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







                         [H.A.S.C. No. 111-156]

 
                         DEFENSE HEALTH PROGRAM

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                             APRIL 21, 2010

                                     
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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                 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
                 Dave Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                      James Weiss, Staff Assistant


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2010

                                                                   Page

Hearing:

Wednesday, April 21, 2010, Defense Health Program................     1

Appendix:

Wednesday, April 21, 2010........................................    31
                              ----------                              

                       WEDNESDAY, APRIL 21, 2010
                         DEFENSE HEALTH PROGRAM
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Subcommittee on Military Personnel.................     1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking 
  Member, Subcommittee on Military Personnel.....................     3

                               WITNESSES

Green, Lt. Gen. Charles B., USAF, Surgeon General, U.S. Air Force    11
Rice, Charles L., M.D., Performing the Duties of the Assistant 
  Secretary of Defense for Health Affairs, and President, 
  Uniformed Services University of Health Sciences, U.S. 
  Department of Defense..........................................     5
Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy.....     8
Schoomaker, Lt. Gen. Eric B., USA, Surgeon General, U.S. Army....     6

                                APPENDIX

Prepared Statements:

    Davis, Hon. Susan A..........................................    35
    Green, Lt. Gen. Charles B....................................    96
    Rice, Charles L., M.D........................................    42
    Robinson, Vice Adm. Adam M...................................    77
    Schoomaker, Lt. Gen. Eric B..................................    61
    Wilson, Hon. Joe.............................................    39

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mrs. Davis...................................................   117
    Dr. Fleming..................................................   117
    Ms. Shea-Porter..............................................   117
    Ms. Tsongas..................................................   118

Questions Submitted by Members Post Hearing:

    [There were no Questions submitted post hearing.]

                         DEFENSE HEALTH PROGRAM

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                         Washington, DC, Wednesday, April 21, 2010.
    The subcommittee met, pursuant to call, at 1:40 p.m., in 
room 2118, Rayburn House Office Building, Hon. Susan A. Davis 
(chairwoman of the subcommittee) presiding.

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

    Mrs. Davis. Good afternoon. Today the Military Personnel 
Subcommittee will hold a hearing on the President's fiscal year 
2011 budget request for the Defense Health Program (DHP).
    Testifying before us are the senior medical leaders of the 
Department of Defense (DOD). Dr. Charles Rice is the President 
of the Uniformed Services University of Health Sciences, and is 
currently performing the duties of the Assistant Secretary of 
Defense for Health Affairs. This office is responsible for the 
preparation and oversight of the Defense health budget, as well 
as the execution of private sector care.
    We also have with us the service surgeons general, 
Lieutenant General Eric Schoomaker from the Army, Vice Admiral 
Adam Robinson from the Navy, and Lieutenant General Bruce Green 
from the Air Force, who are responsible for the provision of 
care in military hospitals and clinics. Thank you all for being 
here. Welcome.
    This year's budget request, much like last year's, lacks 
many of the objectionable proposals of years past. For example, 
there are no onerous TRICARE fee increases that seek to place a 
burden of improving the system on beneficiaries instead of on 
the Department of Defense. There are no ``efficiency wedges,'' 
an interesting term that meant ``We think the services are 
spending too much, but we don't know exactly where, so we are 
just going to cut their budgets and let them figure it out.'' 
There are no proposed conversions of military medical positions 
to civilian medical positions. And the absence of all of these 
things from the proposed budget is a very good start.
    However this budget request, while devoid of these 
negatives, doesn't have so many positives that are forward-
looking. We continue to see little if any evidence of a 
comprehensive, multifaceted strategy for moving the Military 
Health System (MHS) forward. For the past few years Congress 
has been pushing the Department of Defense to improve the 
health status of the beneficiary population and improve cost-
effectiveness of the care provided to our beneficiaries by 
adopting proven practices, the fiscal year 2009 National 
Defense Authorization Act contains many initiatives to improve 
preventive and wellness care. But 18 months, now, after it was 
signed into law, we are still waiting for most of them to be 
fully implemented.
    That same bill also gave the Department great latitude and 
authority to conduct demonstration projects to test other 
methods of improving health while reducing costs. We would like 
to hear today how the Department plans to take advantage of 
that authority.
    Further, the 2010 National Defense Authorization Act 
contained a requirement for the Department to undertake actions 
to enhance the capability of the Military Health System and 
improve the TRICARE program. Congress felt that such action was 
needed because private sector care, which was originally 
intended to be and is still described by the Department as a 
program to fill gaps in the direct care system, is projected to 
account for about 67 percent of the Department of Defense 
health-care expenditures in fiscal year 2011 versus 65 percent 
this year. It is strange logic to characterize something that 
accounts for almost 70 percent of a program as a gap-filler.
    We recognize that several factors have contributed to the 
unintentional growth in private sector care, such as two wars, 
staffing shortages, and broad reserve globalization.
    With that said, without appropriate planning, the effect of 
these factors could be an irreversible trend, placing medical 
readiness in future contingencies in jeopardy. Congress clearly 
believed the Department must develop a long-term plan to 
maximize the capabilities of the direct care system, and we 
would like to hear from our witnesses today any ideas they may 
have.
    This has been a momentous year for health care in this 
country. Last month the Patient Protection and Affordable Care 
Act and the companion improvements bill were signed into law. 
Further, just last week, the Senate unanimously passed the 
TRICARE Affirmation Act introduced by the chairman of this 
committee, Ike Skelton, which had previously passed unanimously 
in the House.
    The TRICARE Affirmation Act explicitly states that TRICARE 
and nonappropriated fund, NAF, health plans meet all of the 
health-care requirements for individual health insurance under 
the newly enacted health-care reform law. TRICARE and the NAF 
health plans already meet the minimum requirements for 
individual health insurance coverage in the recently enacted 
health-care bill, and no TRICARE or NAF nonappropriated fund 
health plan beneficiary will be required to purchase additional 
coverage beyond what they already have.
    However, to reassure our military service members and their 
families and make it perfectly clear that they will not be 
negatively affected by the health-care reform law, the TRICARE 
Affirmation Act explicitly states that TRICARE and the NAF 
health plans meet the minimum requirements for individual 
health insurance.
    Now that the bills are law, parents across the country will 
now be able to extend their health coverage to their dependent 
children up to age 26. Being true to their word, congressional 
Democratic leadership ensured that the health reform bills do 
not involve TRICARE in any way. But since care was taken to 
guarantee that the Department of Defense health programs under 
Title 10, U.S. Code, were not touched by the health reform 
bills, this means that the new law does not allow TRICARE 
beneficiaries to extend their health coverage to their 
dependent children.
    Fortunately, a member of this committee, Mr. Heinrich of 
New Mexico, quickly crafted and introduced a bill, H.R. 4923, 
the TRICARE Dependent Coverage Extension Act, that would amend 
Title 10 to precisely match the health reform law to allow 
TRICARE beneficiaries to extend their health coverage to their 
dependent children up to age 26. I want to thank Mr. Heinrich 
for introducing this important legislation and I want to let 
everyone know that I certainly intend to include that bill in 
this subcommittee's mark for this year's National Defense 
Authorization Act in a few weeks.
    Since Mr. Heinrich is not a member of the subcommittee, I 
would ask unanimous consent that he be allowed to participate 
in today's hearing and be allowed to ask questions after all 
the members of the subcommittee.
    Hearing no objection, thank you for being here.
    Mr. Wilson, we welcome you. We are sorry we got underway 
because we just had everybody ready to go here and we 
appreciate the fact that you were trying to get here as well.
    Please, we are happy to have any of your comments.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 35.]

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

    Mr. Wilson. Thank you, Chairwoman Davis. Today the 
subcommittee meets to hear testimony on the Defense Health 
Program for fiscal year 2011. Although we routinely have an 
annual hearing on the Defense Health Program, I believe there 
is nothing routine about the Military Health System and the 
extraordinary care it provides to our service members and their 
families. I have firsthand knowledge of these remarkable 
military and civilian medical professions from my second son, 
who is an orthopedic resident in the Navy, and my other three 
sons who are current members of the Army National Guard.
    The subcommittee remains committed to ensuring that the men 
and women who are entrusted with the lives of our troops have 
the resources to continue their work for future generations of 
our most deserving military beneficiaries.
    I would like to express my deep appreciation to all the 
Military Health System leadership and personnel who are 
responsible for delivering the highest quality health care 
during these most challenging times.
    To begin, I want to commend the Department of Defense for 
sending us a budget that does not rely on raising TRICARE fees 
to help finance the Defense Health Program. It appears the 
Defense Health Program is fully funded. However, I remain 
concerned a portion of the funding is based on projected 
savings from several programs that may not be fully realized.
    I would like to know how the Department of Defense plans to 
cover any unexpected shortfalls in the Defense Health Program 
if the savings from initiatives such as the Federal Pricing for 
Pharmaceuticals doesn't materialize.
    With that, I am anxious to hear from our witnesses today 
about the progress the Department has made in developing a 
comprehensive approach to providing world-class health care to 
our beneficiaries while at the same time controlling cost. I 
would like to know how the Military Health System is meeting 
the medical needs of our beneficiaries today and what process 
you use for determining the medical requirements of future 
beneficiaries. I am interested in knowing how you have included 
the stakeholders in military health care and the discussions 
about providing world-class health care in the future of the 
Military Health System. Further, I would like to hear from the 
witnesses on how the Defense Health Program supports the 
critical mental health services needed by our service members 
and their families, particularly the National Guard and Reserve 
members who rely primarily on TRICARE standard.
    I would also like to better understand from our military 
Surgeons General whether the Defense Health Program will fully 
support their responsibility to maintain medical readiness, 
provide health care to eligible beneficiaries, provide 
battlefield medicine to our brave men and women in Iraq and 
Afghanistan, care for combat veterans through the long recovery 
process when they become injured and wounded.
    Finally, with regard to TRICARE, which is now regarded as a 
health-care delivery system worthy of emulation, I quite 
frankly don't understand why the Department of Defense would 
not want to explicitly protect it from any unintended 
consequence that may arise from the health-care takeover.
    Congress has already acted to make clear, explicit, that 
the recent health-care bill did not, that TRICARE meets the 
statutory requirement for minimal essential health care. The 
Department of Defense did not object to that recent 
congressional action. Now it is time to make explicit in the 
law what has been promised that would be explicit in the 
health-care reform.
    The Secretary of Defense would remain in control of the DOD 
Health Care Program. No one should object to Congress making 
that control explicit in the law. While some may feel that this 
is an unnecessary precaution, we owe our military that clearly 
stated protection.
    With that, I would like to welcome our witnesses and thank 
them for participating in the hearing today. I look forward to 
your testimony.
    Mrs. Davis. Thank you, Mr. Wilson.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 39.]
    Mrs. Davis. Dr. Rice, please begin.

 STATEMENT OF CHARLES L. RICE, M.D., PERFORMING THE DUTIES OF 
  THE ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, AND 
 PRESIDENT, UNIFORMED SERVICES UNIVERSITY OF HEALTH SCIENCES, 
                   U.S. DEPARTMENT OF DEFENSE

    Dr. Rice. Madam Chair, members of the committee, thank you 
for the opportunity to discuss the military health care 
system's priorities and our budget submission for fiscal year 
2011. It is a privilege to be here with my colleagues, the 
Surgeons General of the three military services.
    We have enduring obligations to the men and women of our 
armed forces, as you have observed, and to their families who 
serve with them, and to the millions of retired personnel who 
have served us in the past. This obligation begins the moment a 
recruit walks through our doors. In our budget for the coming 
year we acknowledge that lifetime commitment we have to those 
who serve today, or who have served in the past, and to their 
families. For those service members who honorably conclude 
their service before reaching military retirement, we have an 
obligation to ensure that their medical experience is fully 
captured and easily shared with the Department of Veterans 
Affairs (VA) or with their own private physician.
    For those who retire from military service, our obligation 
to them and to their families often extends for a lifetime. And 
for those who have borne the greatest burden through injury or 
disease suffered in our nation's conflicts, we have an even 
higher obligation to the wounded and to their families.
    As Secretary Gates stated with the introduction of the 
Defense budget, ``Recognizing the strain that post-9/11 wars 
have put on so many troops and their families, the Department 
will spend more than $2 billion for wounded warrior 
initiatives, with a special focus on signature ailments of the 
current conflict, such as post-traumatic stress disorder and 
traumatic brain injury (TBI), manifestations of the last 
injury.
    ``We will sustain health benefits and enlarge the pool of 
medical professionals. We will broaden electronic information 
sharing between the Department of Defense and the VA for 
wounded warriors making the transition out of military 
service.''
    The budget we are putting forward reflects our commitment 
to the broad range of responsibilities of the military health 
care system; the medical readiness requirements needed for 
success on today's battlefield; the medical research and 
development necessary for success on tomorrow's; the patient-
centered approach to care that is being woven through the 
fabric of the military health care system; the transformative 
focus we have placed on the health of our population; the 
public health role we play in our military community and in the 
broader American community; the reliance we have on our private 
sector health-care partners who provide indispensable service 
to our service members and their families; and our 
responsibility to deliver all of those services with 
extraordinary quality and care.
    The Defense Health Program, the appropriation that supports 
the MHS, is under mounting financial pressure. The DHP has more 
than doubled since 2001 from 19 billion to 50.7 billion in 
2011. The majority of DOD health spending supports health-care 
benefits for military retirees and their dependents, not the 
active force. We projected up to 65 percent of DOD health-care 
spending will be going towards retirees in fiscal year 2011, up 
from 45 percent in 2001.
    As civilian employers' health costs are shifted to their 
military retiree employees, TRICARE is seen as a better, less 
costly option, and they are likely to drop their employer's 
insurance.
    These costs are expected to grow from 6 percent of the 
Department's total budget in 2001 to more than 10 percent in 
2015. Despite these financial challenges, however, the fiscal 
year 2011 budget request provides realistic funding for 
projected health-care requirements, and we are grateful to this 
committee and to the Congress for affirming TRICARE as a 
qualifying plan under the health reform act.
    The unified medical budget, the Department's total request 
for 2011 is $50.7 billion. This includes the DHP appropriation, 
including wounded, ill, and injured care and rehabilitation, 
military personnel, military construction, and normal cost 
contributions for Medicare-eligible retiree health care.
    For military personnel, the unified budget includes 7.9 
billion to support the more than 84,000 military personnel who 
provide health-care services in military theaters of operations 
in fixed health-care facilities around the world. These 
services include medical and dental care, global aeromedical 
evacuation, shipboard and undersea medicine, and global 
humanitarian assistance and response as we recently saw in 
Haiti.
    Funding for the military construction (MILCON) includes a 
billion dollars to improve our medical infrastructure. We are 
committed to building new hospitals, using the principles of 
evidence-based design, and excited to be able to open a 
national showcase in evidence-based design, the new Fort 
Belvoir Community Hospital, in 2011.
    MILCON funding will also be directed toward infrastructure 
enhancements at the interagency biodefense campus at Fort 
Detrick.
    Madam Chair, the military health care system continues to 
provide world-class medical care for a population that demands 
and deserves the best care anywhere. I am proud to be here on 
behalf of the men and women who comprise the military health 
care system, proud to submit to you and your colleagues a 
budget that is fully funded and that we can successfully 
execute in the coming year. I look forward to your questions.
    Mrs. Davis. Thank you.
    [The prepared statement of Dr. Rice can be found in the 
Appendix on page 42.]
    Mrs. Davis. General.

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, SURGEON GENERAL, 
                           U.S. ARMY

    General Schoomaker. Chairwoman Davis and Representative 
Wilson, distinguished members of the Military Personnel 
Subcommittee and the full committee, thank you for inviting us 
to discuss the Defense Health Program and our respective 
medical service programs.
    Now in my third hearing cycle as the Army Surgeon General 
and the Commanding General of the United States Army's Medical 
Command, or MEDCOM, I can tell you that these hearings are 
valuable opportunities for me to talk about the accomplishments 
and challenges of Army Medicine and to hear your collective 
perspectives regarding military health promotion and health 
care. And for the reasons, ma'am, that you mentioned in your 
opening comments, although closely interrelated, I keep 
military health promotion and health care somewhat separate 
issues.
    I am pleased to tell you that the President's budget 
submission for fiscal year 2011 fully funds the Army Medical 
Department's needs. Your support of the President's proposed 
budget will be greatly appreciated.
    One particular area of special interest to this 
subcommittee is our comprehensive effort to improve warrior 
care from the point of injury through evacuation and inpatient 
treatment to rehabilitation and return to duty. There is 
nothing more gratifying than to care for these wounded, ill, 
and injured heroes. We in Army Medicine continue to focus our 
efforts on our warriors in transition, which is our term for 
them. And I want to thank the Congress for your unwavering 
support of these efforts.
    The support of this committee especially has allowed us to 
hire additional providers to staff our warrior transition 
units, to conduct relevant medical research, and to build 
healing campuses, the first of which will open in Fort Riley, 
Kansas very soon.
    I am convinced that the Army has made some lasting 
improvements. The most important improvement will be the change 
in mindset from a focus on disability to an emphasis on ability 
and achievement. Each of these warriors has the opportunity and 
resources to create their own future as soldiers or as 
productive private citizens.
    A second area of special interest for the subcommittee is 
psychological health. Army Medicine, under the direction of our 
new Deputy Surgeon General, Major General Patty Horoho who has 
just relinquished command of the Western Region and has 
traveled here and is replacing David Rubenstein who is headed 
to San Antonio, is finalizing a comprehensive behavioral health 
system of care campaign plan. This comprehensive behavioral 
health system of care is intended to standardize and 
synchronize the vast array of activities across the medical 
command and throughout the Army's force generation cycle, this 
iterative three-cycle process by which we prepare soldiers and 
units for deployment, deploy them and support their families 
back in garrison, bring them back and redeploy them and 
reintegrate them. I look forward to sharing more information 
with you over the next few months as we roll out this exciting 
initiative.
    In keeping with our focus on preventing illness and injury, 
Army leadership is fully engaged in an all-out effort to change 
the military mindset regarding traumatic brain injury, 
especially the milder form, or a concussion. Our goal is 
nothing less than a cultural change in fighter management after 
potential concussive events. Every warrior requires appropriate 
treatment to minimize concussive injury and to maximize 
recovery. And to achieve this goal we are educating the force 
so that we have trained and prepared soldiers, leaders, medical 
personnel to provide early recognition, treatment, and tracking 
of concussive injuries from the moment of the injury on the 
battlefield, homeward. Ultimately this is designed to protect 
warrior health. This also further highlights strong efforts by 
the senior Army and DOD leadership to reduce the stigma 
associated with seeking help for these injuries and for 
behavioral health problems which might be present, separately 
or jointly.
    The Army is issuing very direct standards and protocols to 
commanders and health-care providers. Similar to aviation 
incident actions, automatic grounding and medical assessments 
are required for any soldiers meeting specified criteria. The 
end state of these efforts is that every service member 
sustaining a possible concussion will receive early detection, 
state-of-the-art treatment and a return-to-duty evaluation and 
a long-term digital health record tracking of their management. 
Treatment of concussive injury is an emerging science. The Army 
is leading the way, along with the DOD, in implementing these 
new treatment protocols both for the DOD, and the DOD is 
leading the nation.
    I brought here with me today a brain injury awareness kit 
that I will share with you and your staff. It contains patient 
information materials, as well as a very informative DVD, sort 
of a concussive injury 101.
    Mrs. Davis. Thank you General. I just ask that that be 
included in the record by unanimous consent.
    [The information referred to is retained in the 
subcommittee files and can be viewed upon request.]
    General Schoomaker. Thank you.
    I truly believe our evidence-based directive approach to 
concussion management will change the military culture 
regarding head injuries and significantly impact the well-being 
of the force.
    Ma'am, in reference to your comments about cost containment 
and improvements and health outcomes, the Army Medicine is in 
its fourth year of the performance-based health-care budget 
program which incentivizes our commanders and our clinicians 
for practicing evidence-based medicine and improving individual 
and community health. It has been a very successful campaign. I 
am very eager to address any questions that you may have about 
it.
    In closing, I am very optimistic about the next two years. 
Logic would not predict that we would be doing as well as we 
are in attracting and obtaining and career-developing such a 
talented team of uniformed and civilian military medical 
professionals. I feel very privileged to serve with the men and 
women of Army Medicine, as soldiers, as Americans, and as 
global citizens.
    Thank you for holding this hearing and for your steadfast 
support of Army Medicine. I look forward to your questions.
    Mrs. Davis. Thank you.
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 61.]
    Mrs. Davis. Admiral Robinson.

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

    Admiral Robinson. Good afternoon. Thank you, Chairwoman 
Davis, Representative Wilson, distinguished members of the 
committee, Representative Heinrich, I want to thank you for 
your unwavering support of Navy Medicine, particularly as we 
continue to care for those who go in harm's way, their families 
and all beneficiaries. I am honored to be with you today to 
provide an update of Navy Medicine.
    Navy Medicine, world-class care anytime anywhere. This 
poignant phrase is arguably the most telling description of 
Navy Medicine's accomplishment in 2009 and continues to drive 
our operational tempo and priorities for the coming year and 
beyond.
    Throughout the last year we saw challenges and 
opportunities, and moving forward I anticipate the pace of 
operations and demand will continue to increase. We have been 
stretched in our ability to meet increasing operational and 
humanitarian assistance requirements, as well as maintaining 
our commitment to provide care to a growing number of 
beneficiaries. However, I am proud to say that we are 
responding to this demand with more flexibility and agility 
than ever before.
    The foundation of Navy Medicine is force health protection, 
and nowhere is this more evident than in Iraq and Afghanistan. 
During my October 2009 trip to theater, I saw again the 
outstanding work of medical personnel. The Navy Medicine team 
is working side by side with Army and Air Force medical 
personnel and coalition forces to deliver outstanding health 
care to troops and civilians alike.
    As our wounded warriors return from combat and begin the 
healing process, they deserve a seamless and comprehensive 
approach to their recovery. We want them to mend in body, mind, 
and spirit. Our patient- and family-centered concept of care 
brings together medical treatment providers, social workers, 
case managers, behavioral health providers and chaplains. We 
are working closely with our aligned counterparts in Marine 
Corps wounded warrior regimens, and the Navy's Safe Harbor 
Program to support the full spectrum recovery process for 
sailors, Marines, and their families.
    An important focus for all of us continues to be caring for 
our wounded warriors suffering with traumatic brain injury. We 
are expanding traumatic brain injury training to health-care 
providers throughout the fleet and Marine Corps. We are also 
implementing a new in-theater TBI surveillance system and 
conducting important research. Our strategy is both 
collaborative and integrated by actively partnering with other 
services, Defense Center of Excellence for Psychological Health 
and Traumatic Brain Injury, the Department of Veterans Affairs, 
and leading academic medical and research centers to make the 
best care available to our warriors.
    We must act with a sense of urgency to continue to help 
build resiliency among our sailors and Marines, as well as the 
caregivers who support them. We are aggressively working to 
reduce the stigma surrounding psychological health and 
operational stress concerns.
    Programs such as Navy Operational Stress Control, Marine 
Corps Combat Operational Stress Control Focus, Families 
Overcoming Under Stress, Caregiver Occupational Stress Control, 
and our Suicide Prevention Programs are in place and maturing 
to provide the support to personnel and their families.
    Mental health specialists are being placed in operational 
environments and forward deployed to provide service where and 
when they are needed. The Marine Corps is sending more mental 
health teams to the front lines, and Operational Stress Control 
and Readiness team, also known as OSCAR, will soon be expanded 
to include the battalion level.
    A mobile care team of Navy Medicine mental health 
professionals is currently deployed to Afghanistan conducting 
mental health surveillance, consulting with command leadership, 
and coordinating mental health care for sailors throughout the 
area of responsibility (AOR).
    An integral part of the Navy's maritime strategy is 
humanitarian assistance and disaster response. In support of 
Operation Unified Response Haiti, we deployed USNS Comfort from 
her homeport in Baltimore within 77 hours of the order, and 
ahead of schedule. She was on station in Port-au-Prince five 
days later.
    From the beginning, the operational tempo on board Comfort 
was high and our personnel were challenged professionally and 
personally. For many, this was a career defining experience, 
and I was proud to welcome the crew home last month and 
congratulate them for their outstanding performance.
    I am encouraged with our recruiting efforts within Navy 
Medicine, and we are starting to see the results of new 
incentive programs. But while overall manning levels for both 
officer and enlisted personnel are relatively high, ensuring we 
have the proper specialty mix continues to be a challenge in 
both active and reserve components. Several wartime critical 
specialties, as well as advance practice nursing and physician 
assistant, are undermanned.
    We also face shortfalls for general dentists, oral and 
maxillofacial surgeons, and many of our mental health 
specialists, including clinical psychologists and social 
workers. We continue to work hard to meet this demand but 
fulfilling the requirement among these specialties is expected 
to present a continuing challenge.
    Research and development is critical to Navy Medicine's 
success and our ability to remain agile to meet the evolving 
needs of our warfighters. It is where we find solutions to our 
most challenging problems and, at the same time, provide some 
of medicine's significant innovations and discoveries. Research 
efforts targeted at wound management, enhanced wound repair and 
reconstruction, as well as extremity and internal hemorrhage 
control, phantom limb pain in amputees present definitive 
benefit. These efforts support our emerging expeditionary 
medical operations in aid and support to our wounded warriors.
    Clearly, one of the most important priorities for 
leadership of all the service is the successful transition to 
the Walter Reed National Medical Center on board the campus of 
the National Naval Medical Center, Bethesda. We are working 
diligently with the lead DOD organization, Joint Task Force 
National Capital Region Medical, to ensure that this 
significant and ambitious project is executed properly and 
without any disruption of services to our sailors, Marines, 
their families, and all of our beneficiaries for whom we are 
privileged to serve.
    In summary, I believe we are an important crossroads for 
military medicine. Commitment to wounded warriors and their 
families must never waiver, and our programs of support and 
hope must be built and sustained for the long haul. And the 
long haul is the rest of this century when the young, wounded 
warriors of today mature into our aging heroes in the years to 
come. They will need our care and support, as will their 
families, for a lifetime.
    On behalf of the men and women of Navy Medicine, I want to 
thank the committee for your tremendous support and confidence 
and also for your leadership. It has been my pleasure to 
testify before you today and I look forward to your questions. 
Thank you.
    Mrs. Davis. Thank you.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 77.]
    Mrs. Davis. General Green.

STATEMENT OF LT. GEN. CHARLES B. GREEN, USAF, SURGEON GENERAL, 
                         U.S. AIR FORCE

    General Green. Chairwoman Davis, Representative Wilson and 
distinguished members of the committee, thank you for this 
opportunity to join you today as we address common goals in 
serving our warriors and their families.
    The Air Force is all in to support the joint fight, 
providing global vigilance reaching power for America. The Air 
Force medical service does whatever it takes to get coalition 
wounded warriors home safely.
    I have previously shared the case of a British combatant 
with wounds requiring removal of a lung. It took three 
airplanes and nearly a thousand people coordinating his 
movement on heart-lung bypass to get him back to England. Today 
he is out of the hospital and back to a normal life in 
Birmingham, England.
    You may have seen or heard recent national news reports 
about an amazing operation that took place last month at the 
Craig Joint Theater Hospital at Bagram. Air Force Major Dr. 
John Bini is a seasoned theater hospital trauma surgeon, 
stationed in Wilfred Hall Medical Center, who is deployed to 
Bagram. When the radiologist discovered a live explosive round 
in an Afghan patient's head, Major Bini and his 
anesthesiologist, Dr. Jeffrey Rengold, put on body armor and 
went to work. They evacuated the operating room (OR), leaving 
only themselves and a bomb technician with the patient, because 
any electrical equipment could detonate the round. They turned 
to manual blood pressure cuffs and battery-operated heart 
monitor. Counting drips per minute they administered anesthesia 
the old-fashioned way. Dr. Bini operated and, within 10 
minutes, removed the live round. Miraculously, the patient has 
been discharged, and is recovering, able to walk, talk, and 
feed himself.
    Dr. Bini told the New York Times that technically it wasn't 
a very complicated procedure; it is just something we train 
for, although it is a very uncommon event.
    In short, this is what Air Force and Army medics, along 
with Navy corpsmen, are all about. We are trained and ready as 
a team to meet the mission wherever, whenever, and however 
needed, with cutting-edge techniques and equipment, or the most 
basic of resources if this is our only option. We have the 
lowest died-of-wounds rate in history because of well-trained, 
highly skilled, and extraordinary people.
    Our country should be very proud of our men and women who 
put service before self and demonstrate excellence in all we 
do. We deeply appreciate all you do to ensure we recruit and 
retain these very special medics who are devoted to providing 
trusted care anywhere. We could not achieve our goals of better 
readiness, better health, better care, and best value, for our 
heroes and their families, without your support. Thank you.
    [The prepared statement of General Green can be found in 
the Appendix on page 96.]
    Mrs. Davis. Thank you very much, to all of you, and for all 
the programs that you have highlighted. We know that there are 
men and women behind you that are really performing 
extraordinary feats and have used their education and their 
experience to work on behalf of the men and women who are 
serving, and we are certainly very grateful for that.
    I wanted Dr. Rice to just pick up with one of the 
provisions that the National Defense Authorizations Act (NDAA) 
from 2010, section 721, which basically spoke to the study, and 
a plan to improve military health-care requirement interim 
response by the end, actually, of this week. I am just 
wondering if you know what the status of that response is, 
whether it is being prepared, sort of what strategic evaluation 
and planning has gone into that report.
    Dr. Rice. Madam Chair, I would be happy to get back to you 
with the details. It is my understanding that the draft is well 
underway. Obviously we need to coordinate it with the services 
who deliver the care, but we anticipate having the report in 
very shortly.
    [The information referred to can be found in the Appendix 
on page 117.]
    Mrs. Davis. Thank you. We will be looking forward to that.
    In your remarks you mentioned transformative medical care. 
I wonder if you could--we have heard, certainly from all of you 
to some extent, on medical homes and more healing communities, 
issues of that sort, of that kind of transformative look that 
we are trying to gain, I think, some real progress in today. Is 
that something that you expect out of the report? And if you 
could detail for us a little bit more about what is that kind 
of transformative care that you have in mind, rather than 
perhaps something that I would think that we are talking about 
here.
    Dr. Rice. Well, as you are well aware from the discussions 
that the Congress has had for the past year, wrestling with the 
issues of the delivery of health care while controlling costs 
and ensuring quality is a challenge for the nation as a whole. 
The military health care system is not isolated or insulated 
from that.
    As you are aware, we are close to concluding the award of 
the third-generation TRICARE contracts. Working with Rear 
Admiral Hunter, the Deputy Director of the TRICARE Management 
Activity, we have begun discussions on what the fourth 
generation of TRICARE contracts should look like, so that we 
work with our purchase care contract support organizations to 
incentivize individual patients to take responsibility for 
maintaining and improving their own health and working both 
within the direct care system as well as in the purchase care 
system for making care more efficient, more patient-centered, 
and more successful.
    As you may be aware, the Department has adopted, with 
permission from the Institute for Health Care Improvement, who 
developed what they refer to as the ``triple aim,'' we have 
modified that slightly for the ``quadruple aim,'' the four aims 
that are the experience of care, the quality and safety, an 
emphasis on population health, doing the very best you can to 
make care safe, efficient, and cost-effective and all of those 
surround our core mission which all three of the Surgeons 
General have alluded to, which is readiness--our responsibility 
to provide a medically ready force and a ready medical force.
    We have just begun those conversations on what the fourth-
generation TRICARE contracts will entail, what the underlying 
philosophy is, and I look forward to coming back to report back 
to you and seek your guidance on ways that we should be 
thinking about.
    Mrs. Davis. When do you anticipate that the contracts would 
be awarded?
    Dr. Rice. We expect it to be imminent. As the committee is 
undoubtedly aware, there were protests in two of the regions 
that were upheld by the General Accounting Office (GAO). The 
contracting officer has agreed with the GAO's findings, and we 
are now refining exactly how we will resolve those conflicts. 
The discussions of that are ongoing within the Department and 
we hope that we will have that issue resolved very shortly.
    Mrs. Davis. Thank you very much.
    I am going to come back later. I am just thinking about 
this split of direct cost and essentially bought care. Today we 
are looking at 33 percent, 67 percent. Do you think that is the 
right mix? Where do we want to be in five years from now in 
terms of that breakdown?
    I will come back and let my colleague speak, but that would 
be something that I would like to explore.
    Mr. Wilson.
    Mr. Wilson. Thank you, Madam Chairwoman. Again, thank all 
of you for your service. All of us are concerned, facing an 
asymmetric enemy that seems to have zero morality in terms of 
attacking military civilians. We are so concerned about the 
post-traumatic stress disorder, mental health issues. And I 
want to thank you, General Schoomaker, for your information 
about traumatic brain injury. This is just so helpful and 
positive.
    Yesterday in a hearing we were discussing a concern that I 
know that you have, too, and what can be done; and that is to 
determine for pre-deployment neurocognitive baseline, and also 
then to have a post-deployment assessment.
    For any of who would like to answer that, what is being 
done and how effective do you feel this is?
    General Schoomaker. Well, I will take that on, sir. I would 
say right now the screening for neurocognitive problems as a 
tool or as an instrument for getting both baselines and post-
appointment is fraught with problems. One of the tools that we 
first turned to that was jointly developed between the 
University of Oklahoma and the Army was the Automated 
Neurocognitive Assessment Model, ANAM. ANAM was never designed 
as a screening tool. It is designed as a prospective ongoing 
evaluation of neurocognition to see improvements for people who 
have neurocognitive problems from all causes, not just 
concussive injury or more severe forms of brain injury.
    And when we have looked at this--in fact I sent a team down 
range over a year ago to look in a very careful way at cohorts 
of known concussed soldiers in combat, non-concussed but ill 
soldiers from other causes, and then soldiers without any 
problems whatsoever either from concussion or from other 
illnesses, and discovered in that cohort controlled study, 
conducted by neurologists and scientists, that the ANAM as a 
screening tool was basically a coin flip. We would call it an 
insensitive and nonspecific test, both for non-concussed 
soldiers as well as for soldiers who received concussion.
    So we have turned away from ANAM as a simple screening 
tool. It still has utility for following longitudinally 
patients who might have, or soldiers who might have been 
concussed, but it is not a screen. What we have turned to is 
what we do every day on sports fields in this country, or 
following motor vehicle accidents or anything else. If we 
suspect a soldier, or Marine, or sailor, or airman has had a 
concussion, we evaluate them at the moment of the concussion, 
as quickly as we can, and safely. That is what is in that 
packet there, sir.
    Mr. Wilson. I looked at it, and this looks very positive, 
but it is just obviously is a concern that I have that was 
expressed yesterday. And you are right; whether it be sports or 
auto accidents, that is where military medicine is leading the 
way with prosthetics. I am counting on you all on what can be 
done for pre-deployment, post-deployment.
    Another concern I have has been with the Walter Reed 
National Medical Center, which is to be concluded September 
2011; and that is, will the wounded warrior facilities be 
adequate and will they be contracted out? Are we really 
prepared? I know Admiral Robinson used to have a lot of hair 
until this issue came up, but what is the status of 
development?
    Admiral Robinson. Representative Wilson, the status of 
development is that the Navy, the Army, the Air Force, Joint 
Task Force (JTF) CapMed, are meeting and developing plans for 
wounded warriors. I will speak for the National Naval Medical 
Center--to become the Walter Reed National Military Medical 
Center. We have gone through a long series of discussions and 
talks. There will be 350 wounded warriors coming to the 
National Naval Medical Center, Walter Reed National Naval 
Medical Center, with their requisite nonmedical attendants and 
family members, and also with the requisite staff of 
individuals that will help care for them in terms of all of the 
personnel and other issues that men and women in the military 
need to have. So that number will be 350-plus and there will be 
a tail with that number.
    I think that if you look at the average daily census of 
Walter Reed and Bethesda in terms of their outpatient wounded 
warriors now, I think you will note there is probably a deficit 
of some number, between the 350 that I know about and the rest 
in the National Capital Area. And with that in mind, I think 
that the JTF CapMed and the services need to make sure that we 
have a comprehensive plan for whatever that delta may be for 
those wounded warriors and how they may be in fact cared for in 
the NCA, National Capital Area.
    I think that includes--and during discussions last week 
that will include several other bases in the area, such as Fort 
Meade. That may include Fort Belvoir. That will include other 
areas, and that may include also some reconnoitering of the 
spaces that we have at National Naval Medical Center, so we may 
have to do something a little different there, too. But there 
is a deficit of knowledge regarding that delta of wounded 
warriors in the National Capital Area.
    Mr. Wilson. I appreciate your efforts. Thank you, Madam 
Chairwoman.
    Mrs. Davis. Thank you. Dr. Snyder.
    Dr. Snyder. Thank you. And thank you, gentlemen, for being 
here. Mr. Wilson's opening statement made a comment that there 
is nothing routine about you all's jobs and about military 
health care, and we appreciate you all trying to stay ahead of 
changes that occur in the lives of men and women in uniform and 
their families.
    Dr. Schoomaker, in the information that you handed out, 
give me the 10-second summary, why are over-the-counter pain 
medicines like Ibuprofen not recommended for treatment of mild 
headache associated with concussion?
    General Schoomaker. We are very concerned about the use of 
non-steriodals and aspirin in theater, which would interfere 
with small-vessel blood clotting----
    Dr. Snyder. Okay.
    General Schoomaker [continuing]. When you are at risk for a 
concussive injury or something that may require a robust 
clotting system. So we recommend that soldiers going down range 
suspend the use of aspirin and the non-steroidals.
    Dr. Snyder. That makes sense to me.
    Same thing, Doctor. I had this discussion yesterday, and I 
want to ask you, and it is the issue of--I guess I will say the 
moderately severe traumatic brain injury patients. I am talking 
about the group of people that may have been in your 
rehabilitation facility for several months, have reached the 
point at which we think there is probably the steady state, but 
it becomes apparent to the caretakers and the medical team that 
they are probably going to need to be in a facility that 
watches them.
    I think in the olden days we called it a domiciliary. They 
may not be able to handle meals or they get lost, a fairly 
significant injury, but still walk around. Maybe they will do 
some work under their facility.
    How do you handle those kinds of folks as time reaches for 
them to be discharged from the military? How do we make sure 
that they are immediately transferred to a place in which we 
won't lose them for an hour, a day, or a week, or a month while 
we are trying to find a proper placement for them? Is that an 
issue that you are having to deal with?
    General Schoomaker. Yes, sir. I would explain that, beyond 
moderate brain injury, I would talk about anyone who had a 
lingering or an enduring problem. I think Admiral Robinson 
talks about this passionately in every forum we get to. We are 
into an era in which we are going to have an enduring 
requirement to care for these soldiers and to assist their 
families for decades and decades to come.
    We have been intimately involved with the Veterans 
Administration since the end of the Vietnam War where the 
Defense Veterans Brain Injury Program, which has a network of 
certified centers that are community-based, such as you 
described, for assisting soldiers with moderate brain injury 
problems, but for rehabilitation and for assisting them in 
daily living requirements and location. But by extension, 
anyone who has an enduring physical or behavioral health 
problem, we partner very closely with the Veterans 
Administration. Our warrior transition units have veterans, 
counselors, embedded within them. And we have a program through 
the Army Wounded Warrior Program, any soldier with 30 percent 
disability or greater, with coordination of their care that 
goes into the Veterans Affairs system and beyond.
    So there is a very, very warm handshake now being conducted 
both into the VA system, as well as other private sector care 
that is required for these kinds of patients and patients who 
have other disabilities beyond just brain injury.
    Dr. Snyder. Dr. Rice, in your written statement I think you 
refer to the fact that we still have--I don't know if you said 
too high--but too high levels of smoking amongst our men and 
women in uniform. You also talk about the fact of the retiree 
issue we will be taking care of in terms of health care 
expenses for we hope decades and decades to come, when they 
live long, long lives of being productive Americans after a 
military career. The reality is the expenses for our country 
and their quality of life will not do well if they are smoking 
as young people in the military.
    Now, if we can't get that under control, in the controlled 
situation of the military, I just don't see how we are going to 
do it. Why are we lagging behind on that?
    Dr. Rice. Well, it is a complex issue. As you know, there 
was an Institute of Medicine Report in 2009 that talked about 
controlling tobacco use in the DOD and in the VA. The 
Department has been evaluating that very carefully to see which 
things the Department can enact and undertake on its own and 
those things for which it may need assistance from the 
Congress.
    The Navy--Admiral Robinson can correct me if I misstate 
this--but the Navy has already eliminated tobacco products from 
its commissaries. The Army and Air Force have yet to take that 
step. But we still have pricing for tobacco products in the 
military exchanges that are below the comparable civilian 
market. That is one factor.
    I think by far the most important factor has to do with 
role modeling for young men and women. Basic training is 
already a tobacco-free environment. But as soldiers, sailors, 
airmen, and Marines transition to their first assignments and 
they see older, particularly non-commissioned officers, who 
smoke and, by implication, are led to believe that it is okay 
for them.
    As you know, nicotine, tobacco products, are viciously 
addictive and the Department has--or the Military Health Care 
System has developed a number of smoking cessation programs, so 
that we work very hard to get people to stop smoking. This is 
an effort that will continue for years to come. As I say, there 
are some areas in which we may need your assistance.
    Dr. Snyder. Are you going to let us know what those areas 
are?
    Dr. Rice. Yes, sir.
    Dr. Snyder. I thank the gentleman.
    Mrs. Davis. Mr. Fleming.
    Dr. Fleming. I thank you, Madam Chairwoman.
    Well, first of all let me say to Admiral Robinson, I was a 
physician in the Navy some years ago, and served in three 
stations, enjoyed that, and certainly looked fondly upon those 
days, certainly in uniform. And then certainly for General 
Schoomaker and for Admiral Robinson.
    I have toured and visited with the wounded warriors at 
Walter Reed and Bethesda, and I am extremely impressed with the 
facilities there. You all are taking real good care of our 
wounded warriors. I appreciate that. I am even more impressed 
with the warriors themselves, the true warrior spirit. They 
don't talk about what their service-connected disability will 
be or what their pension is going to be. I am sure it is 
appropriate at some point in time or in the future that they 
will explore that. What they talk about, which inspires me, is 
when they are going to get back to duty and how they are going 
to get back to duty, what they are going to do, and what is the 
best way to do that. So I am extremely impressed with that.
    Now for some questions. Dr. Rice, I have two major military 
installations in my district: Barksdale Air Force Base and Fort 
Polk Army post. I am finding in our area that the reimbursement 
to physicians through TRICARE is oftentimes slow and low, and 
that creates an access issue. It doesn't seem to be quite as 
much a problem at Barksdale, because it is near a very large, 
or certainly a medium-size city where there are many physicians 
in the private marketplace to choose from. But in a more rural 
area like Leesville, Louisiana, there are some limitations.
    So I want to know, as we move forward with new contracts, 
is that being addressed and how is it being addressed?
    Dr. Rice. Dr. Fleming, as you know, the reimbursement level 
for TRICARE is tied to Medicare rates. And so by law, that has 
where that is. I am a little surprised and disappointed to hear 
that perception among the providers is that we are slow to pay. 
We have always prided ourselves on turning around payments very 
promptly. So if there is some specific information that you 
have, I would really be eager to look into that to see if we 
have a systemic problem that we need to fix. That is not the 
Department's policy.
    Dr. Fleming. That is more of a perception from history, not 
necessarily new information. When you say it is tied to 
Medicare, are you saying it is exactly the same for the same 
evaluation and management (E&M) codes or the same procedural 
codes? Or you are saying it is a percent above or a percent 
less than Medicare reimbursement?
    Dr. Rice. I have to check that to make sure, but I believe 
that it is at the same level as Medicare.
    [The information referred to can be found in the Appendix 
on page 117.]
    Dr. Fleming. Okay, great.
    And certainly for the panel at large, if you can answer 
this, I am very interested in the electronic medical records. I 
think that is a very important thing going forward, 
particularly in terms of quality of care and the special need 
for continuity of care when you have a worldwide mission such 
as our military does.
    Also, the interactivity or, if you will, the 
``interfacement'' with the VA system. There have been some 
problems. I am told about the slowness of performance; that is, 
when you are connecting on the Internet and getting records, 
information exchanging, sometimes that can be so slow as to be 
impractical.
    There have been some difficulties with the VA and the 
active duty military systems talking to one another. Can you 
bring me up to date on that?
    Dr. Rice. Yes, sir. As you know, the implementation of an 
electronic health record is an extremely complex undertaking. 
Through my civilian academic career, I implemented two 
intensive care unit-based electronic records and two hospital-
based, and I swore I would never do that again, but here I am.
    There are two or three challenges. First, with respect to 
response time, as you and Dr. Snyder know, we as physicians 
will sit down with a medical chart and spend 15 minutes going 
through to find the consultation report or the laboratory 
result that we want. But let the computer screen sit blank for 
five seconds, and our perception is it is slow.
    With that said, there is no question that performance and 
stability are key issues. Security and scalability are also 
important issues. We are having an intense effort inside the 
Department now to examine the underlying architecture for the 
electronic health record. Then we need to make sure that we 
build applications that sit on top of that underlying 
architecture so that they work for the clinicians. Whether it 
is the nurses, the physicians, the physical therapists, the 
pharmacists, whatever, it has to work for them. If it does not 
work for the clinicians, it is not going to work.
    I think that is a challenge that we have faced by using a 
system that was originally developed for other purposes and 
trying to challenge it towards use as an electronic health 
record. So it is a subject we are actively and vigorously 
pursuing and hope to have a very clear vector ahead very 
shortly.
    Dr. Fleming. Thank you, I yield back.
    Mrs. Davis. Thank you. Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you, and thank you all for being 
here and for the service you are providing our military men and 
women. I have had great concerns about the open-air burn pits. 
And so I wanted to ask you, Dr. Rice, because you did put in 
your testimony the responsibility for public health for the 
military. You said they have been there for eight years. And I 
have received a lot of information over the past year or so 
about the impact and how soldiers have talked about it and 
complained about it and gone to health-care clinics and are 
showing up with skin diseases, blood diseases, neurological 
problems, et cetera.
    And so I know we have worked on it, we have got something 
into the last NDA authorization and will continue to do that. 
But it is a puzzle to me about how this could have gone on for 
so long. I would just ask you if you would tell me, has this 
been something that has been an issue for all of you and has it 
been discussed? And are you keeping the records that you need 
for these men and women when they return from service and for 
the next years of their lives, so we can determine if we have 
had problems with them because of their exposure?
    Dr. Rice. Thank you for that question. The environmental 
impact of burn pits and its impact on our service men and women 
has been a source of concern. Let me ask General Schoomaker. I 
think your Public Health Command has taken a keen interest in 
that problem and has been tracking, which happens; is that 
right?
    General Schoomaker. That is right. We have a Public Health 
Command, previously known as the Center for Health Promotion 
and Preventive Medicine, and the Veterinarian Command now have 
been combining Army Medicine into a single Public Health 
Command. Brigadier General Tim Adams commands that and has 
subject matter experts who have been tracking all of the topics 
that you have described ma'am. And we can take that question 
for the record and give you a more detail accounting of the 
burn pits.
    [The information referred to can be found in the Appendix 
on page 117.]
    Ms. Shea-Porter. Well, I know it is the acknowledgment now 
that this could be playing a factor in the health problems that 
some of the service men and women are experiencing. But my 
concern here is, is there an integrated approach and are we 
moving fast enough to find ways to substitute some of the 
products that are being burned in the pits?
    For example, we do know that we are still burning the 
plastics openly, and we could use recyclable materials in the 
kitchens which are producing a great deal of the plastic refuse 
each day. So can you step it up? And who are you working with? 
I know your field is medical, but are you talking to others who 
are responsible for what is being brought onto the base and how 
it is being disposed of? Are you fully engaged, in other words, 
because eight years is a long time and some of our soldiers 
have been exposed twice, three, and four times to this.
    General Schoomaker. Well, ma'am, certainly there is a good 
linkage between public health monitoring and all the services 
and the operational commanders, specifics about the items you 
just talked about. I can't speak with any real knowledge about 
that, but, again, I am more than happy to take that question 
for the record and give you a detailed accounting to tell you 
what we have done to coordinate with the in-theater operators.
    Ms. Shea-Porter. I thank you, General, and I am not trying 
to trap you. I am just trying to nudge everybody to get this 
taken care of as quickly as possible. Thank you, I yield back.
    Mrs. Davis. Thank you. Ms. Tsongas.
    Ms. Tsongas. Thank you all for your testimony. I appreciate 
the extraordinary range of issues that you have to contend with 
for our young soldiers, and I appreciate the efforts that you 
are putting into it.
    I would like to ask a slightly different question, an 
outgrowth of Defense Authorization Bill. As we were leading 
into it, we were hearing that we needed to extend Reserve 
component access to early eligibility TRICARE from 90 to 180 
days prior to mobilization. I think this was an issue that had 
been around for some time, and the purpose, obviously, being to 
allow service members with treatable medical conditions access 
to TRICARE services earlier, in order to decrease the number of 
medically non-deployable service members.
    Can you all explain the implementation plan for providing 
Reserve component access--to try earlier access to TRICARE 
services in order to meet the provisions of last year's Defense 
Authorization Bill?
    Dr. Rice. Yes, ma'am. I would be happy to tackle the first 
part of that question and then ask my colleagues to amplify.
    The Assistant Secretary of Defense for Reserve Affairs has 
the lead on implementing the statutory change, because it is 
primarily the determination of eligibility. So Reserve Affairs 
is now preparing the DOD policy and the functional requirements 
for the system changes have already been developed. So once the 
personnel have established the eligibility for reservists and 
updated the Dependent Eligibility Enrollment Reporting System 
(DEERS) system, the eligibility recording system, then any 
DEERS-eligible member who presents for care in the military 
health care system is provided that care.
    General Schoomaker. Ma'am, I will just reinforce that to 
say the Army is very, very reliant on its Reserve, National 
Guard, and the United States Army Reserve for the conduct of 
the present conflict. At any one time, tens of thousands of our 
Reserve component soldiers were mobilized for deployment. And 
one of the important things in eliminating steps in getting 
Reserve component soldiers ready to be deployed is medical and 
dental readiness. We know that there are several factors 
involved in that identification of problems that need to be 
reversed in the dental and medical arena. A medical problem 
that may have a solution before a soldier can be deployed or a 
dental problem that needs some time for fixing, we find that.
    For a large portion of the Reserve component who may not 
have health insurance is a consequence of their employment or 
maybe for students don't have programs available. This is an 
important incentive for them to be engaged in their Reserves, 
and it allows us the time necessary to get them fixed before 
they can go out the door.
    So, to my knowledge, the program is being implemented and 
is felt to be a very important adjunct to using the Reserves, 
as they are being used in the Army today, as an operational 
reserve rather than a strategic reserve, held only back for the 
most nation-threatening advance. We currently use them as a 
very active part of the force.
    Admiral Robinson. Ditto, from what has been said earlier 
from the Navy perspective. In addition, as the service member--
the Reserve component service member is transitioning back to 
the private sector, whatever injuries and illnesses that that 
individual may have sustained will be evaluated before they are 
discharged. So the service member will stay on the active roles 
until we understand what the medical or condition is.
    From a family point of view, or from the service member 
transitioning and being able to utilize the TRICARE benefit for 
the 180 days, that can certainly be given, too. But my point 
is, if at 180 days there is not an adjudication, there is not 
some determination of that, then the service member stays and 
is fully cared for until we can come up with that.
    Obviously, the issue is for those people who we say, We 
think we have the answer, but the service member says, I don't 
think you have the answer yet--and there are a few people that 
fall under that category--we usually default--from the Navy and 
from our point of view, I default towards the service member 
and the care. So we usually back off until we thoroughly 
understand what the issue is. So we care for those individuals 
until we have a determination of what is in fact happening.
    General Green. And the Air Force has exactly that same 
program. We keep people who have medical conditions on active 
duty until we have resolved what is going on, and then have a 
transition assistance management program (TAMP) that allows 
them up to six months post-release from deployment, if they 
need that.
    Your specific question, however, is with regards to 180 
days prior. We have tremendous volunteerism in our Guard and 
Reserve, and actually get great volunteers to serve. I am not 
as aware of the 180 days prior, and I am not certain that we 
have the full guidance yet to establish eligibility for that, 
so I am going to have to take that for the record and get back 
to you.
    [The information referred to can be found in the Appendix 
on page 118.]
    Ms. Tsongas. Well, thank you all for your testimony. I know 
that we heard about this issue. I have heard about it quite 
frequently, and am also hearing that it is not being 
implemented as quickly as we might have wished. And so I look 
forward to hearing a little more about your plans to move it 
forward. Thank you.
    Mrs. Davis. Thank you. Mr. Heinrich.
    Mr. Heinrich. Thank you, Chairwoman. And first I want to 
thank Chairwoman Davis and the members of the committee for 
allowing me to be here today.
    Dr. Rice and Surgeons General, as Chairwoman Davis 
mentioned a little bit ago, I recently introduced H.R. 4923, 
the TRICARE Dependent Coverage Extension Act. And if this 
legislation were to pass, it would allow our service men and 
women the opportunity to provide uninterrupted health care 
coverage to their children until the age of 26. This is the 
same opportunity that has been granted to civilians under the 
recently passed health-care reform legislation that was signed 
into law last month. And I was hoping that each of you might be 
able to give me your thoughts on this proposal, and also let me 
know if the Department of Defense is considering taking any 
action similar to this legislation that would bring their 
policies in line with what is now law for civilians.
    Dr. Rice. Thank you, Mr. Heinrich. We are well aware of the 
introduction of H.R. 4923, and have begun thinking through how 
we would implement it if it becomes law. We do not believe that 
the Department has statutory authority to extend eligibility up 
to age 26, absent a change in the law. But if it does become 
law, we have made preliminary estimates about the number of 
potential enrollees and the estimated average annual cost for 
those enrollees.
    Mr. Heinrich. Well, I look forward to getting together with 
you as well on some of those numbers, because that would be 
very helpful for us as well.
    Are there any other instances that any of you have found, 
where the rest of the country will have benefits now that are 
incongruous or inconsistent with what you provide currently 
under the TRICARE system?
    Dr. Rice. No, sir. I am not aware of any others.
    Mr. Heinrich. Thank you very much. I yield back.
    Mrs. Davis. Thank you. I wanted to go back to my question 
at the end of the first round and just ask, you know, as we 
look to the future and we are looking at what makes the best 
sense for our military health care system, what do you think 
that mix should be? There is always an ideal. But what is 
reasonable? Where should we be headed?
    Dr. Rice. Well, my own view----
    Mrs. Davis. Or stay where we are?
    Dr. Rice. My own view is, as you identified in your opening 
comments, the purchase care system was originally intended to 
fill gaps. And the direct care system, I think many of our 
beneficiaries, if the system is convenient and accessible to 
them, many of our beneficiaries clearly prefer to be cared for 
in the direct care system. The challenge, as you pointed out, 
has been that during this eight year conflict, their primary 
care providers are deployed or transferred. And our primary 
focus has to be on the active duty service members.
    The question of what is the right mix is an intriguing one 
and can be looked at, in my view, from two or three different 
perspectives. One is, are we thinking about this from a cost 
perspective? The other is, are we thinking about this from the 
desire of the beneficiary population, where they would most 
likely be seen? And the third aspect that has to be considered 
is, what is the right mix for the training and education of the 
next generation of active duty--of military providers, whether 
nurses or physicians. I am not sure there is a single right 
answer. There is probably an optimum answer. It is one of the 
things that we hope to influence. I am not sure that we can 
control it, but we certainly hope to influence it with the next 
generation of TRICARE contracts.
    General Schoomaker. I think we all have pretty strong 
feelings about this, so I will be as brief as I can. But I 
think this is one of the central issues that we are all 
struggling with. And I would point to the recent Military 
Health System Conference that was conducted in January, in 
which all three of us and Dr. Rice's predecessor, Ellen Embrey, 
spoke; and we brought in national experts like Don Berwick, and 
Jack Wenberg, and John Cortezy and others to talk about the 
challenges that we face not just in the military health care 
system, but in the country at large.
    And I think that what we in the military are focusing upon 
are some of the central themes in a real health-care reform 
package, which is evidence-based practices, which is looking at 
outcomes of care rather than just processes of care.
    And I alluded earlier in my comments to an effort that we 
have undertaken now into its, probably, fifth or sixth year 
within Army Medicine, pioneered it in the southeast, of a 
performance-based budget program that links incentives to 
outcomes of care, evidence-based practices, and improvements in 
Healthcare Effectiveness Data and Information Set (HEDIS) 
measures, the measures of population health, individual health, 
and compliance with evidence-based practices for such things as 
diabetes and asthma and the like. And this has shown very 
positive results. I think that is one that has got to be a 
major part of the centerpiece of what we do.
    We also, I think, universally agree that we need a very 
robust TRICARE system that is centered around a primary care-
based system of the patient- and family-centered medical home 
process that gives continuity, it gives a site for tailorable, 
individuated care, and controls the hemorrhage or leak of care 
into the network. We have got to look very carefully at where 
that cost is coming from.
    Frankly, Army Medicine over the last several years has 
created more capacity. In the last year and a half or so, we 
have conducted about 1 million additional appointments. And we 
are continuing to bring more people into the direct care system 
run by the uniformed side. The problem that we have is that 
growth, especially in the white space between large 
installations and large metropolitan centers where we have a 
very robust system of health care for the direct care system, 
demand in that white space is increasing as we use Reserves 
more and as our TRICARE for Life program grows. So we are 
working very hard, internal to the services, to accommodate 
more and provide greater capacity. And I think we all agree 
very much that maintaining a very robust direct care system is 
one of the centerpieces based upon real reform of the health 
care.
    Mrs. Davis. Thank you.
    Admiral Robinson. I think that what Dr. Rice and General 
Schoomaker said is right. I am going to come back to the 
private sector care and the direct care. It is 67 and 33 
percent respectively.
    I think that the problem is, to some extent, that there is 
a wall between the two care systems. The problem is that there 
is the direct care system and the private sector care system 
that TRICARE Management Activity (TMA) helps to build through 
our networks, and the network providers do an excellent job, 
but we are separated. We need a care system in which the direct 
care, the uniformed services are directly aided by the private 
sector care. They are actually a part of our system. And we can 
utilize them not only around our medical centers and hospitals, 
but in the white spaces, too. And the white space is the one 
area that is harder to get to, so I recognize that private 
sector care may be the method.
    We can still do a lot with the private sector care and how 
we process TRICARE, the types of forms that we use. If we could 
standardize in terms of, you know, a military medical health 
care formed by the different forms that we use.
    But I will get back to this to only say that the direct 
care system and the private sector care system are separate now 
in the sense that the monies that go into private sector care 
must pay bills from the health affairs perspective. I don't 
disagree with that. But there is not a lash-up between the two 
systems that really help us provide the care that we need. I 
think that is the biggest thing that the new contracts--and I 
am thinking in terms of the T-4--could possibly do that would 
be revolutionary, in my opinion, for military medicine.
    Mrs. Davis. General Green, did you want to add anything?
    General Green. I would. Actually, the reality of our 
situation is we are the most distributed system of any, with 75 
bases and about 80 clinics out there. As medicine has changed 
over the years and we have seen higher technology and, 
therefore, larger populations in order to support different 
specialties, what we have seen is we couldn't always maintain 
hospitals in these small areas. Average wing for us is about 
6,000 people, with families maybe 12,000 to 15,000. It is very 
difficult to support specialty mix.
    And so the TRICARE contractors in those areas where we have 
small populations are really the only way to seek that care. In 
other areas where we have larger populations and where we have 
military bases with hospitals, I would love for us to get 100 
percent of that care. And that is what Admiral Robinson is 
talking to, where we try to bring some of the people who are in 
surrounding areas to our facilities.
    I think that it is unreasonable for us to think that we 
would ever be able to provide primary care perhaps to 100 
percent of that population, but there are ways that we can 
reduce federal costs by working arrangements with HMOs, with 
the VA, even with university partners, wherein either we bring 
our patients back to our facilities if we are in the area, or, 
in many cases we take our professionals and work in their 
facilities so that we can actually maintain skills and be ready 
for wartime missions.
    And so I guess I would tell you that it is a mix. In places 
where we are in rural settings, we really rely on the TRICARE 
contractors and the network. And so the mix is going to be 
different. In places where we have hospitals, we should be 
trying to bring everything that we possibly can back into the 
hospital to maintain currency. So my goal would be in larger 
population centers where we have hospitals, to gain 100 percent 
of the market; and in places where we have clinics, the mix 
that you described may be real.
    Mrs. Davis. I appreciate all of your responses. What is 
obviously important here is that people are working hard, 
focusing on this and really trying to address it. And the other 
reality, of course, is there are a lot of other things people 
are working on. And we need to look to the Defense Military 
Affairs and figure out whether we have got the people there 
that are trying to address these issues. And one of the 
concerns that I think we have is that there haven't been the 
kind of political appointees that are there in place, nor are 
the nominations there.
    And I would think that that is a vital part of what we are 
talking about and that we do need to get moving with those. Dr. 
Rice.
    Dr. Rice. I agree with that.
    Mrs. Davis. I know you do. Do you have any suggestions? We 
are open. We are certainly interested. Mr. Wilson.
    Mr. Wilson. In fact, Dr. Rice, with all the hats you are 
wearing, back to your TRICARE hat. My understanding, the number 
of reservists who have taken advantage of TRICARE Reserve 
Select, TRS, is lower than the Department of Defense 
anticipated.
    What factors have contributed to the low take rate? What 
actions has DOD taken to make the program more attractive? Are 
members of the Reserves, who may want to enroll in TRICARE 
Reserve Select, having difficulty finding TRICARE standard 
providers?
    Dr. Rice. Let me defer to my colleague, General Schoomaker, 
who has insight on that.
    General Schoomaker. Yes, sir. I can answer that. You are 
right; we are seeing, overall, a rate of use in the Army of 
TRICARE Reserve Select of only about six percent or so. But it 
is growing very quickly. And in part, it is based upon the 
observation that those that don't have a health-care program, 
we have been quite reluctant to impose a requirement that they 
maintain medical readiness as a condition of their employment, 
even though it is, in the Army regulation, already there.
    In other words, if you are in the Reserves, we expect you 
to be dentally and medically ready to be deployed. In the past, 
because we could not offer good programs necessarily, or 
couldn't require someone who may not have an employment health 
plan--or maybe a student, or be unemployed--to have a plan to 
cover them, commanders were very reluctant on the Reserve side 
to impose or hold them to that standard.
    I think with the TRICARE Reserve Select program, which is 
very robustly supported by the military and by Health Affairs, 
and now with the growing availability of plans under health-
care reform and the like, we are putting teeth into that. And I 
think you will see a growing use of TRICARE Reserve Select as 
we hold soldiers, appropriately, to the requirement that they 
be medically fit.
    Without abusing my executive privilege here, I just want to 
respond to one last thing on this last item, because we are 
also passionate about what we can do to sustain this program 
that we have. We have a very high-quality program.
    To answer Mr. Heinrich's question earlier, I don't see us 
having a lesser plan. I think we have a superior plan to the 
average American right now, and we all want to sustain this. 
But I think historically what we have focused on is business 
rules to control costs, and most of us now I think feel very 
firmly that what we have to focus on is good clinical practices 
and outcomes. And if we focus on that, the cost will be 
stabilized and possibly even be reduced.
    Mr. Wilson. And I want to indeed thank you. I can remember 
during the debate that we had in the Education and Labor 
Committee, that as I was working for an amendment to preserve 
and protect TRICARE, it was brought to my attention--and I can 
remember very well the organization, it was called the Wilson 
Institute, and that they had done a study of satisfaction by 
persons with their health insurance policies, and TRICARE for 
9.2 million was at the tops. And of course, I will never forget 
the Wilson Institute. I was unjustly accused, Madam Chair, of 
making up an organization, but it actually exists.
    Dr. Rice, again, or whoever, the Department of Defense has 
estimated the resulting savings would be $12 billion, fiscal 
years 2010 to 2015, by obtaining federal pricing discounts for 
TRICARE prescriptions dispensed by retail pharmacies.
    Is DOD on track to obtain these estimated savings? Are all 
drug manufacturers complying with requirements? What steps are 
underway to ensure that the required federal pricing discounts 
are obtained?
    Dr. Rice. Mr. Wilson, we are on track to realize that 
outcome. There is still--I think I have this right, and if not, 
I will certainly correct it. I believe there is still a pending 
appeal, but the actions taken thus far have indicated that the 
drug manufacturers are prepared to comply with the federal 
pricing, and we anticipate realizing those savings.
    Mr. Wilson. It is good to hear something is on track. And 
in regard to TRICARE in general, any way that I and our 
subcommittee can be of assistance, we want to work with you. 
Thank you.
    Dr. Rice. Thank you, sir.
    Mrs. Davis. Thank you very much. Thank you, Mr. Wilson. And 
perhaps I will just go back to one of the questions he raised 
earlier.
    Do you think there is any confusion or discomfort believing 
that perhaps the Secretary of Defense is not in charge of 
Military Health Affairs? Do you have any?
    Dr. Rice. I don't think so. I think Secretary Gates has it 
pretty clearly in his mind that he is. And I certainly have 
seen some correspondence from Secretary Sebelius where she has 
indicated that management of the Defense Health Program is 
under the supervision of the Secretary.
    Mrs. Davis. Because I know that has been raised in other 
circles as well, and I appreciate Mr. Wilson raising it.
    If I could, just quickly, I know we are going to have votes 
in a few minutes. The budget was characterized as being fully 
funded. And if I could go to you first perhaps, General Green, 
is that an accurate statement from your vantage point?
    General Green. Yes, it is an accurate statement. We are in 
very good shape for 2011.
    Mrs. Davis. Admiral Robinson.
    Admiral Robinson. Yes. Navy Medicine is fully funded.
    General Schoomaker. Yes, ma'am. Nothing crossed.
    Mrs. Davis. You don't have another list out there 
somewhere? Okay.
    One of the numbers that jumped out at me was just the 
research and development dollars going down somewhere in the 
neighborhood of about 61 percent, I believe, partly because 
there was a reduction in medical research and development 
(R&D). And I think that reflects dollars, $125 million, 
transfer of research to Defense Advanced Research Projects 
Agency (DARPA). But we don't really see an accompanying 
increase in DARPA's program to accommodate that.
    Dr. Rice. Yes, ma'am, I can speak to that. There is a 
decrement of 125 million in the research, development, testing 
and evaluation (RDT&E) priority elements for fiscal year 2010. 
There were decisions made in the Department in the fall of 2008 
which enhanced the medical R&D budget by about $375 million a 
year, with the entire new budget going into the Defense Health 
Program RDT&E budget for fiscal 2010.
    There was an additional Department decision for fiscal 2011 
and out that was that $125 million of that annual cost was to 
be contributed by DARPA, but under their control; that is, not 
transferred from DARPA to DHP, which reduced the new budget 
burden to the Department by 125 million. This would mean that 
DARPA would have to increase their medical RDT&E spending from 
about 144 million by an additional 125 for fiscal 2011. And 
this is a compliance issue that is under that defense 
development research and engineering oversight.
    There is programmatic and regulatory risk when the Defense 
Health Program RDT&E advanced on the portfolio is dependent on 
the science and technology transitions from another agency 
within the Department which is more focused on very high-risk 
and very high-payoff investments. This is under discussion in 
the Department, but it is that decision that results in the 
number that you cited.
    Mrs. Davis. Where would we see the greatest shortfall if 
somehow this isn't worked through, and what kind of R&D? 
Prosthetics? Or what kinds of things could that affect?
    Dr. Rice. It is not clear to me, at least at this point. It 
could be in a variety of areas, from basic research to 
information technology research to advanced battlefield 
efforts.
    Mrs. Davis. Okay. Thank you very much.
    Just one follow-up question to earlier discussion about 
electronic records. And the Virtual Lifetime Electronic Record, 
VLER, was announced by Secretaries Gates and Shinseki together 
that it would be this single record. But now I understand that 
the Department submitted a reprogramming request that would 
take $42 million from the Defense Health Program to establish 
the Office of the VLER. So why is the Defense Health Program 
only paying for that?
    Dr. Rice. The VLER is in part an electronic health record, 
but it also in part has to do with personnel records. So that 
comes outside of the Defense Health Program.
    Mrs. Davis. Is there a VA piece to this as well then?
    Dr. Rice. I am sorry?
    Admiral Robinson. The VLER piece would be actually--and I 
am probably the least information technology (IT) savvy of this 
group--but there will be a VA piece with this. And the VLER 
system will work with an electronic health record system, in 
this instance AHLTA, and with the VA Vista, to hook us to the 
commercial sector so that we can transpose that record to 
hospitals that are not DOD. So there are several sections that 
go with this. And I can't tell you much more, but that I do 
know.
    Mrs. Davis. All right. We hope that comes together and that 
works out.
    And I don't really expect you to answer this in any detail, 
but throughout all of the testimony and through all of the 
discussions that we know in terms of health care nationwide, 
the concern about unmanned positions, any number of 
specialties, practitioners that are needed in this country. Are 
people thinking out of the box about this enough? Because we 
know that bonuses are a good idea. We know that there are 
recruitment strategies, some of which have been very helpful, 
and I know you addressed that.
    But it also feels as if we have a lot of people in our 
country who would have an interest if we actually did something 
quite substantive in the country. People may not have agreed 
with the war on poverty, but at that time there were many, many 
people, myself included, who were incentivized to go into 
helping professions. And I am wondering now whether the 
military plays such a large role in this, and particularly 
among our men and women who are coming back from the war 
theater and have great, I think, aptitude to be able to do this 
with the right encouragement, there are some programs out 
there.
    Are we spending enough time and effort into trying to 
really address this problem?
    Dr. Rice. With my other hat on, as president of the 
university, I spend a lot of time thinking about what our 
health-care system, what our health-care workforce is going to 
look like 15 or 20 years from now.
    We have an enormous challenge in the country as a whole, of 
which the military system is just a small part. And that is 
that the science and mathematics and engineering preparation in 
our middle schools and high schools has not helped focus our 
young people on careers in science and technology. And there 
are a number of misperceptions in students.
    In my previous job at the University of Illinois, I spent a 
lot of time going out and talking to middle school and high 
school students about careers in health care. And there were 
three things that struck me about what they would say about why 
they weren't thinking about health care.
    The first is that they viewed us as low tech. And at times 
I was signing very large purchase orders for very expensive 
pieces of equipment. That didn't resonate quite right to me, 
but that was their perception.
    The second thing is that if you have dealt with teenagers 
lately, you know that they are not interested in hierarchies. 
And the provision of health care is, at least as currently 
practiced, hierarchical.
    And the third factor that turned them off was we have 
schedules. And they are not interested in schedules.
    So I think we are going to have to rethink how we deliver 
health care in a pretty dramatic way, exactly as you allude. We 
are looking at--by the year 2020, it is estimated we will be 1 
million nurses short of what we will need. And as I get into my 
old age, that becomes more and more of an issue for me. We are 
looking at a substantial shortfall in the number of physicians. 
And importing them from other countries is not the answer. That 
simply is not an ethical or moral approach to solving that 
problem. So I do think it is an issue that we need to spend a 
lot of time thinking on.
    Mrs. Davis. I was just going to mention that in last year's 
bill there was a provision for undergraduate education and for 
encouraging more students and scholarships. And I don't know 
whether that is anything that is moving along.
    General Schoomaker. We have a pretty successful and robust 
program right now that I think is now being very successfully 
executed. I certainly agree with everything that Dr. Rice--who 
has a very long and distinguished career in medical education 
and the provision of the workforce.
    We are looking at, I think with the increasing number of 
women going into medicine and health professions who want to do 
job sharing, that want to have shifts--and I don't think it is 
restricted to women only in this perspective--who want to have 
a career in which they can move in and out of the workforce 
more agilely. We are looking at a continuum of care between the 
active component and Reserve component, where you can turn on 
and turn off that kind of a career.
    And, quite frankly, even from my experience among children, 
you have got to begin engaging children who are going into 
these technical fields, in middle school and sometimes earlier. 
So programs that are engaging earlier and earlier and getting 
mentor programs and the like.
    But I would submit in closing, although this really doesn't 
address the problem of the workforce per se, that the real out-
of-the-box thinking that we have to adopt in this country--and 
we are in the military--is one that shifts the paradigm from 
treating disease and treating injury after it has occurred, to 
preventing disease and preventing injury.
    I mean at Fort Jackson, South Carolina right now, we pin a 
hip fracture on a young woman, on average, once a week. Once a 
week. These are 18- and 19- and 20-year-old women who come into 
the force, who begin active lives after being sedentary, who 
are suffering from bone washout from drinking phosphate-rich 
sodas and being sedentary before they come in. And now we are 
getting hip fractures in basic training.
    We have a problem in this country in the overall health and 
fitness of the population and with growing childhood obesity, 
the tobacco problems that you addressed earlier. We have got to 
shift the paradigm away from one of disease and injury 
treatment to one that prevents it from the get-go.
    Mrs. Davis. Admiral Robinson, we have to go vote. But if 
you have a quick comment, that would be great.
    Admiral Robinson. One other thing. Actually, this is 
General Green, and that is, he said something the other day 
that was so intriguing to me; and that is, take enlisted 
personnel and actually get them certified to do mental health. 
So I think--and this happens, this works. But I think my 
addition to everything else is that we need to think in terms 
of how we provide the care. It needs to be preventative and 
wellness, and then we need to think in terms of how that care 
is given. Thank you very much.
    General Green. And just very quickly, I really do think we 
need to think out of the box. We are increasing our number of 
practitioners and extenders. We are looking at the mix to get 
the right team, using medical home to do outreach. For non-
enrolled care, we think emergency rooms are going to be overrun 
in the near future because of the lack of primary care. We are 
preparing fast tracks in acute-care clinics to make sure we are 
ready for the increased workload.
    And I do think we do need to think beyond traditional 
mental health and look at the licensed medical counselors, to 
see whether or not we can train some of our enlisted force. 
Just like we are bringing enlisted to nurses, we may be able to 
increase our diversity by bringing enlisted into medical 
schools as they are prepared.
    So we are doing a lot of things to try to leverage our 
enlisted force to try to create new venues of care.
    Mrs. Davis. Thank you very much. Thank you to all of you. I 
mentioned earlier, it is the Military Undergraduate Nurse 
Training, section 525, from the former authorization that I was 
inquiring about.
    Dr. Rice. Yes, ma'am. There is a report due to Congress. 
The three military nursing chiefs are actively working on that 
and anticipate having a report to you on time.
    Mrs. Davis. Great. Thank you very much to all of you. I 
hope that the hearing was helpful to you as well. It was to us. 
And we look forward to the next one. Thank you very much.
    [Whereupon, at 3:24 p.m., the subcommittee was adjourned.]
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=======================================================================


              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             April 21, 2010

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

      
              RESPONSE TO QUESTION SUBMITTED BY MRS. DAVIS

    Dr. Rice. The initial report on progress made in undertaking 
actions to enhance the Military Health System (MHS) and improve the 
TRICARE program as required in Section 721 of the National Defense 
Authorization Act for Fiscal Year 2010 has been drafted and is in the 
coordination process.
    A high-level working group was formed to address the report 
requirements and included representatives from a number of MHS 
entities. The initial report describes the progress made and future 
plans for improvement of the MHS. DoD senior leadership provided 
further guidance to the subject matter experts working on the areas 
Congress requested DoD study and consider planning to improve access to 
care.
    Note: Representatives from MHS entities include:

      Chief, Policy and Operations Branch, TRICARE Policy and 
Operations Directorate (TPOD)

      Director, DoD/VA Program Coordination Division

      Chief, Purchased Care Systems Integration Branch, TPOD

      Deputy Chief, Human Capital Office OASD(HA)

      Program Director, Health Budgets and Financial Plans 
OASD(HA)

      Director, Operations Division, TPOD

      Director, Strategic Communications and Transformation 
OASD(HA)

      Director, Population Health and Medical Management, 
Office of the Chief Medical Officer

      Chief, Program Evaluation Branch, TPOD

      Chief, TRICARE Operations Center

      Deputy Chief, TRICARE Division

      Army Medical Department (AMEDD) One Staff

      Offices of the Service Surgeons General

    [See page 12.]
                                 ______
                                 
           RESPONSE TO QUESTION SUBMITTED BY MS. SHEA-PORTER

    General Schoomaker. Surveillance documents, laboratory data, and 
field notes are available for future use to investigate the 
occupational and environmental health risks of respective burn pits. 
The US Army Public Health Command (Provisional) is the designated DoD 
lead agent for archiving all deployment occupational and environmental 
health (OEH) surveillance data for US military operations. It maintains 
the DoD OEH surveillance documents in Internet-based unclassified and 
classified document libraries identified as the deployment OEH 
surveillance data portal. US Army Public Health Command (Provisional) 
has a separate DoD database for archiving all of the laboratory data 
and associated field notes for deployment samples (e.g., air, water, 
soil) sent to the Army Public Health Command for analysis. This sample 
database is identified as the Defense Occupational and Environmental 
Health Readiness System--Environmental Health Module. [See page 19.]
                                 ______
                                 
             RESPONSE TO QUESTION SUBMITTED BY DR. FLEMING

    Dr. Rice. By law, Title 10 United States Code Section 1079(h)(1), 
TRICARE's payment for a charge for services by an individual health 
care professional must be equal to an amount determined to be 
appropriate, to the extent practicable, in accordance with the same 
reimbursement rules as apply to payments for similar services by 
Medicare. Statute permits TRICARE reimbursement rates to be less than 
Medicare rates when providers have agreed to give network discounts. In 
addition, there is statutory authority to set TRICARE rates above 
Medicare rates if necessary to obtain an adequate network of providers 
or to prevent severe access to care deficiencies. [See page 17.]
                                 ______
                                 
             RESPONSE TO QUESTION SUBMITTED BY MS. TSONGAS

    General Green. Based on my understanding of NDAA 2010, Section 702, 
when Guard/Reserve members receive federal delayed-effective-date 
active duty orders for more than 30 consecutive days in support of a 
contingency operation, the service member and their family are eligible 
for TRICARE. TRICARE coverage will begin the date the order was issued 
or 180 days prior to activation date, whichever is later. Current 
TRICARE coverage is for 90 days prior to activation date.
    As Dr. Rice mentioned, Reserve Affairs will be sending out the DOD 
policy to enforce this change. Although eligibility determination 
belongs to Air Force Manpower & Personnel (AF/A1), the Air Force 
Medical System (AFMS) will work with AF/A1 to ensure full compliance 
across the Air Force. We have verified that the implementation date is 
projected for 1 Oct 10.
    Once implemented, Guard/Reserve members will need to register their 
family members and their records in the Defense Enrollment Eligibility 
Reporting System (DEERS) through the nearest service personnel office, 
ID card-issuing facility or DEERS Support Office. Once eligibility 
verification is made by AF/A1 and is accurately reflected in DEERS, the 
AFMS is prepared to provide the medical care to all eligible members 
and their dependents. [See page 21.]

                                  
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