PA)
         Development of Clinical Instrumentation for Tinnitus 
        Measurement (Portland, OR)
         Cerebrospinal Fluid (CSF) and Plasma Pro-Inflammatory 
        Cytokines: Relationship to Combat Exposure, PTSD and Health 
        Status (San Diego, CA)
         Basic Mechanisms in Hearing Loss of Cochlear Origin (San 
        Diego, CA)
         A Biological Interface for Cochlear Implants in Auditory 
        Rehabilitation (San Diego, CA)
         Progressive Intervention Program for Tinnitus Management 
        (Tampa, FL)

    In addition to the above projects, VA will initiate in fiscal year 
2008 a multi-site observational cohort study titled Neuropsychological 
and Mental Health Outcomes of OIF: A Longitudinal Cohort Study to 
examine war-related mental health dysfunction. The study will collect 
long-term follow-up data 3-5 years after military personnel return from 
their initial deployment to Iraq. The study will also determine the 
prevalence and course of PTSD among OIF veterans and assess the 
persistence of previously observed neuropsychological changes (in 
attention, verbal learning, visual memory, and reaction time) following 
war-zone participation. TBI will be examined as a possible risk factor 
for PTSD.
    Veterans suffering from moderate to severe TBI may benefit from a 
more applied series of rehabilitation research projects that examine 
veterans' reintegration into home and family, school and work, and a 
broader community. Other VA research priorities include the use of 
biomedical engineering or assistive devices that improve treatment and 
rehabilitation. Examples include:

         Pathways to Vocational Rehabilitation: Enhancing Entry and 
        Retention (Bedford, MA)
         A SCI Vocational Support Program: Implementation and Outcomes 
        (Cleveland, OH; Dallas, TX; and San Diego, CA)
         Rehabilitation Outcomes Research Center for Veterans with CNS 
        Damage (Gainesville, FL)

    Secretary Geren and General Schoomaker. The Army core research 
program is currently focused on diagnostics using biomarkers in the 
blood to help identify the level of physical injury to the brain and on 
the development of neuroprotection drugs to limit the amount of 
subsequent damage to the brain tissue if they are administered early 
after the injury.
    The Fiscal Year 2007 Supplemental funded-PTSD/TBI Research Program 
supports basic and clinically oriented research that will: (1) result 
in substantial improvements over today's approach to the treatment and 
clinical management of TBI, including diagnostics, (2) facilitate the 
development of novel preventive measures, and (3) enhance the quality 
of life of persons with TBI. Congress mandated that the Program be 
administered according to the highly-effective U.S. Army Medical 
Research and Materiel Command two-tier review process that includes 
both external scientific (peer) review, conducted by an external panel 
of expert scientists and programmatic review. Programmatic review is 
conducted by a Joint Program Integration Panel (JPIP), which consists 
of representatives from the Departments of Defense, Veterans Affairs, 
and Health and Human Services. The JPIP identified several gaps in TBI 
research including: (1) treatment and clinical management, (2) 
neuroprotection and repair strategies, (3) rehabilitation/reintegration 
strategies, (4) field epidemiology, and (5) physics of blast. Research 
proposals that address these gaps will have the highest priority in 
funding.
    Dr. Chu. There are priorities that are developed by consensus via 
the Tri-Service Joint Integration Program Panel hosted at the Army 
Medical Research and Materiel Command that will inform acquisition. 
There are priorities within the areas of prevention, detection, and 
management that may impact acquisition. Prevention priorities include 
primary prevention with a focused program on helmet protection that 
will span the spectrum from impact concussive injury to ballistic and 
blast injury using novel helmet design and composite materials such as 
cushioned pads for impact injury and nano-fibers for ballistic and 
blast mitigation. Detection and management priorities include 
evaluation of the optimal cognitive assessment instrument through a 
head-to-head analysis of the five leading products that will best 
inform acquisition. There continues to be treatment trials using a 
variety of modalities, techniques, and devices that will further inform 
acquisition decisions. Other priorities include the study of long-term 
sequela of TBI as evidenced by the congressionally-mandated 15-year 
study. There has also been identified a need to better understand the 
cumulative effects of repeat concussions.

    57. Senator Chambliss. Secretaries Mansfield, Geren, Chu, and 
General Schoomaker, what new basic research funding are DOD and the VA 
budgeting or planning for in developing new, more effective treatments 
for TBI?
    Secretary Mansfield. In fiscal year 2007, VA's Office of Research 
and Development supported over $43 million of research aimed at 
developing new, more effective treatments for the broad area of 
neurotrauma, including TBI, spinal cord trauma, neural regeneration, 
and associated sensory disorders. VA estimates funding a similar amount 
this fiscal year. However, because VA may still fund additional 
projects this fiscal year, total funding for fiscal year 2008 is not 
available until after the close of the fiscal year.
    To advance the treatment and rehabilitation of soldiers returning 
with these types of injuries, VA issued a request for research 
proposals that focus on TBI; cervical spinal cord injury; co-morbid 
conditions such as PTSD and trauma to extremities; screening and 
diagnostic tools related to mild TBI; and continuity of care between 
DOD and VA.
    Many exciting projects have emerged from this solicitation and 
other funding mechanisms to help veterans suffering from mild to severe 
TBI, including: (1) studying neural repair after brain injury to build 
a better understanding of cognitive rehabilitation, as well as find 
potential targets for practical treatments that enhance quality of 
life; (2) developing a project exploring community reintegration for 
servicemembers with TBI (to promote seamless transition between 
servicemembers currently being treated, or who will one day be treated, 
in both DOD and VA medical facilities); and (3) several studies 
assessing the relationship between TBI and PTSD and their impact on 
health outcomes.
    In addition, several VA scientists with expertise in neuroimaging 
and neuropsychology are turning their efforts to further understanding 
the brain changes that occur in TBI. This is important because 
following TBI there may be subtle, yet distinct, brain damage that 
results in memory, attention, thinking and personality changes that are 
difficult to diagnose and treat with current knowledge. A new study 
will start this year combining state-of-the-art imaging techniques 
(e.g., three-dimensional brain imaging and diffusion tensor imaging to 
examine white matter changes) with comprehensive neuropsychological 
assessments to fully characterize patients with TBI compared to other 
types of brain damage such as stroke. Knowledge from this study will 
help inform rehabilitation and diagnostic strategies.
    Further, VA has established a polytrauma and blast-related injury 
quality enhancement research initiative (PT/BRI QUERI) coordinating 
center to promote the successful rehabilitation, psychological 
adjustment, and community reintegration of veterans suffering from 
complex, multiple injuries. Two priorities have been identified: (1) 
TBI with polytrauma, and (2) traumatic amputation with polytrauma. The 
PT/BRI QUERI is working closely with VA polytrauma rehabilitation 
centers to identify needs and gaps in care, as well as best practices. 
VA also recently issued a special solicitation for research projects on 
the long-term care and management of veterans with polytrauma, blast-
related injuries, and/or TBI.
    Secretary Geren and General Schoomaker. The DOD Blast Injury 
Research Program has identified DOD basic research programs ($9 
million) for the Army and basic research unfunded requirements ($99.6 
million) from the Army and Navy, and the Defense Veterans Brain Injury 
Center for fiscal year 2008-fiscal year 2015 that address the Treatment 
and Clinical Management gap areas identified by the Joint Program 
Integration Panel which was convened in response to the fiscal year 
2007 war supplemental funding. These unfunded requirements will be 
identified in a future Program Objective Memorandum request.
    Additionally, through the fiscal year 2007 war supplemental, PTSD/
TBI Research Program is offering competitive funding for a Clinical 
Consortium, which will combine the efforts of the Nation's leading 
investigators to bring to market novel treatments or interventions that 
will ultimately decrease the impact of military-relevant PTSD and TBI 
within the DOD and the VA. Further, the Clinical Consortium is required 
to integrate with the DOD Center of Excellence (DCoE) for PTSD and TBI, 
which supports the DCoE's expediting the fielding of PTSD and TBI 
treatments and interventions. Several other award mechanisms offered by 
the PTSD/TBI Research Program will also support preclinical and 
clinical trials for more effective treatments for TBI.
    Dr. Chu. The DOD is completing the award process for $150 million 
authorized by Congress for TBI research. The allocations will include 
prevention, surveillance, and approaches to both basic science 
examining etiologies and mechanisms of TBI and diverse clinical 
treatments that include virtual reality, pharmacology, rehabilitation, 
and cognitive retraining. The listing of detailed grants funding will 
be available from the congressionally-directed Medical Research Program 
office following final approval.

    58. Senator Chambliss. Secretaries Mansfield, Geren, Chu, and 
General Schoomaker, what new basic research funding are DOD and the VA 
budgeting or planning for in developing treatments for the chronic 
treatment of TBI that may aid in neuroregeneration, as opposed to acute 
treatments for the earliest stages of the injury process?
    Secretary Mansfield. VA has established a PT/BRI QUERI coordinating 
center to promote the successful rehabilitation, psychological 
adjustment, and community reintegration of veterans suffering from 
complex, multiple injuries. Two priorities have been identified: (1) 
TBI with polytrauma, and (2) traumatic amputation with polytrauma. The 
PT/BRI QUERI is working closely with VA polytrauma rehabilitation 
centers to identify needs and gaps in care, as well as best practices.
    VA also recently issued a special solicitation for research 
projects on the long-term care and management of veterans with 
polytrauma, blast-related injuries and/or TBI.
    In addition, VA plans to expand its research efforts in 
regenerative medicine, using state-of-the-art techniques including cell 
and gene therapies, bioengineering and biomaterials, and molecular 
therapeutic agents. Molecular therapeutic agents may include, but not 
limited to enhancing the body's intrinsic repair mechanisms, as well as 
to replace damaged cells and tissues.
    In fiscal year 2007, VA's Office of Research and Development 
supported over $43 million of research aimed at developing new, more 
effective treatments for the broad area of neurotrauma, including TBI, 
spinal cord trauma, neural regeneration and associated sensory 
disorders. VA estimates funding a similar amount this fiscal year. 
However, because VA may still fund additional projects this fiscal 
year, total funding for fiscal year 2008 is not available until after 
the close of the fiscal year. Some exciting work in this area sponsored 
by VA includes:

         Delivery of Therapeutic Proteins to the CNS (Baltimore, MD)
         Help-seeking Behavior and Participation in Visual Impairment 
        Rehabilitation (Decatur, GA)
         Home-Based Tele-Health Stroke Care: A Randomized Trial for 
        Veterans (Decatur, GA)
         Diagnosing Combat-related Mild TBI using 
        Magnetoencephalography (San Diego, CA)
         Cognitive-Behavioral Treatments for PTSD Sleep Disturbance 
        (Philadelphia, PA)
         Clinical Translational Strategies for Neurological Recovery 
        (West Haven, CT)

    Secretary Geren and General Schoomaker. Research for long-term 
chronic care is not a core military research, development, test, and 
evaluation (RDT&E) funded program and therefore DOD has no new basic 
research funding currently planned or programmed specifically for 
chronic TBI treatment that may aid in neuroregeneration. The core 
military RDT&E combat casualty care research mission for TBI is focused 
on neuro-protection and acute treatment for the early stages of injury 
to prevent or minimize the level of injury. Within the planned military 
core research areas for neuro-protection and extremity tissue 
regeneration, new technologies and biologic mechanisms may be 
discovered that may lend to the future work in neuroregeneration.
    The fiscal year 2007 supplemental funded-PTSD/TBI Research Program 
does have a component with a focus on neuro-protection and repair 
strategies. There are 17 proposals focused on neuro-protection and 
repair strategies competing for the $63 million TBI research funds for 
which funding recommendations will be made in early March.
    Dr. Chu. The Department plans to develop at least one regenerative 
center utilizing the latest technology in autologous stem cell 
research. In addition, the Defense Center of Excellence for 
Psychological Health and Traumatic Brain Injury is interacting with 
Stem Cell Incorporated, a company that has developed hormonal 
stimulation techniques for endogenous neural stem cells in stroke using 
Food and Drug Administration approved drugs. The direct transfer of 
such technology to TBIs may require more preclinical data but it is 
possible that such an approach could then be fast-tracked into a 
randomized clinical trial. The Defense and Veterans Brain Injury Center 
network would be the ideal environment and context in which to develop 
such a trial.

    59. Senator Chambliss. Secretaries Mansfield, Geren, Chu, and 
General Schoomaker, what new basic research funding are DOD and the VA 
budgeting or planning for in pre-clinical research into TBI treatments 
in the acute or chronic stages of the disease?
    Secretary Mansfield. In fiscal year 2007, VA's Office of Research 
and Development supported over $43 million of research aimed at 
developing new, more effective treatments for the broad area of 
neurotrauma, including TBI, spinal cord trauma, neural regeneration and 
associated sensory disorders. VA estimates funding a similar amount 
this fiscal year. However, because VA may still fund additional 
projects this fiscal year, total funding for fiscal year 2008 is not 
available until after the close of the fiscal year.
    Some exciting work in this area sponsored by VA includes:

         Neural Transplantation of Cultured Human-Derived Cells in 
        Stroke (Augusta, GA)
         Schwann Cell Influence on Pathway Reinnervation (Durham, NC)
         Nogo-A Blockade and Functional Recovery after Stroke in the 
        Aged (Hines, IL)
         Templated Scaffolds for Spinal Cord Regeneration (San Diego, 
        CA)
         Investigation of Rehabilitation-Induced Plasticity in Brain 
        Networks (San Francisco, CA)

    Secretary Geren and General Schoomaker. The DOD Blast Injury 
Research Program has identified DOD pre-clinical programs ($23.8 
million) and unfunded requirements ($9.5 million) for the Army in 
fiscal years 2008-2015.
    The DOD's investment strategy for the fiscal year 2007 war 
supplemental appropriation (TBI $150 million) included multiple 
Intramural (DOD and VA) and Extramural award mechanisms focused 
primarily on pre-clinical TBI research. The funding mechanisms include 
the Concept award, which supports the exploration of a new idea or 
innovative concept that could give rise to a testable hypothesis; the 
Investigator-Initiated Research award which supports basic and 
clinically oriented research; the Advanced Technology-Therapeutic 
Development Award, which supports demonstration studies of 
pharmaceuticals (drugs, biologics, and vaccines) and medical devices in 
preclinical systems and/or the testing of therapeutics and devices in 
clinical studies; the New Investigator award, which supports bringing 
new researchers into the field of TBI; and the Multidisciplinary 
Research Consortium Award is intended to optimize research and 
accelerate the solution of a major overarching problem in TBI research 
within an integrated consortium of the most highly-qualified 
investigators.
    Dr. Chu. Both the Defense Center of Excellence for Psychological 
Health and Traumatic Brain Injury and the Armed Forces Institute of 
Pathology have collaborated to develop a Biophysics Traumatic Brain 
Injury Laboratory which will focus on pre-clinical investigations to 
include development and testing. Further indications of pre-clinical 
priorities can be found in the Broad Agency Announcement of the 
congressionally-directed Medical Research Program project being managed 
by the Army Medical Research and Materiel Command (MRMC). The final 
round of MRMC programmatic review for funding is being completed this 
week. The funded research includes extensive funding for protocols 
involving pre-clinical research into treatments for both acute and 
chronic TBI.
                                 ______
                                 
              Questions Submitted by Senator Roger Wicker

                            MEDICAL RECORDS

    60. Senator Wicker. Secretary England and Secretary Mansfield, I 
appreciate the progress the two Departments have made in sharing health 
information. I am frustrated that what you have described still seems 
to be a patchwork of link-ups between legacy systems. What progress has 
been made and what obstacles are there to developing a personal, 
portable electronic medical record for members and veterans?
    Secretary England. Leveraging existing complex clinical systems and 
in-place infrastructure has allowed the DOD and the VA to make 
significant strides in information sharing over the past several years. 
At the same time, we have taken advantage of the support that Congress 
has provided through the direction to establish a Joint Incentive Fund 
and the authorization to initiate pilot projects under the National 
Defense Authorization Act.
    This strategy has allowed us to share clinically useful information 
more quickly. It has also provided us with a better understanding of 
how best to proceed in our broader, more mature DOD/VA enterprise-level 
information sharing efforts.
    Currently, we are developing a Joint DOD/VA Information 
Interoperability Plan as a roadmap to better integrate our approach to 
implementing information sharing. The basis for our sharing of 
information requires an agreement on what data elements need to be 
shared and, for each, the level of interoperability. The ability for a 
clinician to be able to view a particular piece of information is 
obviously valuable. However, for some purposes, significant additional 
value can be derived if the data elements can be shared in such a way 
to enable computer assisted decisionmaking or computation.
    While we believe that we have optimized information sharing from 
our existing legacy systems, we also believe more can be done to add 
greater long-term value to the clinicians and servicemembers, veterans, 
and their families. The interoperability plan will guide us in 
prioritizing our sharing efforts and determining how best to address 
the development and/or procurement of new software applications and 
information technology systems jointly. Approaching these broader 
initiatives jointly helps to ensure that we will be able to more easily 
share information between the clinicians in our two Departments.
    The DOD/VA inpatient electronic health record initiative builds on 
the lessons learned and successes from legacy system data sharing, and 
is a prime example of how we are moving towards greater and greater 
interoperability. The feasibility assessment was completed. We are now 
in the process of assessing alternative technical approaches. This 
assessment will result in the selection of a technical approach in the 
fall of this year.
    Further, DOD and VA are jointly working to develop network trusted 
partnership which will allow the Departments to securely share data 
seamlessly across our communication infrastructures. Additional 
communication gateways are planned to allow for the increased volume of 
data sharing and provide redundancy. This infrastructure enhancement 
will serve as the backbone for implementation of many of the 
initiatives highlighted in the Dole/Shalala report.
    A personal, portable electronic medical record will draw 
information from the clinical information repositories, potentially 
from both DOD and VA sources. Some of that data will be from legacy 
systems, bringing with it the challenges inherent in working with the 
older technology. The implementation of newer technologies will address 
many of those challenges. The trusted partnership will address current 
challenges and any need for linkages to systems across DOD and VA.
    In December 2007, DOD initiated a proof of concept project to 
provide beneficiaries who have common access card access to a subset of 
data drawn from the DOD electronic health record, AHLTA. That data set 
includes the ability for the beneficiary to view allergy information, 
demographic information (name, social security number, date of birth, 
gender, marital status, race, religion, contact information, 
eligibility and enrollment data, and other health insurance). It also 
allows the beneficiary to view their medication profile including 
medication information from MTFs, civilian pharmacies, TRICARE Mail 
Order Pharmacy (TMOP), VA, and over the counter medications.
    The next phase of the DOD personal health record (PHR) project will 
allow the beneficiary to view nonsensitive chemistry and hematology lab 
results, and encounter notes (nonmental health). It will also enable 
beneficiaries to self enter information into a personal health journal. 
Initially this will be health history and health trackers. During phase 
II, options will be explored to enable PHR access for those who do not 
have Common Access Cards.
    Further development will continue to expand the scope of the PHR 
and extend it to all beneficiaries.
    Secretary Mansfield. VA and DOD are working together to address 
challenges related to VA obtaining access to DOD data. Despite these 
challenges, VA and DOD are now sharing unprecedented amounts of 
electronic medical data. Over the past several years, VA and DOD have 
worked to develop incremental data exchange, which now support the one 
way and bi-directional exchange of most health data that are available 
in electronic format. VA and DOD continue to collaborate in developing 
innovative methods of sharing data between one another. Some examples 
of these efforts include:

         1. Bi-directional exchange of data. In order to better support 
        VA/DOD interoperability, particularly in the global war on 
        terror efforts, both organizations are emphasizing bi-
        directional information exchange as a central requirement. Data 
        from areas such as pharmacy, allergy, laboratory, and radiology 
        are currently exchanged in a textual format for full data 
        sharing. This information exchange means that a veteran's 
        record becomes immediately more comprehensive and more 
        portable.
         Taking this exchange one step further, both VA and DOD are 
        working toward establishing data exchange that are both fully 
        bi-directional, as well as computable, which means the data can 
        be leveraged by both systems' electronic decision support 
        tools. Examples of VA/DOD data sharing efforts include both bi-
        directional health information exchange (BHIE) and clinical 
        health data repository (CHDR), details of which include:

                 a. BHIE. Deployed to all VA facilities in October 
                2004.
                 b. CHDR. Shares computable health record data elements 
                between DOD's clinical data repository (CDR) and VA's 
                health data repository (HDR). Data are exchanged for 
                patients identified and matched as active dual 
                consumers (ADC) of both VA and DOD health care. VA and 
                DOD conducted the first successful test of CHDR in a 
                live patient environment in June 2006, and expanded to 
                seven locations between DOD and VA. The key feature of 
                CHDR is the exchange of standardized, computable (as 
                opposed to textual) data. CHDR currently exchange 
                pharmacy and allergy data elements. In April 2007, VA 
                released remote data interoperability (RDI), which 
                extended the existing local drug-drug and drug-allergy 
                order checks, to include data from all VA and DOD 
                facilities, at which a patient was treated. This 
                ensures electronic decision support tools are based on 
                all available electronic patient health information.

         2. Global War on Terror. The ``Big 7'' projects are developed 
        to facilitate a smooth transition between DOD and VA for global 
        war on terror veterans and expedite transfer and improve 
        management of polytrauma and TBI patients. The ``Big 7'' 
        include:

                 a. OEF/OIF combat veteran identifier
                 b. TBI database which supports tracking, care quality 
                monitoring, trend analysis, and performance improvement
                 c. Polytrauma marker

                         i. Addresses special needs of polytrauma 
                        patients
                         ii. Provides alerts and reminders and supports 
                        consistent management, reporting and displaying 
                        of important patient characteristics

                 d. DOD/VA BHIE-CDR (theater) interface provides an 
                interface to OEF/OIF theater data in DOD's theater 
                medical data system (TMDS) using BHIE framework
                 e. Joint patient tracking application (JPTA)/veterans 
                tracking application (VTA)

                         i. Gives VA providers access to critical 
                        demographic and patient health information from 
                        the theater of operations in DOD's JPTA system
                         ii. Establishes a link in VA's VistAWeb and 
                        the CPRS tools menu

                 f. Clinical transfer form acts as nursing patient 
                transfer document providing patients situation, 
                background, assessment, and recommendations
                 g. DOD scanning interface attaches scanned DOD patient 
                records to clinical document notes accessible across VA

         In March 2008 we completed three data sharing initiatives (1) 
        inpatient consults, (2) operative reports, and (3) establishing 
        plans for the movement of medical images.
         3. National Health Information Network (NHIN): Led by Health 
        and Human Services, the VA and DOD both participate in the 
        establishment of the NHIN. The NHIN is intended to provide a 
        secure, nationwide, interoperable health information 
        infrastructure that will connect providers, consumers, and 
        others involved in supporting health and health care. The NHIN 
        will enable health information to follow the consumer, be 
        available for clinical decisionmaking, and support appropriate 
        use of healthcare information beyond direct patient care so as 
        to improve health. The Office of the National Coordinator for 
        Health IT has invited a Federal Consortium of 26 agencies, 
        including VA, DOD, HIS, and SSA to participate in the NHIN 
        fiscal year 2008 trial implementation and fiscal year 2009 
        production deployment. The Health Information Technology 
        Sharing (HITS) Program and Software Engineering and Integration 
        (SE&I) architects are engaged in the fiscal year 2009 objective 
        to demonstrate patient data exchange among selected agencies in 
        a production environment based on the standards specifications 
        from Integrating the Healthcare Enterprise (IHE) and the Health 
        Information Technology Standards Panel (HITSP). Implementation 
        of this project will support sharing of standards-based 
        electronic patient health information with private and Federal 
        health care providers.
         Future Plans. In light of the global war on terror efforts and 
        other existing VA/DOD information exchange programs, the two 
        organizations have a number of plans for future efforts. The 
        table below provides timelines regarding detailed information 
        sharing milestones, and the list following the table, provides 
        insight into additional efforts.

------------------------------------------------------------------------
                                              Target Completion (by the
         Data Sharing Initiatives                      end of)
------------------------------------------------------------------------
Vital signs...............................  June 2008
Joint inpatient phase 2 analysis -          July 2008
 technical feasibility.
Family history............................  September 2008
Questionnaires and forms..................  September 2008
Other history.............................  September 2008
Social history............................  September 2008
Bidirectional health information exchange - September 2008
  VA-DOD imaging.
------------------------------------------------------------------------

         1. Continue to support one-way and bi-directional exchange 
        with existing domains of textual data through BHIE (laboratory, 
        pharmacy, radiology, and allergy) and FHIE.
         2. Enhance BHIE to exchange medical images and scanned 
        documents.
         3. Expand the use of CHDR for exchange of computable 
        electronic health record data to other appropriate and agreed-
        upon domains.
         4. Automate marking of active dual consumers.
         5. Enhance RDI to include additional CHDR data elements in 
        electronic decision support as they become available.

    Challenges: The issues which the implementation of VA/DOD 
interoperability projects face centered around the difficulty both VA 
and DOD staff have encountered in maintaining a solid operating status 
in the production environment of the current system. While the HHS-led 
NHIN effort could be considered a long-term strategy for 
interoperability, it is not yet mature. In working on this and the 
other interoperability solutions, neither agency foresaw the level of 
resource allocation, necessary to preserve the production linkage, and 
pinpointing the exact sources of the issues has proven difficult. 
Additionally, these projects are largely based upon the future 
HealtheVet/common services environment. Because not all components of 
this infrastructure are as yet in place and mature, the development 
staff on the project sometimes must engineer alternate solutions, 
slowing progress on overall system development. Finally, the mediation 
of standards between agencies presents some management challenges.

                            LEGAL ASSISTANCE

    61. Senator Wicker. Secretary Geren, during our examination of 
Walter Reed and our military healthcare process, I was troubled to 
learn of the many soldiers waiting for legal assistance during the 
Physical Evaluation Board (PEB)/Medical Evaluation Board (MEB) process. 
In some cases, soldiers hired their own attorneys at personal expense 
because of the tremendous backlogs. As a former member of the House 
Appropriations Defense Subcommittee, I offered an amendment that was 
accepted into last year's supplemental appropriation that would 
implement the recommendations of the Army Inspector General to provide 
trained military attorneys dedicated to representing soldiers who are 
pursuing claims before evaluation boards. What obstacles lay in the way 
of recruiting and retaining staff, case managers, advocates, and legal 
staff?
    Secretary Geren. Recruiting and retaining case managers, advocates, 
and legal staff can be challenging, particularly in some of the rural 
areas where our WTUs are located. Despite these challenges, our WTUs 
were staffed at about a 90 percent staffing level on February 6, 2008. 
We have used a combination of civilian hires and military personnel 
from the Active and Reserve components in order to achieve this level 
of staffing.
    The Army has demonstrated its commitment to provide soldiers and 
families the legal advocacy and assistance they require by specifically 
addressing this important support in the Army Medical Action Plan. The 
Army mobilized 18 Reserve component lawyers and legal assistants to 
provide legal counsel and advocacy for soldiers going through the Army 
Physical Disability System process. We are also pursuing a plan to 
expand this program by providing a lawyer and a paralegal at every 
Warrior Transition Battalion.
    The Army is greatly appreciative of the assistance Congress 
provided in the Fiscal Year 2007 Supplemental Appropriations Act and 
the National Defense Authorization Act for 2008. The expanded hiring 
authorities in these Acts will help DOD attract and hire needed 
healthcare professionals. We have hired 138 mental health professionals 
with the intent to hire a total of 274.

    [Whereupon, at 12:04 p.m. the committee adjourned.]

                                 
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