[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


                                     

                         [H.A.S.C. No. 111-26]

                      MEDICAL INFRASTRUCTURE: ARE

                         HEALTH AFFAIRS/TRICARE

                     MANAGEMENT ACTIVITY PRIORITIES

                   ALIGNED WITH SERVICE REQUIREMENTS?

                               __________

                             JOINT HEARING

                               BEFORE THE

                    MILITARY PERSONNEL SUBCOMMITTEE

                          MEETING JOINTLY WITH

                         READINESS SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                             MARCH 18, 2009

                                     
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13

                                     

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                    MILITARY PERSONNEL SUBCOMMITTEE

                 SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas                 JOE WILSON, South Carolina
LORETTA SANCHEZ, California          WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam          JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania      THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia                MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire     JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
                David Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                     Rosellen Kim, Staff Assistant
                                 ------                                

                         READINESS SUBCOMMITTEE

                   SOLOMON P. ORTIZ, Texas, Chairman
GENE TAYLOR, Mississippi             J. RANDY FORBES, Virginia
NEIL ABERCROMBIE, Hawaii             ROB BISHOP, Utah
SILVESTRE REYES, Texas               MIKE ROGERS, Alabama
JIM MARSHALL, Georgia                TRENT FRANKS, Arizona
MADELEINE Z. BORDALLO, Guam          BILL SHUSTER, Pennsylvania
HANK JOHNSON, Georgia                K. MICHAEL CONAWAY, Texas
CAROL SHEA-PORTER, New Hampshire     DOUG LAMBORN, Colorado
JOE COURTNEY, Connecticut            ROB WITTMAN, Virginia
DAVID LOEBSACK, Iowa                 MARY FALLIN, Oklahoma
GABRIELLE GIFFORDS, Arizona          JOHN C. FLEMING, Louisiana
GLENN NYE, Virginia                  FRANK A. LoBIONDO, New Jersey
LARRY KISSELL, North Carolina        MICHAEL TURNER, Ohio
MARTIN HEINRICH, New Mexico
FRANK M. KRATOVIL, Jr., Maryland
BOBBY BRIGHT, Alabama
               David Sienicki, Professional Staff Member
                Thomas Hawley, Professional Staff Member
                     Megan Putnam, Staff Assistant


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2009

                                                                   Page

Hearing:

Wednesday, March 18, 2009, Medical Infrastructure: Are Health 
  Affairs/TRICARE Management Activity Priorities Aligned with 
  Service Requirements?..........................................     1

Appendix:

Wednesday, March 18, 2009........................................    23
                              ----------                              

                       WEDNESDAY, MARCH 18, 2009
MEDICAL INFRASTRUCTURE: ARE HEALTH AFFAIRS/TRICARE MANAGEMENT ACTIVITY 
             PRIORITIES ALIGNED WITH SERVICE REQUIREMENTS?
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Military Personnel Subcommittee....................     2
Ortiz, Hon. Solomon P., a Representative from Texas, Chairman, 
  Readiness Subcommittee.........................................     1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking 
  Member, Military Personnel Subcommittee........................     3

                               WITNESSES

Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for 
  Health Affairs.................................................     4
Potochney, Peter, Director, Basing, Office of the Deputy Under 
  Secretary of Defense, Installations and Environment............     7
Robinson, Vice Adm. Adam, USN, Surgeon General, U.S. Navy........    10
Roudebush, Lt. Gen. James G., USAF, Surgeon General, U.S. Air 
  Force..........................................................     9
Schoomaker, Lt. Gen. Eric, USA, Commanding General, U.S. Army 
  Medical Command, Surgeon General, U.S. Army....................    12

                                APPENDIX

Prepared Statements:

    Casscells, Hon. S. Ward......................................    32
    Davis, Hon. Susan A..........................................    28
    Forbes, Hon. J. Randy, a Representative from Virginia, 
      Ranking Member, Readiness Subcommittee.....................    30
    Ortiz, Hon. Solomon P........................................    27
    Potochney, Peter.............................................    47
    Robinson, Vice Adm. Adam.....................................    63
    Roudebush, Lt. Gen. James G..................................    58
    Schoomaker, Lt. Gen. Eric....................................    68
    Wilson, Hon. Joe.............................................    31

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mr. Kline....................................................    77

Questions Submitted by Members Post Hearing:

    Ms. Bordallo.................................................    88
    Mr. Kissell..................................................    87
    Mr. Wilson...................................................    81


 
MEDICAL INFRASTRUCTURE: ARE HEALTH AFFAIRS/TRICARE MANAGEMENT ACTIVITY 
             PRIORITIES ALIGNED WITH SERVICE REQUIREMENTS?

                              ----------                              

        House of Representatives, Committee on Armed 
            Services, Military Personnel Subcommittee, 
            Meeting Jointly with Readiness Subcommittee, 
            Washington, DC, Wednesday, March 18, 2009.

    The subcommittees met, pursuant to call, at 2:06 p.m., in 
room 2118, Rayburn House Office Building, Hon. Solomon P. Ortiz 
(chairman of the Readiness Subcommittee) presiding.

 OPENING STATEMENT OF HON. SOLOMON P. ORTIZ, A REPRESENTATIVE 
          FROM TEXAS, CHAIRMAN, READINESS SUBCOMMITTEE

    Mr. Ortiz. The subcommittee will come to order.
    Today, the Readiness Subcommittee and the Military 
Personnel Subcommittee will meet in a joint session to receive 
a briefing on how the Department is managing their medical 
military construction program.
    As our Nation responds to different threats, we adapt and 
change our strategy and the force structure of our military, 
and one of the most recent decisions to change our force 
structure has been to expand the Army and Marine Corps and add 
74,000 soldiers and 27,000 Marines.
    The services have been steadily applying facility funds to 
accommodate this growth, but some areas are significantly 
lacking, including medical facilities to support the growing 
force.
    It is imperative that the men and women that join our Armed 
Forces are provided the best medical care possible.
    To this end, I am glad that we provided almost $1.3 billion 
to support medical facilities deficiencies in the stimulus 
bill.
    I hope that the witnesses will take the opportunity to 
address the Department's investment priorities on how they are 
managing to address medical facilities needs for all of our 
growing installations.
    On a related point, our subcommittees had the opportunity 
to visit Bethesda yesterday and we were amazed at the 
resilience of the wounded warriors, their high spirits, their 
bravery, their dedication to our country.
    And to receive men and women at Bethesda within 48 hours of 
a casualty from anywhere in the world is an amazing feat, and I 
was very, very impressed to know that.
    This capability that exists today will be particularly 
challenged when the Walter Reed complex is realigned to 
Bethesda and Fort Belvoir.
    We were briefed that the majority of care will be moved 
from the Walter Reed campus in August of 2011. With the 
construction of almost $2 billion in the National Capital 
Region (NCR), in addition to commissioning the facilities and 
installing complex equipment, there is no question that this 
will be a very difficult task.
    A seamless transition from Walter Reed to Bethesda and Fort 
Belvoir is essential to provide the quality of care for our 
wounded warriors.
    [The prepared statement of Mr. Ortiz can be found in the 
Appendix on page 27.]
    The chair now recognizes the distinguished chairwoman from 
California, Mrs. Davis, for any remarks that she would like to 
make.
    Mrs. Davis.

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
    CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE

    Mrs. Davis. Thank you. Thank you, Chairman Ortiz, Mr. 
Forbes and Mr. Wilson, for this joint hearing of the Readiness 
and Military Personnel Subcommittees.
    The Military Personnel Subcommittee is tasked with 
oversight of the defense health program and the Readiness 
Subcommittee with the oversight of military construction.
    While our staffs have already spent lots of quality time 
together on this topic, it is good that we are meeting jointly 
to receive testimony and explore the issue of medical military 
construction.
    As Chairman Ortiz mentioned, it is vital that we program 
and build the infrastructure required to support the expansion 
of the Army and the Marine Corps. It is our responsibility to 
ensure that our service members and their families, 
specifically, their families, too, have the facilities they 
need from the outset and not be forced to wait years before 
these facilities are even programmed, let alone built.
    We must also ensure that the recommendations of the Base 
Realignment and Closure Commission are implemented.
    Yet another reason to have this hearing is the fact that 
medical military construction is handled differently by the 
Department of Defense and all other military construction 
(MILCONs). That is not to say that it is bad different or good 
different, just different.
    Consequently, it is both appropriate and responsible 
oversight for our two subcommittees to examine this process so 
that we may understand exactly how the Department analyzes, 
prioritizes, budgets and then builds medical facilities.
    We must also keep in mind the long-term enduring costs of 
maintaining these facilities once they are completed.
    Today, we will hear from all of the relevant parties within 
the Department of Defense (DOD). Dr. Ward Casscells, the 
Assistant Secretary of Defense for Health Affairs, will 
describe how Health Affairs/TRICARE Management Activity (TMA) 
prioritizes projects.
    Mr. Peter Potochney, director of basing for the office of 
the deputy under secretary of defense for installations and 
environment, will speak to Base Realignment and Closure (BRAC) 
issues.
    Finally and importantly, we will hear from the service 
surgeons general, Lieutenant General Roudebush from the Air 
Force and Vice Admiral Robinson from the Navy, and Lieutenant 
General Schoomaker from the Army, of how well the current 
process supports their requirements.
    Welcome to all of you and thank you very much for being 
with us.
    Throughout our conversations today, it should go without 
saying that all of us, both members of the legislative and 
executive branches, are committed to providing the very best 
care possible to service members, their families and our 
retirees.
    Chairman Ortiz rightly mentioned the impressive feats that 
our military health system has made routine.
    On Monday, many of us had a chance to meet and speak with a 
wounded warrior at Bethesda. Given how recently he was wounded 
and the type and extent of his injuries, it was awe inspiring 
to see how far he has come so quickly.
    All of his caregivers agreed that just a few years ago, any 
recovery, let alone one as dramatic as his, would have been all 
but impossible. That the standard of care has risen to such a 
high is a testament to the commitment displayed on a daily 
basis by everyone who is associated with the military health 
system.
    We must all do our part to make sure this trend continues.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 28.]
    Thank you, Mr. Ortiz. We look forward to the hearing.
    Mr. Ortiz. The chair now recognizes the distinguished 
gentleman from South Carolina, Mr. Wilson.

   STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH 
   CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. Wilson. Thank you, Chairman Ortiz.
    And it is an honor for me to be here today with Chairwoman 
Davis. I appreciate joining our good friends on the Readiness 
Subcommittee, led by Chairman Solomon Ortiz and Ranking Member 
Randy Forbes, for our hearing on military medical construction.
    I welcome the distinguished members of our witness panel.
    At this time, Congressman Forbes is actually in a markup of 
the Judiciary Committee, and I would like to move for unanimous 
consent to submit his opening statement for the record.
    Mr. Ortiz. Without objection, so ordered.
    [The prepared statement of Mr. Forbes can be found in the 
Appendix on page 30.]
    Mr. Wilson. I believe that there is nothing more important 
than providing the outstanding members of our military, their 
families and our retirees with world-class health care 
delivered in world-class medical facilities.
    There is no question, in my mind, that they deserve nothing 
less.
    As the grateful father of four sons in the military today, 
our family has experienced the quality service, with two 
grandsons born at Bethesda National Naval Medical Center, and a 
granddaughter born at Portsmouth Naval Hospital.
    With that being said, I understand that there are a number 
of military treatment facilities that are 30 or more years old. 
In the district I represent in South Carolina, Moncrief Army 
Community Hospital at Fort Jackson was built in 1972 and the 
Navy hospital at Beaufort was built in 1947.
    I know that the outstanding medical personnel in each of 
these facilities provide excellent care to our troops and their 
families.
    On personal tours of each facility, I have been very 
impressed by the dedicated and competent professional personnel 
I have met.
    I also know that as a medical facility gets older, it is 
more challenging to keep up with the advances in medicine.
    As I prepared for the hearing today, I was reminded that 
the planning process for military medical construction is very 
different than that for other types of construction within the 
Department of Defense.
    I am interested to hear from our panel why medical 
construction is unique within the Department. To that end, 
today, I hope to hear from our witnesses how the Department and 
the military services plan to spend medical construction 
dollars to either replace or modernize our military hospitals.
    The members of our Armed Forces deserve the best.
    With that, I would like to thank our witnesses for 
participating in the hearing today. I look forward to your 
testimony.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 31.]
    Mr. Ortiz. Today, we are very honored to have with us five 
distinguished witnesses representing the Department of Defense.
    We have the honorable Ward Casscells, the Assistant 
Secretary of Defense for Health Affairs; Mr. Pete Potochney, 
Office of the Under Secretary of Defense for Installations and 
Environment; Lieutenant General Eric Schoomaker, the Surgeon 
General of the Army; Vice Admiral Adam Robinson, Surgeon 
General of the Navy; and, Lieutenant General James Roudebush, 
Surgeon General of the Air Force.
    Without any objection, all of your testimony will be put in 
the record.
    Mr. Casscells, whenever you are ready, you can begin your 
testimony, sir.

STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY 
                 OF DEFENSE FOR HEALTH AFFAIRS

    Secretary Casscells. Thank you, Chairman Ortiz, Chairwoman 
Davis, Ranking Member Wilson.
    I am delighted to be here with my colleagues and I cannot 
tell you how much we appreciate your interest in our facilities 
and your recent visit to Walter Reed.
    Joining me here today, from left to right, I think you have 
already mentioned, General Schoomaker, General Roudebush, Mr. 
Pete Potochney, who is representing Wayne Arny, the director of 
installations and environment, and Vice Admiral Robinson.
    Secretary Gates has said over and over again that our 
service members and their families deserve the best medical 
facilities possible. We certainly agree with him and we 
appreciate very much the fact that the Congress has taken that 
to heart.
    Let me be frank. We do not have big corporations and others 
for whom this is a top priority calling you. This is the group 
that advocates for military medical facilities and we are very 
grateful that you have taken it to heart.
    We are in a bit of an awkward position today, because the 
President's budget won't come to you until April. In fact, we 
don't have the details ourselves.
    We know what we have requested, and this is being arm-
wrestled with the Office of Management and Budget (OMB) and the 
comptroller and so forth now.
    So we don't know. We won't be able to answer some of your 
questions the way we would like to.
    Likewise, the details of the stimulus proposal and our 
military medical construction proposals, as part of that bill, 
are not yet approved. I can tell you that we have requested a 
balanced construction program favoring the urgent, the 
strategic and the joint.
    We also are a little bit handicapped today in the sense 
that we don't have the report from the independent review of 
the hospital design. This group is due to report now to the 
defense health board and we should have that report, also, in a 
matter of weeks.
    Together, these have put us in a position of delay, as your 
staffs know well. The report that was due in January was only 
delivered to you, I understand, on your way out to Walter Reed, 
and I apologize for that. We had hoped you would have several 
days to digest that. And we will have a full report of all of 
this in early summer.
    Mr. Chairman, you alluded to the fact that we have a 
different funding mechanism, as did Mr. Wilson. We do, indeed, 
and as opposed to regular military construction, which is done 
by a top line allocation to the services, the medical 
construction is done differently, as recommended by or as 
required by Congress, and as we, the surgeons and I and 
installations and environment leaders, as we have jointly 
designed.
    The way this works has been different from other military 
construction since the defense health program was created by 
Congress several decades ago.
    And what it means is that instead of having service 
surgeons general having to ask the line leaders for their 
budget, Congress set this up so that there would be a defense 
health program so that the budgets could be put together 
jointly and we wouldn't be trading hospitals versus weapons 
systems.
    I think the wisdom of Congress' decision here is apparent, 
because we are now once again building hospitals, and I think 
that is good.
    There was a time when we were letting the hospital 
maintenance be deferred year by year by year. I think the 
members of these committees are well aware that our 
accreditation has been--we have passed, our hospitals pass 
their inspections, but not with commendation, typically.
    Usually, we are cited for deferred maintenance and we take 
the pledge to get to it. But you cannot defer these things 
indefinitely. Otherwise, you may compromise medical care 
eventually.
    We are not doing that at this time, but we cannot defer the 
upgrades of these hospitals forever.
    As you mentioned, sir, some of these hospitals were built 
before any of us were even in medical school. So that is 35 
years ago. So they can't be neglected indefinitely.
    The mechanism that we use now to determine these 
allocations, the priorities, are set by something called the 
capital investment decision model, or CIDM.
    This is something that we and our predecessors actually 
developed. It has been a painstaking business model that has 
been developed, and we took our cues from the business 
community and, particularly, from the Veterans Administration 
(VA), which, as you know, has revitalized their facilities over 
the past couple of decades and they have some really first 
class hospitals now.
    One of the things that has come out of that is commercially 
available software that facilitates this decision-making. So 
this is what we have used. We have worked on it together, and I 
hope that what we will be able to do today, if not answer every 
single question about a given facility, is at least persuade 
you that we are working on it in a transparent and in an 
earnest and joint fashion.
    It remains to be seen whether this new process, CIDM, will 
actually be the right one or whether it is just another layer 
of DOD bureaucracy laid over top of service bureaucracies. None 
of us wants that.
    What we want, of course, is to have an even playing field 
and to have people speak and meet together, share their best 
ideas, cross-fertilize, and reach a consensus on what the 
military hospital should look like, and I believe we have.
    We want hospitals that will be welcoming, that will be 
empowering for the patients, that will be comforting. They will 
be a little bit different than the civilian hospitals. We 
compare ourselves constantly to what is happening at the Mayo 
Clinic or the Cleveland Clinic or Kaiser Permanente.
    Our needs are a little bit different, because we have such 
a preponderance of psychological issues to deal with.
    But many of the features are ones that we have been able to 
take from the VA and from the commercial competitors, and I say 
competitors in a respectful way, but we are the only Health 
Maintenance Organization (HMO) that deploys. I am sure you have 
heard that expression. And it is critical that the military 
treatment facilities (MTFs) be maintained strong and, in fact, 
be strengthened.
    The future of the military health system requires this. We 
cannot outsource everything. There are things we can do in that 
vein and I want to commend what the Air Force has done, with 
great wisdom and great innovation, working with the private 
universities and private hospitals, where that is the best 
thing to do.
    In other areas, we are working closely with the VA. So we 
have joint facilities.
    Still, we have to have a core called the MTFs, the military 
hospitals or military treatment facilities, where people train 
together and so that they can deploy together. This is critical 
for the efforts we are engaged in overseas, whether it is the 
wars in Iraq and Afghanistan, caring for our wounded, whether 
it is the best preventive, getting them in the best shape to 
deploy, and whether it is teaching the Iraqis and the Afghans 
to take care of their own people medically.
    All these are things that we train to do together and the 
health of the MTFs is critical.
    So thank you for supporting them. It is very heartening for 
us to have this opportunity to talk to you about the military 
treatment facilities.
    I think next is General Schoomaker, and I think then we 
will have some questions at the end.
    But thank you, again, on behalf of my colleagues and the 
Department of Defense for this opportunity.
    [The prepared statement of Secretary Casscells can be found 
in the Appendix on page 32.]
    Mr. Ortiz. Mr. Potochney, go ahead, sir.

 STATEMENT OF PETER POTOCHNEY, DIRECTOR, BASING, OFFICE OF THE 
     DEPUTY UNDER SECRETARY OF DEFENSE, INSTALLATIONS AND 
                          ENVIRONMENT

    Mr. Potochney. Good afternoon, Chairman Ortiz, Chairwoman 
Davis, Congressman Wilson and distinguished members of the 
subcommittees.
    I am honored to appear today before you. I am taking the 
place of my boss. That is Wayne Arny, the deputy under 
secretary of defense for installations and environment, who is 
today attending his son's change of command at Naval Air 
Station (NAS) Lemoore. He is the outgoing Strike Fighter 
Weapons School Commanding Officer (CO).
    Absent a significant personal commitment like that----
    Mr. Ortiz. Sir, if you could get a little closer to your 
mic, sir. Thank you.
    Mr. Potochney. Absent a personal commitment like that, he 
would be here.
    I will keep my remarks brief, and I would like to relate 
what we do in the installations community, in the construction 
world, compared to what we do with the other witnesses today, 
in the health affairs world, as well as BRAC.
    So let me begin.
    The installations and environment community, my world, has 
oversight responsibility for the Department's installation 
portfolio. We are the advocates for ensuring our facilities 
compete effectively for the investment necessary to sustain, 
restore and modernize them to ensure their continued operation 
in support of their mission occupants.
    As such, we support our colleagues in the medical community 
in their application of the resources supporting the Defense 
Department's health program facilities.
    The Department places great emphasis on sustaining all of 
our facilities. Sustainment is the term we use to describe what 
is necessary to keep facilities in good working order and the 
preventative maintenance necessary to avoid the increased costs 
and mission impacts that result from premature deterioration.
    To this end, we use something called the facilities 
sustainment model, and it is a robust tool we have developed to 
parametrically estimate the funding required for this purpose, 
and it allows us to gauge our investment against the 
requirement, and that was a substantial and significant 
development for us over the last couple of years, because now 
we had a tool to better compete for the limited resources we 
have in the Department, particularly because sustainment has 
been traditionally underfunded in the Department.
    In the 2009 President's budget, we were at 90 percent of 
the overall requirement and health facilities were at 93 
percent of the overall requirement. That is better than it used 
to be, but it is certainly not where it should be, and we are 
continuing to work to get it up, frankly, to 100 percent.
    Sustainment is only one piece of the equation. Facilities 
must also be modernized through the investment we make in their 
recapitalization.
    Modernization is driven by new standards, new technology 
and changing missions and, as such, it is not easily modeled.
    However, the fact that the average age of our hospitals is 
less than other facilities indicates we recognize the relative 
importance of their modernization.
    But here, too, there is certainly more to do and the 
witnesses at this table will provide details of the work we are 
doing in order to respond to medical care advances.
    Restoration is the final part of the equation. While, in 
the past, the Department had focused on recapitalizing 
facilities on a yearly rate, essentially, a ratio of the 
funding we were placing in the budget compared to the 
replacement value of all of our facilities and then our 67-year 
goal was something I think you heard about in the past, we have 
recognized the limitations of this metric, particularly with 
regard to medical facilities and are working on more 
comprehensive measures.
    To that end, we are using Q ratings now, much more so than 
in the past, and that is Q1 through Q4, Q1 being the best, Q4 
the lowest, and they are essentially the percentage of work 
orders to repair a building compared to the building's 
replacement cost.
    Medical facilities have a higher Q rating than the rest of 
the Department, but they are not a good indicator of our 
medical facilities' health, because--no pun intended--because 
medical facilities have a high priority, as I just said, and 
they are subject to accreditation requirements, and the 
accreditation requirements drive us to more robust engineering 
assessments of the individual condition of the facilities in 
coming up with our estimates.
    So we are continuing to refine our approach and right now 
that is the best means we have available to gauge what it is we 
are doing as far as investing in recap, sustainment and 
restoration.
    There is one special area that I need to note, and that is 
BRAC. Particularly, here in the National Capital Region (NCR) 
and in San Antonio, those are the two major BRAC areas.
    BRAC is a significant recapitalization engine for the 
Department. BRAC is pouring a lot of money into our facilities 
across the board, but particularly in the medical community.
    Through BRAC, the Department is realigning, rationalizing 
military health care, particularly in the NCR in San Antonio, 
as I said. In the NCR, we have avoided recapitalizing the aged 
Walter Reed facility so that we can instead focus our resources 
more effectively by realigning functions into the new Walter 
Reed National Military Medical Center.
    We are also building a new facility at Fort Belvoir that 
will address the significant demographic shift in patient 
population that has occurred in this area.
    In San Antonio, we are consolidating inpatient services 
into a recapitalized Brooke Army Medical Center and converting 
the aging Wilford Hall to an ambulatory care center.
    These two initiatives have produced investments in medical 
care in the NCR and San Antonio of $2 billion and $900 million, 
respectively. These two areas, coupled with lesser BRAC 
initiatives, represent a substantial recapitalization effort.
    In closing, I want to thank the subcommittees for this 
opportunity. The Department's medical construction program has 
made great progress, but certainly more work remains, as you 
will hear from the other witnesses.
    We also recognize and appreciate the great support you have 
demonstrated for all of our efforts.
    Thank you.
    [The prepared statement of Mr. Potochney can be found in 
the Appendix on page 47.]
    Mr. Ortiz. Thank you, sir.
    General Roudebush, go ahead, sir.

    STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH, USAF, SURGEON 
                    GENERAL, U.S. AIR FORCE

    General Roudebush. Thank you, sir. Chairman Ortiz, 
Chairwoman Davis, Ranking Member Wilson, it truly is a pleasure 
to be here today to review our MILCON activities with you, to 
hear your thoughts and to provide ours.
    We believe this is a very, very useful and necessary 
opportunity. Thank you.
    First, let me express our gratitude for the overwhelming 
support that Congress and you, in particular, have provided to 
address the critical needs of our medical facilities. Your 
efforts will greatly assist us in building and sustaining the 
state-of-the-art medical facilities that we require now and for 
the future.
    This is especially important in the Air Force, as much of 
our medical infrastructure was built in the 15 years following 
the establishment of the Air Force in 1947.
    The shortage of MILCON funds in the past several years has 
forced us to pursue ever increasing Operations and Maintenance 
(O&M) repairs on buildings well past their useful life.
    While we have been successful in implementing stopgap 
measures in this manner, we cannot sustain an adequate baseline 
of maintenance and repair.
    To properly characterize and prioritize our Air Force 
MILCON requirements, our Air Force health facilities division 
aggressively engages with each medical facility leadership to 
identify those modernization requirements that are most 
pressing.
    Our prioritization of these requirements is then aligned to 
an Air Force-wide perspective.
    For requirements that drive a MILCON solution, we now 
prepare a capital investment proposal and submit to the TRICARE 
management activity to be scored in the military health service 
capital investment decision model, the CIDM process, which you 
have heard a bit about this afternoon.
    This CIDM process was successfully applied in 2008 to 
determine the Department of Defense fiscal year 2010-2011 
military MILCON priorities, and I can report to you that the 
Air Force's most pressing medical projects were appropriately 
prioritized within this process.
    As a result, we are beginning to turn the corner on our 
MILCON shortfalls. As we work to recapitalize our 
infrastructure in both the MILCON and O&M arenas, it is 
important to note that green design initiatives and energy 
conservation continue to be high priorities in the Air Force 
medical service.
    We are already incorporating nationally recognized 
benchmark processes to design and construct buildings with 
sustainable design elements, such as increased natural day 
lighting, recycled or recyclable materials, and optimized 
energy performance.
    We have established a rigorous system to capture and 
compare energy consumption data from all of our major 
facilities using the Energy Star measurement tool, and this 
system is already up and running at the majority of our medical 
facilities.
    And finally, we recognize that caring for our airmen, 
soldiers, sailors, Marines, and their families in safe and well 
maintained medical facilities is both our duty and a national 
priority.
    I assure you that the Air Force is meeting these 
expectations. All 74 Air Force medical facilities undergo 
regular and thorough inspections, both scheduled and 
unannounced, by two national accreditation organizations, the 
joint commission and the Accreditation Association for 
Ambulatory Health.
    All Air Force medical facilities have passed inspection and 
are fully accredited.
    Again, we thank you and look forward to your continued 
strong support in this critically important task, and I look 
forward to your questions.
    Thank you.
    [The prepared statement of General Roudebush can be found 
in the Appendix on page 58.]
    Mr. Ortiz. Thank you, sir.
    Admiral Robinson.

  STATEMENT OF VICE ADM. ADAM ROBINSON, USN, SURGEON GENERAL, 
                           U.S. NAVY

    Admiral Robinson. Good afternoon, Chairman Ortiz, 
Chairwoman Davis, Ranking Member Wilson, distinguished members 
of the committee.
    Thank you very much for the opportunity to testify before 
you today on the prioritization of military construction of 
medical facilities.
    Your unwavering support of our service member, especially 
those who have been wounded, is deeply appreciated.
    Navy medicine continues making significant strides in 
enhancing both living quarters and medical treatment facilities 
for our sailors and Marines. The military health systems 
capital investment decision model was implemented in May 2008 
and was used in the programming and budgeting of military 
construction projects slated for construction beginning with 
fiscal year 2010.
    This new system serves all the services by carefully 
evaluating proposed medical MILCON projects through a rigorous 
capital investment prioritization method across the entire 
enterprise.
    In addition, the new methodology allows more costly 
projects to receive the funding they need by harnessing the 
global, enterprise-wide perspective to effectively prioritize 
scarce resources.
    Another positive aspect of the CIDM prioritization process 
is the inclusive representation of those who care for our war 
fighters as members of the military health systems capital 
investment review board (CIRB).
    Clinicians, health system managers, resource managers and 
health care facility experts from the services and from TMA are 
all voting members of the capital investment review board. They 
represent their services or TMA and play pivotal roles in 
creating an enterprise-wide assessment of projects needed.
    As Navy Surgeon General, I, as well as my Army and Air 
Force colleagues, can engage the capital investment decision 
model process to clearly articulate our views and priorities to 
all the members of the CIRB for consideration and deliberation.
    The CIDM and the CIRB delivered the integrated military 
health system priority list of projects for the programming 
period from 2010 through 2015. The services surgeon generals 
and the TRICARE Management Activity came to a joint agreement 
on the top priority construction project, and it is the Naval 
Hospital Guam replacement.
    This antiquated facility was built in 1954 and has survived 
55 years in tropical climates.
    The new prioritization system allows us to maximize our 
limited project planning money by focusing on projects that are 
considered by all to be a major priority and the best and most 
efficient use of limited resources.
    Distinguished members of the Readiness and Military 
Personnel Subcommittees, thank you again for the opportunity to 
testify before you today on the positive results Navy medicine 
has experienced from the new medical MILCON prioritization 
process.
    I believe that the military health systems' CIDM and 
associated CIRB, as implemented to date, offers the military 
health system enterprise the best overall means to properly 
prioritize military medical projects.
    In addition, this new process ensures projects of the 
highest relative merit are consistently programmed, budgeted 
and executed first in a coherent fashion, while still ensuring 
the focus of the entire MILCON evaluation process remains where 
it should always be, namely, the health care needs of our 
sailors, our Marines, and their families, as our number one 
priority.
    Thank you very much.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 63.]
    Mr. Ortiz. General Schoomaker.

STATEMENT OF LT. GEN. ERIC SCHOOMAKER, USA, COMMANDING GENERAL, 
     U.S. ARMY MEDICAL COMMAND, SURGEON GENERAL, U.S. ARMY

    General Schoomaker. Chairman Ortiz, Chairwoman Davis, 
Representative Forbes and Representative Wilson, distinguished 
members of the Readiness and Military Personnel Subcommittees, 
thank you for inviting me and my colleagues here to discuss 
this really important subject today of our medical 
infrastructure.
    Before I go on, I would just like to take a moment to 
introduce my battle buddy, my Command Sergeant Major Althea 
Dixon. Although we are talking about buildings, brick and 
mortar today, I think we can all agree that the centerpiece of 
our formation are our people.
    And the Army has declared this year the year of the 
noncommissioned officer, the NCO, and probably nobody better 
symbolizes the NCOs of our Army than my senior medic here to my 
left, who has kept me honest and on track for a number of years 
now.
    The condition of our military medical facilities speaks 
volumes to our staff and our beneficiaries about how much the 
Nation values their service and their well-being. In fact, I 
used these exact words when I turned the soil with my 
colleagues at the new hospital at Fort Belvoir.
    The most tangible evidence of the Nation's investment in 
the health and well-being of our people are the facilities that 
we build for them.
    As I testified before the two Defense Appropriations 
Subcommittees last year, medical facility infrastructure was 
and remains today one of my top concerns.
    On behalf of the 130,000 team members that comprise the 
Army medical department throughout the world and our 3.5 
million beneficiaries whom we serve within Army medicine, I 
really want to thank you all here and the Congress as a whole 
for listening to our concerns about military medical 
infrastructure and taking some significant action to improve 
our facilities.
    With your help, I think we have made some real progress in 
the last year.
    Funding provided for military hospitals in the fiscal year 
2008 supplemental bill and what we hope to have in the American 
Recovery and Reinvestment Act of 2009 will positively impact 
the quality of life of thousands of service members, family 
members, retirees, as we build new world-class facilities in 
places like Fort Benning, Georgia, Fort Riley, Kansas, and San 
Antonio, Texas.
    And I think we can all sit here and talk to you about the 
abysmal state of some of our facilities, but I don't want to 
get in a contest with my colleagues here. We all are working 
very, very hard to raise the quality of our facilities and, 
while doing that, using our Sustainment, Restoration and 
Modernization (SRM) dollars to maintain the safety and the 
reliability of even these aging facilities.
    Modern new facilities not only stimulate the local economy, 
they energize the hospital staff who work in these new spaces 
and they comfort the military beneficiaries who seek care in 
them. They become healing environments for our patients and 
they inspire confidence in their families.
    As a child who was raised in and around Army hospitals and 
clinics myself, a husband and a parent of an Army family who 
has received care in these same and some newer medical 
treatment facilities, and as an Army physician who has served 
and commanded a variety of hospitals, I can tell you I have 
witnessed firsthand the impact that improvements of our 
infrastructure made.
    I was one of the first chiefs of medicine at the new 
hospital that we opened in 1992 in Madigan Army Medical Center 
at Fort Lewis, Washington and I helped lead the transition from 
that.
    The impact of that new facility was really nothing short of 
startling.
    The old hospital, although it was beloved for this 
sprawling one-story cantonment facility, it covered many, many 
acres and miles and miles of corridors, it was really a 
challenge for all of those who attended to the sick and for our 
patients, as well.
    And the new hospital, when we built it, was sited such that 
it either looked out over Mount Rainier or the Olympic 
Peninsula, and it had an instantaneous effect on patients.
    It created a sense of patient and family-centered care and 
patient-friendly waiting areas and clinic spaces, the impact of 
all that light and fresh air, and even the selection of 
photographs, of artistic photographs that we had really was 
instantaneous on patients.
    I saw it in my patients' faces, I heard it in the voices of 
their families, and I witnessed it in the renewed energy of our 
staff.
    We really had little difficulty, following opening that 
building, attracting trainees into my department and we used it 
as a major recruiting tool for Army medicine, and continue to 
this day.
    The three services and the TRICARE Management Agency have 
worked hard to develop an objective process for prioritizing 
medical MILCON requirements through this capital investment 
decision model. I won't go into it at length. You have heard 
about it from my colleagues.
    But its criteria focus on supporting all of our needs 
simultaneously and, also, targets the heart of health care, 
looking at the need for functional modernization and customer 
and patient-centered care, our productivity and how we use our 
space.
    In 2008, we in the Army participated in the development of 
the first version of this prioritization model and I believe it 
really is a step in the right direction. But it requires 
continuous development and refinement.
    The Army is challenged, as all my colleagues have 
described, with aging facility infrastructure, with growing 
workload, and caring for a large portion of our DOD 
beneficiaries. We maintain about 40 percent of the total 
inventory of medical buildings, 1,800 in total, of which 386 
are direct health care facilities with a replacement value of 
about $9 billion.
    Our critical priorities right now for hospital replacement 
are at Fort Hood, Texas and Fort Bliss, Texas, Landstuhl, 
Germany, Fort Irwin, California, and Fort Knox, Kentucky.
    We have identified requirements for another 12 hospital 
expansions, 25 health and dental clinic replacements or 
expansions, and 16 force projection projects. These are 
research facilities and blood centers and preventive medicine 
clinics and training facilities.
    As Landstuhl Regional Medical Center, which many of you, if 
not all of you have gone through and probably been impressed by 
its critical role in evacuation of casualties back home, 
approaches its 56-year anniversary, we see this as a critical 
need for replacement.
    Landstuhl is an enduring part of our evacuation and 
treatment plan for wounded, ill and injured soldiers throughout 
the world and I would ask you to consider it as a significant 
infrastructure need.
    We also continue construction on a state-of-the-art 
replacement facility for the United States Army Medical 
Research Institute for Infectious Diseases, the hot zone up in 
Fort Detrick, Maryland. This is part of a national interagency 
bio defense campus that has partnered with the National 
Institute for Allergy and Infectious Diseases, the Centers for 
Disease Control and Preventive Medicine, the Department of 
Homeland Security, and the United States Department of 
Agriculture.
    It is a realization of a post-9/11 vision that brings 
vastly different and new government agencies together for a 
common cause. Providing appropriate facilities for this and 
other areas of medical research are just as important as our 
hospitals and contribute greatly to the readiness of our 
soldiers and the defense of our country.
    I respectfully request that we continue the support of the 
DOD medical construction requirements that deliver treatment 
and research facilities that are the pride of this Department.
    In closing, I want to thank you on the Readiness 
Subcommittee for your interest in this issue and the Military 
Personnel Subcommittee for your vigorous and enduring support 
of the defense health program and of Army medicine.
    I greatly value the insights of the Armed Services 
Committee and look forward to working with you and your staffs 
over the next year.
    Thank you for holding this hearing and thank you for your 
continued support of the Army medical department for our 
warriors and our families.
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 68.]
    Mr. Ortiz. General, thank you so much. And we want to thank 
all the witnesses and all the staff for the fine work that you 
have done and will continue to do for delivering the best that 
you can medically for our soldiers.
    Mr. Potochney, let me ask you a question. On Monday, we had 
the opportunity to visit Bethesda and see the magnificent care 
that is being provided to the wounded warriors, and, frankly, I 
was very, very impressed. So were the members who were with us 
on this tour.
    We were also briefed on the magnitude of the BRAC effort 
associated with the realignment of Walter Reed. We were told 
that the moves associated with this realignment would occur in 
August 2011, one month before the statutory deadline.
    Maintaining the quality of care that exists today is 
extremely important. Now, how important, in your estimation, is 
meeting the September 2011 deadline and what steps will be put 
in?
    I have been here several years in the Congress. I am just 
wondering, how did we get to the 2011 date? Was it you in the 
medical field? Was it DOD? How did we get to that date, 2011? 
Was it the BRAC commission?
    Maybe that is the first question that we would like to 
know.
    Mr. Potochney. I will take the first shot at it, if I 
could, sir. The Department is implementing the BRAC commission 
recommendation on the schedule that it established.
    A year and a half ago or so, the Department also decided to 
enhance and accelerate, but mostly enhance, some of the 
construction and the facilities at Bethesda, which has 
stretched out some of the construction.
    So the Department itself, and we can't blame it on the 
commission, has decided upon a construction schedule, a 
facilitization schedule that brings us bumping up against the 
end of the statutory six-year period, which is September 2011.
    That is the answer to your first question, sir, I believe. 
Yes, we did it.
    Mr. Ortiz. The thing is this, I know you are going to 
receive the hospital when the construction is finished, but 
then you are going to have to buy a lot of equipment and a lot 
of equipment would be there, there would be testing on the 
equipment.
    Is it realistic to say that by September 2011, not only 
will the hospital be finished, but that you will also have all 
the equipment to start functioning as a first class hospital?
    Mr. Potochney. Yes, sir. I wouldn't argue that it is an 
aggressive schedule and it is a challenge. Admiral Madison, who 
you all met on Monday, is confident, and we have spoken at 
length about this, that while it is aggressive and it is a 
challenge, he can do it and he wants to do it that way.
    He will have equipment delivered before then and the 
hospital will be run through its paces. But the actual 
transition of patients over into the new facility will happen 
in a compressed period of time within the statutory deadline.
    Why is it a compressed period of time? Admiral Madison 
feels strongly, based on his own opinion and the research that 
he has done, that doing it in a compressed period of time is 
the best for the patients.
    In other words, if you will permit me, it is do it in a 
concentrated effort, get it over with quick, so you are back up 
and running as fast as you can, and that is his position.
    Mr. Ortiz. So you feel comfortable that by the date of 
September 2011, you will be running smoothly and ready to go.
    Mr. Potochney. Yes, sir. But I can't say that we are not 
wary and exercising a fair amount of vigilance to make sure 
that it remains on track.
    Mr. Ortiz. We want to be sure that this does not degrade 
the quality of care. This is why earlier I said what we would 
like to do--and I don't want you to feel pressure from me or 
from some of the members here--we want you to do it right.
    Mr. Potochney. Yes, sir. So do we.
    Mr. Ortiz. And this is more important than anything of 
meeting a deadline. But it will not degrade the quality of care 
that you are going to----
    Mr. Potochney. Yes, sir. We have signed up to that and 
right now we are on a schedule that we can meet.
    If something changes, I am sure you will be seeing that as 
quickly as we are.
    Mr. Ortiz. And just like I stated earlier, we walked into 
the hospital and we were so impressed. For once, I saw 
something that I said, ``My God, they have it right,'' the way 
you are giving treatment to the warriors.
    I don't want to take too much time, because we have got a 
lot of members here who have a lot of questions.
    But I would like to turn it over now for questions to my 
good friend, the chairperson of the Military Personnel 
Subcommittee, Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman.
    Again, thank you, all of you, for being here and for your 
service to our country.
    General Schoomaker, I wanted to ask you about any 
limitations that the Army may have providing care as a 
consequence of an undersized or antiquated military treatment 
facility.
    The issue really is that if we have an MTF commander who 
feels a need to send a beneficiary downtown, for example, 
because they can be treated in the facility for whatever reason 
that might be, perhaps it is because they would get treatment 
sooner if they did that, if they went to another facility.
    Does the MTF then not get credit for that workload and can 
that come back at some future time to suggest that the workload 
isn't as great as they might be representing? How might it 
affect future budgets down the line?
    How does the decision-making around that impact future 
budgets or even the workload generally?
    General Schoomaker. Well, ma'am, I think that is an 
excellent question. I would say in the past, we would have been 
much more focused on what I call how many widgets of health 
care we build and deliver in sort of a simple productivity 
model.
    But I think that led to some bad clinical and business 
practices, not the least of which was an impetus to hospitalize 
people when perhaps management in an ambulatory setting was 
much more important.
    What we in Army medicine are doing, and I am pleased to say 
that we, across the Military Health System (MHS) are doing 
increasingly, is shifting to a model that really looks at the 
total outcome of care and asks the question, ``What is best for 
a patient and what does the patient need for that particular 
condition and/or what can we do to prevent the beneficiary from 
being a patient at all by doing preventive measures.''
    And so we are shifting a lot of our resources and our 
revenue generation, if you will, toward prevention and toward 
outcomes.
    I, frankly, spend more time with my commanders, regional 
commanders and, through them, my medical treatment facility 
commanders, focusing on, ``Are you practicing good evidence-
based medicine? Are you practicing good preventive medicine,'' 
and not whether they are shifting work downtown or keeping it 
within the hospital.
    Mrs. Davis. Is there a lot of care that is being shifted? 
How would you characterize the kind of care that needs to be 
diverted from a major facility?
    General Schoomaker. Well, we still perform the vast 
majority of the care, both inpatient and ambulatory care, 
within the direct care system. We are sending more cases of 
patients that are enrolled in our facilities downtown, as we 
are taking care of more wounded, ill and injured soldiers, as 
we are more intensively placed in there, as we deploy our own 
caregivers to theater of operation and don't prompt replacement 
because of hiring lags and the like.
    But those are the dynamics that generally--and then there 
are highly specialized care that may be given, say, in South 
Carolina at Columbia. We won't necessarily have highly 
specialized cancer care or something and so we lean upon or we 
depend upon our colleagues in the VA and Columbia or in the 
private sector to deliver that care.
    That is really kind of the rubber band between the direct 
care system, as we call it in our uniformed services, and our 
TRICARE managed care support contractors.
    Mrs. Davis. I know in certain areas it is going to be more 
than others, but is there a way of saying that a third of the 
care, a quarter of the care?
    General Schoomaker. No, ma'am. I would say my ballpark 
would be across Army medicine, I would estimate that probably 
no more than about 20 percent of the care that we enrolled in 
our hospitals is going downtown and that shift to downtown for 
specialty care or when families are displaced by soldiers that 
are growing in the community, that is occurring in a minority 
of the cases.
    Does that answer your question, ma'am?
    Mrs. Davis. I think so. I think part of the concern is I 
think initially is that there is--is there a reluctance to even 
send a beneficiary for care someplace else?
    General Schoomaker. Yes, ma'am. I think there is very much 
a reluctance, in part, because when we use the network of care, 
if I have enrolled--we use very, very strict enrollment models 
to ensure that our hospitals do not over-enroll to their 
capacity to deliver primary care, which is the principal driver 
for getting sub-specialty care.
    There is a reluctance to send our enrollees into the 
network, for a number of reasons. Number one, it disrupts 
continuity of care. Number two, we don't have the information 
systems that give us ready access to what is done downtown and 
it may take us a month or longer sometimes to get information 
back about the patient that has gone downtown.
    So is there a reluctance? There is, but I have given direct 
and specific orders to all of my subordinate commanders that 
they will not compromise access standards under the TRICARE 
published access standards in order to hang onto a patient that 
should go downtown.
    Mrs. Davis. All right. Thank you. I appreciate that.
    Kind of quickly, I think it has been mentioned, Dr. 
Casscells mentioned the fact that there are about 59 hospitals 
in the military health system.
    And how many of those, Dr. Schoomaker, are Army of those 
59?
    General Schoomaker. I have a total of how many 36--35, 35 
hospitals in the Army.
    Mrs. Davis. When you look at the system that is being used 
now in terms of the prioritization, and we, obviously, have 
representation here in Congress, no matter how many issues we 
have, we have one vote on a particular issue.
    Does that in any way compromise the outcome whether or not 
you could move and each have a single vote as opposed to a 
collective vote on those issues or even a proportional vote?
    General Schoomaker. Well, I have suggested that I get the 
entire vote, but that didn't go over very well with my 
colleagues.
    Ma'am, I think this is one of the really tough things about 
running the CIDM process is trying to decide the strategic 
value of various installations and various facilities and 
ensuring that, as a Department, that we don't leave someone 
behind simply because they don't have a constituency.
    You heard my comments about Landstuhl. I think you heard 
Admiral Robinson's comments about Guam. It is very hard to get 
a constituency for some of our Outside the Continental United 
States (OCONUS) facilities, even though they may have strategic 
value to the force.
    So I look at the CIDM process, I characterize it the way we 
look at personnel sometimes, we are not happy until everybody 
is equally unhappy.
    Mrs. Davis. Thank you. Thank you, Mr. Chairman.
    Mr. Ortiz. Mr. Wilson.
    Mr. Wilson. Thank you, Chairman Ortiz.
    I want to join you and my colleagues for the opportunity 
that we had to meet with Admiral Madison and his staff. It was 
really exciting to me, just as it was for you, to see the 
dedicated staff.
    They were so interested in the wounded warriors, each one. 
They were so proud of the progress that they were making. It 
just made you feel so good to see the extraordinary planning 
and thoughtfulness put into the individual care given to each 
one of these young people who make such a difference for our 
country.
    Additionally, for each of the surgeon generals, I think you 
should be--I want to thank you for making military medicine 
some of the most advanced in the world.
    It is looked to around the world as leading the efforts in 
terms of prosthetics, in terms of trauma care, in terms of 
preventive virtual medicine, on and on. I wish the American 
people knew of how extraordinary military medicine is and the 
challenge that you have.
    And for each of the surgeon generals, and you have touched 
on this, but all of you have hospitals and military facilities 
that would be considered old by any standard.
    How do you each of you prioritize the facilities that you 
submit to the military health system MILCON prioritization 
process and what are your top priorities for medical MILCON for 
the next five years?
    Admiral, I had the opportunity to fly over, I didn't 
actually visit, the Naval hospital last month at Guam, but I am 
very happy, as the Marines are being relocated there, to hear 
that that is proceeding.
    Admiral Robinson. Yes, sir. Thank you very much for the 
opportunity.
    Guam is proceeding. I think that Guam represents the 
overseas OCONUS facility that doesn't necessarily have the 
constituency, does not necessarily have the TRICARE network 
downtown that can take care.
    Not suggesting a network doesn't exist, but it doesn't have 
the robust network that a CONUS facility may have.
    So the point is that the educational, development, 
instructional programs, the exceptional family member programs, 
the programs that are related to specialty care with the 
network, all of those programs may be at either lesser 
condition or may not exist OCONUS, which then makes those 
facilities a top priority, from a Navy medicine perspective, 
because then I would have to make sure that the men and women 
and families there are cared for appropriately in that 
particular geographic location.
    I also think, related to the question of network care and 
going downtown, network care and access standards are always 
going to drive how we do business, and they should.
    At the same time, the reasons that patients often don't 
want to go downtown or we send them downtown is that they don't 
want to go down, they would rather stay with us.
    With that said, we will never degrade care or get into a 
quality issue with the patient related to an access standard.
    I would suggest that if we could relook at network and how 
we run military networks within a geographic area and give more 
responsibility to local commanders with the network, that there 
could be a more seamless and effective method of how we would 
actually run our patients and the network, both from the direct 
and the purchase care side, so that we could have a better and 
a much easier system of care, and I think the continuity and 
the quality would follow.
    General Roudebush. Mr. Wilson, I appreciate your question, 
because it helps me put things in context for the committee.
    As I mentioned, a significant amount of our medical 
facilities were built within 15 years after the Air Force was 
established.
    The Air Force is positioned across the United States, 
generally in small communities, and many of our medical 
facilities were, in fact, small hospitals.
    But we very appropriately followed the U.S. medical model 
and we closed those small hospitals in favor of ambulatory 
clinics, because they didn't have the critical mass, they were 
costly, and, frankly, they were not safe.
    They didn't have the caseload and complexity to maintain 
the currency that the staff would require.
    So we followed that model and we have a significant number 
of ambulatory facilities, which really are in old inpatient 
chasses which have been modified over the years.
    So those do, in fact, create a concern.
    Now, I will tell you that we have 15 hospitals and we have 
leveraged our O&M dollars, as well as our MILCON, to maintain 
those platforms, although several of those come up on the 
priority list that you asked about, and two primary ones would 
be the Wilford Hall Medical Center, which, under BRAC, becomes 
a large ambulatory surgical center, as does the Andrews 
Hospital become an ambulatory surgical center.
    So from an aging infrastructure standpoint, they need to be 
replaced, and from an alignment with BRAC, to assure that they 
are viable parts of that BRAC outcome, they need to be 
replaced.
    So that is, in fact, driving our prioritization as we work 
through this process, along with other facilities in the 2010-
2011 window, but that is where we find ourselves with aging 
facilities, but also the need to align appropriately with other 
activities, with our sister services and BRAC.
    General Schoomaker. Sir, we use a model of prioritization 
that is based upon three principal factors, what the current 
condition of the hospital or the facility is and how much it is 
going to cost to repair that.
    Obviously, the more that is going wrong within a facility 
that we can't get back to a safe and high standard, then the 
more impetus to replace it.
    We look at the population that is supported by that 
facility and what its capacity is to take care of that 
population, to include the population that is moving.
    I think you all are aware that the Army right now is going 
through four simultaneous kind of word salads--Global Defense 
Posture Realignment, Grow the Force or Grow the Army, Army 
modularity, and Base Realignment and Closure--GDPR, GTA, AMF 
and BRAC are moving about 250,000 people right now, the largest 
movement of soldiers and their families across communities in a 
generation.
    And so we are also looking at projected populations served 
by those facilities.
    The last thing I will make a comment about, as General 
Roudebush says, although we tend to be sort of hospital-centric 
in our thinking, we are comprehensive in building facilities 
that attend to the health requirements and dental requirements 
and preventive medicine requirements and veterinary public 
health requirements of that community, and I don't think we 
want to lose track of that.
    Mr. Wilson. Thank you very much.
    In the interest of time, I will submit further questions, 
because we have votes.
    Mr. Ortiz. We will now allow Mr. Reyes to ask a question, 
because it will take 45 minutes before we come back and you are 
very important individuals. We don't want to keep you here.
    So we will proceed with Mr. Reyes. Do you have a question?
    Mr. Reyes. Yes, Mr. Chairman, thank you.
    Secretary Casscells, the Navy surgeon general stated in his 
opening statement that the replacement of the Naval hospital at 
Guam is the top military construction priority identified by 
the capital investment model.
    Can you share that report with our committee and, also, can 
you tell us how new missions, like expansion or Grow the Army 
and return of overseas troops are accounted for in that model?
    Secretary Casscells. Mr. Reyes, I will be able to share the 
detailed analyses that Admiral Robinson mentioned in just a few 
weeks' time.
    I can say, as a general matter, that Grow the Force and 
Grow the Army initiatives are generally paid for by the Army, 
not by the defense health program.
    The defense health program pays for the bulk of the 
replacement and maintenance of these facilities, but those two 
initiatives are really line initiatives.
    We work closely with the services, for example, Fort Bliss, 
as you know, and Fort Sam Houston, which are both impacted by 
multiple Army initiatives, transformation, Grow the Force and 
so forth.
    So all the cards are on the table when we make the--when 
the military health system makes its decision.
    As you know, it is a process that the surgeons and I 
jointly devised and we jointly participate in with our staffs, 
equal votes. And I must say these are some tough calls, but we 
have ended up in unison on these so far.
    What we hope to be able to tell you in a few weeks is the 
detailed results of that as part of the President's budget and, 
hopefully, a year from now, those who will still be with you, 
like General Schoomaker, will be able to tell you whether the 
capital investment decision model is, in fact, the plus that we 
think it is right now.
    Right now, it is promoting communication and transparency 
and unity. So far, it looks good.
    Mr. Reyes. Well, it doesn't look too good from where I am 
sitting, because Fort Bliss is about to quadruple in size, in 
troop size. We are going to have 100,000 to 125,000 people that 
are going to depend on the facility there, which was designed 
to accommodate about 12,000 troops.
    So my concern, and this is why I asked the question, my 
concern is being up there as the next priority, because if we 
are not, then we are not going to have a medical facility ready 
and prepared for all the troops that get assigned to Fort 
Bliss.
    I had a discussion with General Schoomaker earlier on that 
and he has promised to get back to me on several questions that 
I had. But there has got to be a way to factor into your 
formula, into your decision, facilities like mine that don't 
have adequate medical facilities and are going to grow the way 
they are.
    So I hope you take that into account and I am going to 
follow up with both you and General Schoomaker in the next week 
or so.
    Secretary Casscells. Yes, sir. May I just follow on and say 
that my medical privileges as an Army Reserve doctor are at 
William Beaumont and I know it well. I know its shortfalls. 
That was where my pre- and post-deployment experiences were. I 
have been a patient there, and I absolutely agree with you.
    I can only say that our understanding with the Army now is 
that they have got that covered, but it is our obligation 
collectively to make sure that that comes true.
    Mr. Reyes. Very good. Thank you.
    Thank you, Mr. Chairman.
    Mr. Ortiz. Thank you so much.
    I would like now to allow members--I am sorry.
    Mr. Kline, do you have a question?
    Mr. Kline. I do, Mr. Chairman, thank you very much. I will 
just get the answer for the record once I ask for a nod.
    General Schoomaker, you mentioned there are three services, 
and, of course, there are, that provide medical services. But 
there is a fourth service that uses those medical services, 
generally, in the responsibility of the admiral.
    But I know, from my past experience, there are a lot of 
Marines who live down at Quantico who go to Fort Belvoir 
because there is no Naval hospital at Quantico, and we are 
building a new facility there, as we are BRACing Walter Reed 
and so forth.
    And I just want to be reassured that CIDM and the system is 
accounting for that fourth service.
    And there will not be time for an answer, because we have 
got a vote. But if the system accounts for that, then we are on 
track. But it is an Army hospital. It has got a lot of Marines 
and other service, but particularly because there is a very 
large Marine contingent at Quantico, if somebody will just tell 
me that the system has accounted for that.
    [The information referred to can be found in the Appendix 
on page 77.]
    Secretary Casscells. Absolutely, absolutely.
    Admiral Robinson. It not only does, because Guam is a 
number one priority partly because of the Marine growth at----
    Mr. Kline. I understand that, but that is because of 
Marines living there at Guam. This is a little bit different 
situation.
    We have got a vote. I am going to yield back, but I would 
like to follow up with your staffs on how that works.
    Thank you.
    Mr. Ortiz. Thank you so much.
    What I would like to do is to allow other members who 
couldn't be here to submit questions for the record, and I know 
that there are many questions.
    I wonder if my good friend, the chairwoman of the 
personnel--do you have any statement?
    Thank you so much. You were outstanding witnesses today.
    The hearing stands adjourned.
    [Whereupon, at 3:14 p.m., the subcommittees were 
adjourned.]
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                            A P P E N D I X

                             March 18, 2009

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                             March 18, 2009

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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             March 18, 2009

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

      
              RESPONSE TO QUESTION SUBMITTED BY MR. KLINE

    Secretary Casscells. The respective priorities of each component of 
the Military Health System (MHS) have been reflected in the efforts to 
develop and employ the Capital Investment Decision Model (CIDM). 
Representatives from the Surgeons General of the Army, Navy, and Air 
Force actively participated in the development of the CIDM. They 
collectively helped establish the evaluation criteria and business 
rules associated with the CIDM. The Capital Investment Proposals that 
were submitted for evaluation and prioritization were all generated by 
the staffs of the Surgeons General and reflected their highest 
priorities at the time of submission in May of 2008. One of the key 
evaluation factors for each proposal was alignment with elements of the 
MHS Strategic Plan, developed in concert with the Assistant Secretary 
of Defense (Health Affairs) and Surgeons General. Every effort has been 
made, and will continue to be made, to ensure the priorities of each of 
the Military Services find voice in the process to identify, evaluate, 
and prioritize medical capital investments in the MHS.
    With respect to Quantico, the Navy provides medical support to the 
Marines and operates the existing medical facilities on the 
installation, including the Branch Health Clinic and smaller clinics at 
the Officer Candidate School and the Basic School. The ongoing 
initiative to ``grow the Marine Corps'' will result in modest increases 
of approximately 300 per year to the levels of officers and officer 
candidates that receive training at Quantico. This increase is not 
sufficient to significantly augment the existing medical facility 
infrastructure or provide inpatient services at Quantico.
    The National Capital Region (NCR) is one of the largest and most 
complex markets in the MHS. The NCR is also experiencing profound 
change resulting from Base Realignment and Closure (BRAC): Walter Reed 
Army Medical Center will close; the current National Naval Medical 
Center will expand and become the Walter Reed National Military Medical 
Center; and the obsolete hospital at Fort Belvoir will be replaced with 
the most robust community hospital in the Department of Defense's 
(DOD's) inventory. Construction of the new facilities is well underway 
at Bethesda and Fort Belvoir. To support coordinated execution of the 
changes wrought by BRAC and manage the market-wide delivery of health 
care services, DOD established a Joint Task Force. The Joint Task Force 
will continue to assess demand within the market and will allocate 
resources to facilities in the NCR to best meet that demand. Should the 
Joint Task Force eventually determine the need to further expand 
medical capability in or around Quantico, it will pursue the 
appropriate facility or operational solution. But, for the foreseeable 
future, specialty care, hospital services, and inpatient care will 
continue to be provided at the hospital on Fort Belvoir. [See page 22.]
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=======================================================================


              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             March 18, 2009

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

      
                   QUESTIONS SUBMITTED BY MR. WILSON

    Mr. Wilson. I have heard that a major problem with military medical 
construction projects is that by the time the facility opens its door 
for the first time it is already either too small or not properly 
designed to accommodate the current and future population it is meant 
to serve. How does the new prioritization process produce a facility 
better aligned to the population it is intended to serve?
    Secretary Casscells. Reducing the ``time to market'' required to 
bring new medical facilities online is a challenge faced in both the 
public and private sectors. The increasingly rapid evolution of health 
care technology, information systems, and clinical practices makes 
accurate forecasting of facility size and configuration extremely 
difficult.
    One of the stated goals of implementing the new Capital Investment 
Decision Model (CIDM) is expediting the planning and acquisition of 
military medical facilities. The template used by the Army, Navy, and 
Air Force for submission of proposed capital investments has been 
standardized and simplified. CIDM has emphasized increasing the use of 
parametric cost estimating in lieu of devoting the time and resources 
necessary to attain a 35% design. Less specificity on the exact size 
and content of a proposed facility is required prior to submission for 
approval. CIDM encourages the execution of more parallel activities and 
acquisition strategies such as design/build, in which the designer and 
builder work together. This contrasts with the more traditional design/
bid/build approach, which relies on a sequential processing of tasks 
that in turn extended the time to market.
    There are other initiatives underway by the Military Health System. 
The United States Army Corps of Engineers and the Naval Facilities 
Engineering Command intend to expedite the delivery of Department of 
Defense medical facilities. Successful implementation of CIDM is one of 
many efforts that, hopefully, will reduce the potential for a 
misalignment of facility capability with the needs of the population.
    Mr. Wilson. How does the new Capital Investment Decision Model 
(CIDM) differ from the process used by the Department of Defense (DOD) 
and the Military Services to develop priorities for nonmedical military 
construction? What is the benefit of having a unique process for 
medical construction?
    Secretary Casscells. The Military Health System (MHS) needed a 
rational, transparent, and structured method to evaluate competing 
priorities for a finite pool of military construction (MILCON) 
resources. Prior to implementation of the CIDM, a satisfactory process 
did not exist to prioritize candidates for MILCON funding. There was 
not a reliable procedure to rank order potential MILCON investments 
that reflected both the needs of each Military Service as well as the 
strategic imperatives of the MHS overall. The CIDM is similar to the 
manner the Department of Veterans Affairs (VA) has ranked their 
proposed facility projects for several years. As is the case with the 
MHS, the VA must also use a rational and structured process to identify 
its highest priorities across a large, complex organization with 
multiple stakeholders.
    The processes employed by the Military Services and other entities 
within DOD to prioritize their respective MILCON programs vary and may 
be influenced by such factors as size, scope, complexity, and culture. 
Each component establishes their own business rules and evaluation 
criteria consistent with particular needs as they strive to meet 
individual challenges in setting priorities and allocating resources. 
However, several components have adopted the same approach and employed 
the same commercial software product, Decision Lens, as the MHS. For 
example, Decision Lens is used by the following entities to support 
their respective decision-making in the areas noted:

          Joint Staff

            Budget Allocation, Capabilities Planning, IT 
        Selection, and Source Selection

          National Geospatial Intelligence Agency

            Budget Allocation, IT, Human Resources, and 
        Intelligence Analysis

          United States Navy--Commander, Navy Installations 
        Command

            Budget Allocation

          United States Army Special Operations Command

            Budget Planning

          United States Air Force Research Lab

            Strategic Planning, Budget Allocation for Research 
        and Development

          United States Navy N6--SPAWAR--NETWARCOM--PEO C4I

            IT Capital Planning and Portfolio Management

    The logic and approach to the CIDM is not unique to DOD or the 
Federal Government. The basic concept of using transparent evaluation 
criteria within a structured process to determine priorities is logical 
and has been employed in varying forms throughout the public and 
private sectors. It has proven to be particularly useful for the MHS 
for several reasons. Typically, medical facilities are some of the most 
expensive and complex buildings within the DOD. Health care is one of 
the most dynamic fields of endeavor, subject to constant change in 
medical technology, information systems, clinical practice, diagnostic 
techniques, and patient and family expectations. Few other facility 
types within the DOD inventory must address the challenges of cost, 
complexity, and dynamism. In today's challenging environment, the MHS 
needs an approach to the capital investment decision making process 
that is transparent, logical, structured, and addresses the needs of 
each of the Military Services and MHS. Implementing the CIDM last year, 
and continuously striving to improve future versions, will help ensure 
precious medical MILCON resources are used to their best advantage.
    Mr. Wilson. I have heard that a major problem with military medical 
construction projects is that by the time the facility opens its door 
for the first time it is already either too small or not properly 
designed to accommodate the current and future population it is meant 
to serve. How does the new prioritization process produce a facility 
better aligned to the population it is intended to serve?
    Mr. Potochney. Reducing the ``time to market'' required to bring 
new medical facilities on-line is a challenge faced in both the public 
and private sectors. The increasingly rapid evolution of health care 
technology, information systems, and clinical practices makes accurate 
forecasting of facility size and configuration extremely difficult.
    One of the stated goals of implementing the new Capital Investment 
Decision Model (CIDM) is expediting the planning and acquisition of 
military medical facilities. The template used by the Army, Navy, and 
Air Force for submission of proposed capital investments has been 
standardized and simplified. CIDM has emphasized increasing the use of 
parametric cost estimating in lieu of devoting the time and resources 
necessary to attain a 35% design. Less specificity on the exact size 
and content of a proposed facility is required prior to submission for 
approval. CIDM encourages the execution of more parallel activities and 
acquisition strategies such as design/build, in which the designer and 
builder work together. This contrasts with the more traditional design/
bid/build approach, which relies on a sequential processing of tasks 
that in turn extended the time to market.
    There are other initiatives underway by the Military Health System, 
the U.S. Army Corps of Engineers, and the Naval Facilities Engineering 
Command intended expedite the delivery of DOD medical facilities. 
Successful implementation of CIDM is simply one of many efforts that 
hopefully will reduce the potential for a misalignment of facility 
capability with the needs of the population.
    Mr. Wilson. How does the new Capital Investment Decision Model 
differ from the process used by DOD and the military services to 
develop priorities for non-medical military construction? What is the 
benefit of having a unique process for medical construction?
    Mr. Potochney. The Military Health System needed a rational, 
transparent, and structured method to evaluate competing priorities for 
a finite pool of military construction (MILCON) resources. Prior to 
implementation of the Capital Investment Decision Model (CIDM), a 
satisfactory process did not exist to prioritize candidates for MILCON 
funding. There was not a reliable procedure to rank order potential 
MILCON investments that reflected both the needs of each of the 
military services as well as the strategic imperatives of the overall 
MHS. The CIDM is similar to the manner in which the Department of 
Veterans Affairs (VA) has ranked their proposed facility projects for 
several years. As is the case with the MHS, the VA must also use a 
rational and structured process to identify its highest priorities 
across a large, complex organization with multiple stakeholders.
    The processes employed by the military services and other entities 
within DOD to prioritize their respective military construction 
programs vary and may be influenced by such factors as size, scope, 
complexity, and culture. Each establishes their own business rules and 
evaluation criteria consistent with their needs as they strive to meet 
their own challenges in setting priorities and allocating resources. 
However, it is worth noting that several have adopted the same approach 
and employed the same commercial software product, Decision Lens, as 
the MHS. For example, Decision Lens is used by the following entities 
to support their respective decision-making in the areas noted:

          The Joint Staff

            Budget Allocation, Capabilities Planning, IT 
        Selection, and Source Selection

          National Geospatial Intelligence Agency

            Budget Allocation, IT, Human Resources, and 
        Intelligence Analysis

          US Navy--Commander, Navy Installations Command

            Budget Allocation

          US Army Special Operations Command

            Budget Planning

          US Air Force Research Lab

            Strategic Planning, Budget Allocation for Research 
        and Development

          US Navy N6--SPAWAR--NETWARCOM--PEO C4I

            IT Capital Planning and Portfolio Management

    Decision Lens also has several other clients within the Federal 
Government and private industry, including the Department of 
Agriculture, National Archives and Records Administration, the Nuclear 
Regulatory Commission, Amtrak, and eBay.
    The logic and approach to the CIDM is not unique to the DOD or even 
the Federal Government. The basic concept of using transparent 
evaluation criteria within a structured process to determine priorities 
is logical and has already been employed in varying forms within the 
public and private sectors. It is has proven to be particularly useful 
for the MHS for several reasons. Typically, medical facilities are some 
of the most expensive and complex buildings within the DOD. Health care 
is one of the most dynamic fields of endeavor, subject to constant 
change in medical technology, information systems, clinical practice, 
diagnostic techniques, and even expectations of patients and families. 
Few other facility types within the DOD inventory can match these 
challenges of cost, complexity, and dynamism. In today's challenging 
environment, the MHS clearly needs an approach to capital investment 
decision making that is transparent, logical, structured and addresses 
the needs of each of the military services as well as the MHS. 
Implementing the CIDM last year, and continuously striving to improve 
future versions, will help ensure that precious medical MILCON 
resources are used to their best advantage.
    Mr. Wilson. I understand that the new MILCON prioritization process 
has only been in place for a short time but from your perspective how 
can it be improved to better meet service priorities?
    General Schoomaker. The three Services, in conjunction with the 
TRICARE Management Activity, are currently working on the next version 
of the medical MILCON prioritization process with the intent of using 
this new process during the next program build. Areas for improvement 
include refining evaluation criteria, structuring submissions to ensure 
a consistent approach in addressing criteria, and accounting for the 
various service equities (for example, the Army comprises 46% of the 
overall medical building square footage in the Military Health System). 
The evaluation criteria should separately address the different types 
of medical facilities (i.e. hospitals versus medical clinics versus 
dental clinics versus veterinary clinics versus medical warehouses) 
rather than attempting to compare them against each other. The criteria 
should validate the beneficiary populations versus the enrolled 
populations when describing the required capacity, and should normalize 
the infrastructure assessments across the three Services to achieve an 
equivalent comparison.
    Mr. Wilson. The military medical facilities at Ft. Jackson, Naval 
Hospital Beaufort and Naval Hospital Charleston in South Carolina are 
all at least thirty-five years old. What are your plans to either 
modernize or replace these facilities?
    General Schoomaker. Fort Jackson is an important installation that 
supports the Army's training mission. In FY08, the Army funded a 
facilities planning effort at Fort Jackson to determine whether any 
gaps exist between healthcare requirements and facility capabilities. 
This effort will also scope requirements to address any identified 
gaps. The analysis is still underway and will culminate with the most 
critical military construction requirements being prioritized in the 
spring of FY10 for inclusion in future budget requests.
    Mr. Wilson. What are some of the challenges of providing world-
class medicine in aging facilities?
    General Schoomaker. The greatest challenge is keeping our 
facilities functionally relevant to the changes in the provision of 
care. Adaptability and flexibility are the keys to meeting the facility 
needs of a dynamic healthcare system. A properly maintained facility 
``ages'' due to the lack of proper recapitalization to meet the 
changing needs. The Military Health System (MHS) recently established a 
31-year capitalization rate, with the expectation of several 
renovations before the 30-year mark. The decision to reduce this rate 
from the original 50-year target led to a requirement to increase the 
overall funding in the medical military construction program. DOD 
responded by providing a significant increase in funding, which will 
help us improve our facilities after years of flat funding.
    Healthcare advances through improvements in technology and use of 
evidence-based medicine. In many cases, improved practices and 
procedures rely on equipment and infrastructure to ensure proper 
clinical outcomes. A great example is the diversity of imaging, which 
focused on the traditional X-ray for many years. This area has now 
grown into multiple forms of imaging, to include interventional 
radiology where procedures are conducted using real-time imaging. These 
changes require the facility to transform to accommodate the technology 
and the procedures.
    Keeping pace with these changes in aging facilities requires more 
frequent renovations to meet the demand. The MHS is faced with facility 
functional failure, as opposed to infrastructure failure. The Army 
Medical Department's aggressive approach to Facility Life Cycle 
Management ensures reliable facility infrastructure, but is limited in 
addressing a facility's functionality. The majority of the Army's 
healthcare facilities were designed between 1950 and 1980, when our 
focus was on inpatient care. Healthcare delivery has changed 
significantly from inpatient to outpatient settings and now includes 
new methods such as same-day surgery and mother-baby care. The 
inability of some of our facilities to adjust to these changes has 
rendered them functionally failing.
    Maintaining relevancy in a dynamic healthcare environment requires 
either more flexibility in using operations and maintenance funding 
and/or a military construction program that is more adaptable to the 
environment. Current budget planning cycles do not allow for rapid 
adjustments. The current ``new work'' limitations for DOD facilities 
severely limits the use of operations and maintenance funds to meet 
rapid changes in healthcare. This leads to operating outpatient clinics 
and administrative functions within inpatient spaces, resulting in high 
maintenance costs, poor space utilization, and frustrated staff.
    Mr. Wilson. Over the past twenty years BRAC requirements and 
decisions by the military services have significantly changed the size 
and type of medical facilities in the Military Health System. How well 
do the remaining hospitals and clinics meet our beneficiaries' needs 
and where would you make additional changes to provide the best care 
possible? With so many clinics and small hospitals, how do you provide 
medical personnel with the necessary experience to maintain their 
clinical skills?
    General Schoomaker. With the reduction in medical services 
available because of BRAC and Overseas Contingency Operations, the Army 
Medical Department (AMEDD) has taken steps to ensure that our 
beneficiaries continue to receive the highest level of care. For 
example, the AMEDD routinely cross-levels resources from areas of less 
need to areas of greater need. In addition, we hire contract providers 
and use TRICARE network providers in the local community.
    BRAC and Grow the Army decisions drove construction and staffing 
requirements to meet the expanded population's health and dental care 
needs. In some cases, with the help of the DOD and Congress, we were 
able to consolidate these growth requirements with additional funding 
to completely recapitalize a facility instead of adopting a piecemeal 
approach. The DOD also recognized the positive impact that facilities 
have on the quality of care and increased the levels of funding in our 
medical MILCON program. Additional actions to provide the best care 
possible include continued full funding in our Sustainment account (to 
ensure proper maintenance) and continued funding of a robust medical 
MILCON program to address all our medical facilities beyond the current 
focus on hospitals. This would include medical, dental, and veterinary 
clinics.
    Medical personnel within the Military Health System maintain their 
clinical skills in a fashion similar to their civilian colleagues. 
Licensure and credentialing criteria apply for each individual, as well 
as a competency-based assessment system. This system sets certain 
thresholds that medical personnel must meet to maintain credentials in 
their specific specialty. If a facility is unable to supply the 
resources a provider requires to perform in his/her specialty, the 
provider will be moved to a location where resources remain available. 
Our staffing is frequently adjusted to optimize use of our providers 
and to ensure all providers have the necessary experience to maintain 
their clinical skills.
    Mr. Wilson. I understand that the new MILCON prioritization process 
has only been in place for a short time but from your perspective how 
can it be improved to better meet service priorities?
    Admiral Robinson. As the Navy Surgeon General, I was able to use 
the new Capital Investment Decision Model (CIDM) process to clearly 
articulate my views on Navy Medicine MILCON priorities for the current 
budget cycle. The new evaluative process also accounts for the MILCON 
priorities of my colleagues in the Army and Air Force through 
decisional criteria weighting which helps ensure overall Service 
priorities are considered on a level playing field. This process fully 
reflects common agreement achieved to support the new Medicine MILCON 
prioritization system across the Services. Current efforts underway by 
the CIDM Tri-Service Working Group to refine the CIDM evaluative 
process will retain this key decisional factor to ensure the Services 
and Military Health System (MHS) leadership share a common 
understanding of high priority Medicine MILCON needs. The CIDM process 
also allows the MHS enterprise the ability to communicate those urgent 
needs to leadership of the Department of Defense and beyond. The 
Medicine MILCON project priority list delivered through CIDM represents 
the core success of the new system over the previous allocation system 
which did not capture the critical enterprise perspective required to 
effectively program vital capital investments.
    Mr. Wilson. The military medical facilities at Ft. Jackson, Naval 
Hospital Beaufort and Naval Hospital Charleston in South Carolina are 
all at least thirty-five years old. What are your plans to either 
modernize or replace these facilities?
    Admiral Robinson. The Medical Facilities on Fort Jackson are owned 
by the Army and are under the purview of the Army Surgeon General.
    The replacement facility for existing Naval Health Clinic 
Charleston is in the final stages of construction, and is scheduled to 
be operational by 30 Nov 2009. The replacement facility in Charleston 
will be classified as a Naval Ambulatory Care Center with state of the 
art ancillary services required to support our beneficiary population. 
All inpatient services will be handled by the TRICARE network and 
supported by local community hospitals in the area and other Military 
Treatment Facilities as required.
    Naval Hospital Beaufort is approaching 60 years of age and is in 
need of replacement. The aging infrastructure at Beaufort is not 
conducive to modern, outpatient-centric, healthcare delivery. We have 
developed planning and programming documents for a 17 bed, 233,847 
square foot replacement hospital and have submitted them to Office 
Assistant Secretary of Defense, Health Affairs/Tricare Management 
Activity for project consideration within the Defense Health Program 
Military Construction Program. We have also secured site approval on 
Marine Corps Air Station Beaufort for the replacement facility.
    Mr. Wilson. What are some of the challenges of providing world-
class medicine in aging facilities?
    Admiral Robinson. Aging infrastructure is not conducive to modern, 
outpatient-centric healthcare. Aged facility designs are not energy 
efficient and create dysfunctional flow for both healthcare providers 
and patients alike. Further, modern healthcare legislation and 
accreditation practices such as the Americans with Disabilities Act, 
Health Insurance Portability and Accountability Act, and Joint 
Commission on Accreditation of Healthcare Organizations are major 
drivers for current Military Health System (MHS) space requirements. 
Worth mentioning is the vast change in healthcare architecture and 
engineering. Modern healthcare design and construction has led to 
better patient outcomes and satisfaction. Modernizing our facilities 
will greatly complement our efforts to provide world-class medicine 
moving forward. Finally, aged infrastructure prevents us from taking 
full advantage of new medical technologies and equipment that enhance 
health outcomes in similar populations across the United States.
    Mr. Wilson. Over the past twenty years BRAC requirements and 
decisions by the military services have significantly changed the size 
and type of medical facilities in the Military Health System. How well 
do the remaining hospitals and clinics meet our beneficiaries' needs 
and where would you make additional changes to provide the best care 
possible? With so many clinics and small hospitals, how do you provide 
medical personnel with the necessary experience to maintain their 
clinical skills?
    Admiral Robinson. Navy Medicine is committed to meeting the health 
care requirements of our beneficiaries by maintaining a well-qualified 
and robust complement of health care providers. Although Base 
Realignment and Closure (BRAC) may ultimately alter the size and scope 
of the health care services provided at medical treatment facilities 
(MTFs), those changes are addressed and mitigated by Navy Medicine 
during the BRAC planning process. In those instances where MTFs are 
reduced in capability and capacity, the delivery of health care is 
complemented by civilian-based provider networks established through 
the TRICARE Program.
    As active participants in the Joint Commission accreditation 
process, we embrace the Joint Commission standards that focus on 
maintaining the clinical skills of our providers. Joint Commission 
standards include the Focused Provider Performance Evaluation (FPPE) 
and Ongoing Provider Performance Evaluation (OPPE) programs. To 
maintain an infrequently used skill, a provider can go to another 
facility for temporary additional duty (TAD) where the patient volume 
and MTF capacity and capability exist.
    In the event that medical procedures cannot be safely supported 
with the required staff and resources at a facility, those privileges 
will not be granted to the provider and the medical procedure will not 
be performed. Upon the providers transfer to another MTF, the provider 
participates in FPPE to assure clinical competency.
    Navy Medicine incorporates a Quality Assurance system and robust 
Graduate Medical Education programs to maintain provider skills and 
meet the health care needs of our beneficiaries. The Navy Medicine 
Quality Assurance system provides continuous monitoring of the medical 
practice of every privileged provider. Trends and deficiencies are 
identified for corrective training. In addition to the informal TAD 
training noted above, Navy Medicine has initiated a formal Professional 
Update Training program that coordinates periodic clinical training to 
ensure that specialists maintain their clinical skills when the 
circumstances of their current assignment do not provide cases in 
sufficient numbers or diversity to maintain all the clinical skills 
required by their clinical privilege sheets. Navy Medicine also engages 
centers of excellence, fostering internal and external partnerships, 
and leverages our Navy Fellowship Training Program to provide our 
physicians with training in the latest treatment and surgical 
modalities.
    Currently, Navy Medicine is focused on improving the integration of 
health care delivery between the MTFs and the civilian networks. Our 
main objective is to improve the continuity of patient and family-
centered care as patient care is provided in multiple venues. This area 
represents an opportunity of improvement for the entire Military Health 
System, including our civilian partners.
    Mr. Wilson. I understand that the new MILCON prioritization process 
has only been in place for a short time but from your perspective how 
can it be improved to better meet service priorities?
    General Roudebush. The Capital Investment Decision Model (CIDM) was 
developed by TMA and the Services to assist in prioritizing future 
capital investments across a diverse Defense Health Program (DHP) 
facility inventory. Lessons learned from CIDM 1.0, the model used to 
prioritize the FY10-15 DHP MILCON POM, are being incorporated into CIDM 
2.0--building on our successes with selection criteria and overall 
process. It is important to recognize that CIDM provides a baseline 
priority list to be further shaped by variables that may include 
alternative budget constraints, incremental versus phased or full 
funding guidance, or supra-departmental ``must-pay'' project inserts. 
Various scenarios may be presented to the Service Deputy Surgeons 
General and the DASD (Health Affairs) for consideration. Their 
recommendation going forward to the Service Surgeons and ASD (HA) 
provides for a full vetting/advocacy of Service-specific priorities. 
While CIDM 2.0 is not intended to exclusively address AFMS priorities, 
it provides a reasonable and appropriate balance of our needs against 
those of our sister Services and TMA.
    Mr. Wilson. The military medical facilities at Ft. Jackson, Naval 
Hospital Beaufort and Naval Hospital Charleston in South Carolina are 
all at least thirty-five years old. What are your plans to either 
modernize or replace these facilities?
    General Roudebush. Since these are Navy facilities, the Air Force 
defers the response to the Navy.
    Mr. Wilson. What are some of the challenges of providing world-
class medicine in aging facilities?
    General Roudebush. The challenges in delivering world-class 
medicine within our aging facilities occur in four major categories; 
patient safety, technology integration, cost, and functional 
efficiency. In aging facilities, ensuring patient safety becomes 
increasingly challenging. Infection control is a major facet of patient 
safety. Numerous studies have shown that modern air handling systems 
decrease the risk of hospital acquired infections, and the installation 
of anti-microbial surfaces can also decrease hospital acquired 
infections. Another aspect of patient safety is minimizing falls, which 
can be accomplished through proper facility design.
    Integrating new technologies is difficult, with many of our legacy 
facilities having limited floor-to-floor heights that preclude larger 
duct sizes, fiber optic backbones, and enhanced air handling for rooms 
with the latest equipment.
    The financial burden of higher sustainment costs necessary to 
provide world-class medicine in older, often re-purposed, former 
inpatient facilities has been significant. In one study of 3 bases with 
former hospitals operating or proposed to operate as clinics, the 
estimated additional cost for maintaining the outmoded and oversized 
infrastructure was $29.5M per year.
    Clinics operating in former hospital chassis often maintain excess 
emergency generators, medical gas systems, inefficient air handling 
systems, steam boilers, and nurse call systems. Functional efficiency 
is compromised due to operating in ``as-is'' inpatient footprints. 
Clinicians cannot optimize their practice when operating around 
existing load bearing walls, tight column grids, and inefficient 
circulation patterns. While this issue is challenging, we appreciate 
that Congress has provided funding to make targeted renovation 
investments where appropriate and replacement when necessary.
    Mr. Wilson. Over the past twenty years BRAC requirements and 
decisions by the military services have significantly changed the size 
and type of medical facilities in the Military Health System. How well 
do the remaining hospitals and clinics meet our beneficiaries' needs 
and where would you make additional changes to provide the best care 
possible? With so many clinics and small hospitals, how do you provide 
medical personnel with the necessary experience to maintain their 
clinical skills?
    General Roudebush. Our beneficiaries tell us we are doing extremely 
well. Their satisfaction rate for the past 6 consecutive years has been 
the highest among 50 leading healthcare plans according to independent 
Wilson Health Information surveys. We've accomplished this through the 
care we provide in our Military Treatment Facilities and our Managed 
Care Support Partnerships. These complementary means of healthcare 
delivery have allowed us to optimize our services as directed by BRAC 
while still delivering a world-class benefit to our military families 
through our civilian partners when needed.
    The Air Force Medical Service is undertaking two additional 
strategies to further optimize services, the Family Health Initiative 
(FHI) and Surgical Optimization. The two primary goals for these 
programs are to enhance access and continuity of services to our 
population, and increase the complexity of the patients seen. FHI 
utilizes a patient centered medical home model to provide appropriate 
staffing. This model makes the coordination of all a patient's care the 
primary focus of the team and is led by a Family Practice Physician. 
Surgical Optimization combines AFSO 21 advanced management and 
production techniques to decrease operating room changeover time 
resulting in a greater throughput of surgical cases. This increase in 
cases bolsters the currency of surgeons and their staff. It also 
improves outcomes through increased proficiency of surgical techniques.
    The Air Force Medical Service has developed a variety of training 
programs to ensure our health care providers remain the best trained 
and equipped in the world. The Air Force Expeditionary Medical Skills 
Institute's Center for Sustainment of Trauma and Readiness Skills (C-
STARS) is a medical training program embedded in three civilian 
academic trauma centers. C-STARS is a skills sustainment platform with 
multiple affiliations to refresh or hone trauma and reconstructive 
surgical skills. A newer training platform, Sustainment of Trauma and 
Resuscitation Skills-Program (STARS-P) has begun at five other 
locations. STARS-P is a readiness skills verification training platform 
providing personnel the opportunity to perform clinical rotations 
several weeks annually at host facilities for the purpose of skills 
sustainment. Training is also accomplished using no cost Training 
Affiliation Agreements (TAAs) with civilian or other sister-service 
facilities to include VA Sharing Agreements. Since 2006, the AF has 
entered into over 262 TAAs for clinical proficiency and sustainment 
training. Another trend is using Simulation Laboratories (SIMLABs) 
utilizing high quality human-like training models. The Air Force has a 
network of simulation laboratories to enhance skills sustainment. Each 
year AFMS personnel retain professional licensure and certification 
status by attending civilian conventions/symposia or military formal 
training courses to obtain continuing education. Humanitarian missions 
also expose our practitioners to pathology and challenging cases that 
improve diagnostic and clinical skills when treating a large number of 
patients in a short time period.
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MR. KISSELL

    Mr. Kissell. I represent the Fort Bragg area. Fort Bragg is 
projected to grow from just 57,000 military personnel assigned in 2006 
to just under 70,000 by the end of fiscal year 2011. These numbers, of 
course, do not include all of additional family members that will come 
with these 12,000+ soldiers. Now, Womack Army Medical Center is a 
relatively new and unquestionably beautiful facility, but it doesn't 
seem large enough for our current population on Fort Bragg, let alone 
the growth we're expecting over the next few years. For example, the 
emergency room waiting area is tiny, with something like twenty chairs. 
What analyses have the Army done to assess the capacity of the current 
facility, and what plans have been made to ensure that the military 
personnel assigned to Fort Bragg, and their families, will have access 
to the care they need?
    General Schoomaker. Based on the projected population growth at 
Fort Bragg, the Army has planned and programmed medical military 
construction projects totaling $141M to support the projected increase 
of Soldiers and Family members. These projects include: an addition/
alteration to the Robinson Health Clinic ($18M, FY 08), a new Primary 
Care Clinic ($27M, FY 10), a new Blood Donor Center ($4.8M, FY 10), a 
new Behavioral Health clinic ($32M, FY10), and an addition/alteration 
to Womack Army Medical Center (WAMC) that will expand the Emergency 
Department, Women's Health, Pediatrics, Pharmacy Services, and various 
other departments ($59M). This addition/alteration is desired in the FY 
12 program following completion of the new Behavioral Health Clinic, 
which is programmed in FY 10. That stand-alone facility will remove 
Behavioral Health Services from WAMC to accommodate staffing increases 
and allow for the expansion of hospital-based functions, such as the 
Emergency Department.
    Once completed, the MILCON projects will significantly expand the 
medical infrastructure at Fort Bragg. Approximately 65% of the Fort 
Bragg growth in population has already been realized. A dedicated 
recruitment effort has led to filling 82% of the new positions 
identified to support this population. In the interim period while 
MILCON construction is ongoing, WAMC is coordinating with Pope Air 
Force Base to assume control of the Pope Clinic in July 2010. This will 
provide a partial expansion of primary care until the new clinic is 
built. In 2008, WAMC completed a construction project that converted 
12,700 square feet of storage area into administrative and educational 
space which freed approximately 16,000 square feet of clinical space. 
Currently, WAMC has initiated a renovation project that converts seven 
former administrative offices into treatment rooms for the Emergency 
Department. Additionally, we relocated the TRICARE offices to provide 
the Emergency Department a secondary waiting room and an additional 10 
offices or exam rooms.
    The most profound change has been the development of the Warrior 
Transition Battalion (WTB), which at Fort Bragg has grown to four 
companies. Until the Warrior Transition Complex is completed, the 
hospital has dedicated over 20,000 square feet of clinical space to the 
WTB. Clinical services for all beneficiaries, not just the Warriors in 
Transition, continue to improve and expand. At Fort Bragg, prominent 
examples are Traumatic Brain Injury (TBI) treatment and research, and 
the Pain Clinic's advanced technology and multidisciplinary alternative 
therapies. Behavioral health services are another area of growth that 
is defined by the population's increase as well as the population's 
increasing needs.
    In summary, the Army has assessed the projected population growth 
at Fort Bragg and is implementing actions to provide all the necessary 
health care services to support these beneficiaries.
    Mr. Kissell. And since we are talking about how medical military 
construction is centrally managed by Health Affairs/TRICARE Management, 
is it the Army's responsibility or Health Affairs' responsibility to do 
these analyses?
    General Schoomaker. The US Army Medical Command (MEDCOM) conducts 
the detailed analyses required to develop medical military construction 
requirements. These analyses include facility requirements, staffing 
requirements, and the right mix of personnel skills to ensure we 
properly support our beneficiary population. MEDCOM provides our 
completed analyses and facility requirements to Health Affairs/TRICARE 
Management Activity for prioritization and programming.
                                 ______
                                 
                  QUESTIONS SUBMITTED BY MS. BORDALLO

    Ms. Bordallo. My question is about how the Navy, in conjunction 
with the TRICARE Management Activity and the Department of Defense's 
Office of Health Affairs, developed the requirements for number of beds 
and services that will be added as a result of the renovations. It is 
my understanding that the current requirement will only increase the 
number of beds by eleven and given that the military build-up will 
include, at the very least, 8,000 additional Marines and 9,000 family 
members, is that an adequate enough requirement to meet the demands 
with increased personnel on Guam? I understand from your testimony that 
Navy implemented the Capital Investment Decision Model (CIDM) in 2008 
which will impact Fiscal Year (FY) 2010 projects. If the CIDM were 
implemented early, would that have potentially altered the requirements 
for the hospital?
    Admiral Robinson. The CIDM, which was employed for the first time 
last year, identified replacement of the United States Naval Hospital 
on Guam as the highest priority for medical military construction 
funding. The CIDM is used to prioritize competing proposals and not to 
develop specific facility requirements. Navy medical planners, in 
concert with others, analyzed the specific requirements for the 
replacement facility and determined the appropriate mix of capabilities 
required to support the needs of the projected population. The planning 
process was continuously updated as the scope of the Guam military 
build-up was refined. It is unlikely that implementing CIDM prior to 
2008 would have altered the requirement for the new hospital.
    Ms. Bordallo. Additionally, can you comment on the anticipated 
level of increase in specialty care that might be offered on Guam as a 
result of the increased military presence on Guam as well as 
renovations to the facility that will allow such services to be 
offered? Many of my constituents have concerns about the current level 
of services that are available at the Naval Hospital and see the 
military build-up as an opportunity to attract additional specialty 
care services to the island.
    Admiral Robinson. The United States Naval Hospital, Guam 
replacement facility will support delivery of a broad range of primary 
and specialty care services. The new hospital will provide 42 inpatient 
beds for provision of intensive care, general medicine, surgery, 
orthopedics, obstetrics, urology, ophthalmology, proctology, 
otorhinolaryngology, behavioral health, and oral surgery. It will 
operate four operating rooms and two rooms dedicated to performing 
Caesarian Sections. Robust diagnostic imaging will include magnetic 
resonance imaging (MRI) and computerized axial tomography (CT) scan 
capabilities as well as full laboratory and pharmacy capacity. In 
addition to a Level III emergency room, outpatient capabilities will 
include a variety of primary and specialty care services, including 
diet and wellness, dermatology, nuclear medicine, physical therapy, and 
environmental health.
    The new community-based Outpatient Clinic now under construction 
will increase the range of potential for sharing with the Department of 
Veterans Affairs (VA). Its location adjacent to the new hospital will 
increase both the visibility of the clinic and its accessibility to VA 
beneficiaries.
    Ms. Bordallo. To what extent has the Department of Defense worked 
with the Department of Veterans Affairs pursuant to Section 707 of H.R. 
5658, the House-passed National Defense Authorization Act for Fiscal 
Year 2009? Are there any issues of concern regarding the development of 
these implementation guidelines?
    Secretary Casscells. The DOD and the DVA studied a combined federal 
health facility as identified in H.R. 5658, Section 707, but the DVA 
decided they could not support a joint effort. Therefore, planning and 
programming of Naval Hospital Guam replacement was performed with 
Presidential Executive Order 13214 (dtd 28 May 2001) and Public Law 
108-136, Section 583 as the drivers for extensive collaboration with 
the DVA from a health facility perspective. The planned replacement of 
Naval Hospital Guam accounted for all workload currently performed in 
support of the robust resource-sharing agreements in place between Navy 
and the DVA for inpatient, specialty, diagnostic, and ancillary 
services. In addition, the DVA is currently constructing a new 
Community-Based Outpatient Clinic on a convenient site provided by the 
Navy to the DVA immediately adjacent to the Naval Hospital campus. The 
DVA designed their new outpatient clinic to enhance DVA primary care 
capabilities to better serve the Guam veterans.
    Ms. Bordallo. I am wondering why the Department of Defense has not 
designated Guam or the other territories, specifically Puerto Rico as a 
Prime Service Area for military retirees to be eligible to receive 
TRICARE Prime? If specialty care services will not increase to cover 
all the needs of our local retiree population isn't there a benefit to 
extending TRICARE Prime to the territories? I see this as a key quality 
of life measure and as a commitment to those who served our nation.
    Secretary Casscells. It is recognized under 32 CFR Sec. 199.17, 
(a), (3), the Assistant Secretary of Defense (Health Affairs) has the 
authority to modify the scope of the TRICARE program as implemented 
outside the 50 States and the District of Columbia. Currently, TRICARE 
Prime is not available as an option for retired service members and 
their eligible dependents in the territories of Puerto Rico and Guam.
    Navy Medicine recognizes the tremendous contribution and sacrifice 
that all of our current and prior military members and their families 
have endured to serve our Nation. They deserve a generous health care 
benefit in recognition of their important service. The extension of 
TRICARE Prime in Puerto Rico and Guam for retired service members and 
their eligible dependents may improve the health of those members as a 
result of improved access to care, and would create parity of health 
care benefits with those beneficiaries residing in the 50 States and 
the District of Columbia.
    If implemented, the broader challenge will remain in meeting the 
specialty care requirements in remote locations with limited local 
health care resources. The TRICARE program relies heavily on civilian-
based provider networks to augment and support the Direct Care System 
(Military Treatment Facilities--MTFs) in meeting their mission. Any 
actions taken to expand or change the health care benefit in Puerto 
Rico and Guam must be carefully reviewed to consider the impact on 
existing resources, both civilian and military.

                                  
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