[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]




                         [H.A.S.C. No. 112-19]

                                HEARING

                                   ON

                   NATIONAL DEFENSE AUTHORIZATION ACT

                          FOR FISCAL YEAR 2012

                                  AND

              OVERSIGHT OF PREVIOUSLY AUTHORIZED PROGRAMS

                               BEFORE THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

               SUBCOMMITTEE ON MILITARY PERSONNEL HEARING

                                   ON

    MILITARY HEALTH SYSTEM OVERVIEW AND DEFENSE HEALTH PROGRAM COST 
                              EFFICIENCIES

                               __________

                              HEARING HELD
                             MARCH 15, 2011













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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                  JOE WILSON, South Carolina, Chairman
WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
MIKE COFFMAN, Colorado               ROBERT A. BRADY, Pennsylvania
TOM ROONEY, Florida                  MADELEINE Z. BORDALLO, Guam
JOE HECK, Nevada                     DAVE LOEBSACK, Iowa
ALLEN B. WEST, Florida               NIKI TSONGAS, Massachusetts
AUSTIN SCOTT, Georgia                CHELLIE PINGREE, Maine
VICKY HARTZLER, Missouri
               Jeanette James, Professional Staff Member
                 Debra Wada, Professional Staff Member
                      James Weiss, Staff Assistant














                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2011

                                                                   Page

Hearing:

Tuesday, March 15, 2011, Military Health System Overview and 
  Defense Health Program Cost Efficiencies.......................     1

Appendix:

Tuesday, March 15, 2011..........................................    35
                              ----------                              

                        TUESDAY, MARCH 15, 2011
    MILITARY HEALTH SYSTEM OVERVIEW AND DEFENSE HEALTH PROGRAM COST 
                              EFFICIENCIES
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

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

                               WITNESSES

Green, Lt. Gen. Charles Bruce, USAF, Surgeon General, U.S. Air 
  Force..........................................................    12
Robinson, VADM Adam M., USN, Surgeon General, U.S. Navy..........     9
Schoomaker, LTG Eric B., USA, Surgeon General, U.S. Army.........     6
Stanley, Hon. Clifford L., Ph.D., Under Secretary of Defense for 
  Personnel and Readiness........................................     4
Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for 
  Health Affairs.................................................     5

                                APPENDIX

Prepared Statements:

    Davis, Hon. Susan A..........................................    42
    Green, Lt. Gen. Charles Bruce................................   109
    Robinson, VADM Adam M........................................    82
    Schoomaker, LTG Eric B.......................................    59
    Stanley, Hon. Clifford L., Ph.D., joint with Hon. Jonathan 
      Woodson, M.D...............................................    44
    Wilson, Hon. Joe.............................................    39

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Dr. Heck.....................................................   131

Questions Submitted by Members Post Hearing:

    Mrs. Davis...................................................   135
    Dr. Heck.....................................................   144
 
    MILITARY HEALTH SYSTEM OVERVIEW AND DEFENSE HEALTH PROGRAM COST 
                              EFFICIENCIES

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                           Washington, DC, Tuesday, March 15, 2011.
    The subcommittee met, pursuant to call, at 10:03 a.m., in 
room 2212, Rayburn House Office Building, Hon. Joe Wilson 
(chairman of the subcommittee) presiding.

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

    Mr. Wilson. Ladies and gentlemen, I would like to welcome 
everyone to the Military Personnel Subcommittee hearing today 
on the Military Health System [MHS] overview and Defense Health 
Program cost efficiencies.
    And today, the subcommittee meets to hear testimony on the 
Military Health System and the Defense Health Cost Program for 
the fiscal year 2012. I would like to begin by acknowledging 
the remarkable military and civilian medical professionals who 
provide extraordinary care to our service members and their 
families along with veterans, here at home and around the 
world, often in some of the toughest and most austere 
environments.
    I have recently returned from Balad and Bagram where I am 
always appreciative of the professionals who have saved so many 
American, Iraqi, and Afghani lives. I have firsthand knowledge 
of their dedication and sacrifice from my second son, who has 
served in Iraq and is now an orthopedic resident in the Navy, 
but we are joint service. As a grateful dad, as a military 
family, I was reassured to the medical care available for my 
Army son and my Air Force nephew who also both served in Iraq.
    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. Even in this tight 
fiscal environment, the Military Health Care System must 
continue to provide world-class health care to our 
beneficiaries and remain strong and viable in order to maintain 
that commitment to future beneficiaries.
    The Department of Defense [DOD] has proposed several 
measures aimed at reducing the cost of providing health care to 
our service members and their families and military veterans. 
While I appreciate that your plan is a more comprehensive 
approach than previous cost cutting efforts, the challenge here 
is to find a balance between fiscal responsibility while 
maintaining a viable and robust military health care system.
    We must be sure to remember these proposals have complex 
implications that ``go beyond beneficiaries.'' They also affect 
the people who support the defense health system, such as local 
pharmacists, as health care employees at hospitals and 
contractors. The subcommittee has a number of concerns about 
the Department's initiatives. To that end, we would expect the 
Department's witnesses to address our concerns, including 
first, the proposed TRICARE Prime fee increase for the fiscal 
year 2012, while appearing to be modest, is a 13 percent 
increase over the current rate.
    DOD proposes increasing the fee in the out years based on 
an inflation index. You suggest 6.2 percent but it is not clear 
which index you are using now and in the future. Second, you 
plan to reduce the rate that TRICARE pays the sole community 
hospitals for inpatient care provided to our Active Duty, 
family members, and veterans.
    Several of these hospitals are located very close to 
military bases; in fact some are right outside the front gates, 
especially important for 24-hour emergency care. What analysis 
have you done to determine whether reducing these rates will 
affect access to care for our beneficiaries and in particular 
the readiness of our Armed Forces? I would also like our 
witnesses to discuss the range of efficiency options that were 
considered but not included in the President's budget.
    I would appreciate hearing your views on the recent GAO 
[Government Accountability Office] recommendations included in 
their report on Federal duplication, overlap and fragmentation. 
GAO made recommendations regarding establishing a unified 
medical command and for the DOD to finally jointly modernize 
their electronic health record system with the Veterans 
Administration.
    In addition, I would like to hear from the military 
surgeons about efforts they are taking within the military 
departments to increase the efficiency of the health care 
systems and reduce cost. I would also like the military 
surgeons' views on areas where additional efficiencies can be 
gained across the DOD health system.
    The Department of Defense, just last week, recently 
announced they have hired Governor John Baldacci, the former 
Governor of Maine, to undertake a full-scale review of the 
military health care and the impacts of military health care on 
the forces. I would appreciate hearing from Dr. Stanley the 
considerations for this review and what the Department hopes to 
gain from Governor Baldacci's efforts. I am concerned.
    First of all, I have faith in Dr. Stanley. He is a graduate 
of South Carolina State University. So I know of his 
capabilities. Why is having a military health care czar not a 
duplication of the duties already assumed by Under Secretary 
Stanley and Assistant Secretary Woodson?
    Finally, I would like to make it clear that in the effort 
to reduce the cost of military health care and find 
efficiencies in the military health care system, we must never 
lose sight of the population that the military medical system 
serves. The members of the Armed Forces and their families who 
currently serve and those who served as veterans for a full 
career in the past warrant the best health care system 
available. Reducing cost must never result in reduced quality 
of the availability, or the availability of health care they 
earned and they deserve.
    I hope that our witnesses will address these important 
issues as directly as possible in their oral statements and in 
the response to Members' questions. Before I introduce our 
panel, let me offer Ranking Member, who is a distinguished 
former chairman of this subcommittee, Congresswoman Susan Davis 
an opportunity to make her opening remarks.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 39.]

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
 CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mrs. Davis. Thank you. Thank you, Mr. Chairman. And thank 
you for summarizing many of the issues that are before us 
today, I look forward to hearing from Under Secretary Stanley 
and Assistant Secretary Woodson on their views on the status of 
the military health care system, particularly the TRICARE 
program and their efforts to improve the care that we are 
providing to our service men and women, retirees, survivors, 
and their families.
    Assistant Secretary Woodson, we welcome you. We are 
delighted that you are here. And I understand that it is your 
first testimony before this subcommittee. I am pleased that the 
Senate finally confirmed you as the Assistant Secretary for 
Health Affairs. The Department is confronting many issues and 
having you there is important if we are to be successful in 
facing those challenges.
    I also look forward to hearing from our Surgeon Generals, 
General Schoomaker and Admiral Robinson, thank you very much 
for your service. And I know that both of you, I believe, are 
retiring this year. So we will miss you. It has been a pleasure 
working with both of you over the past several years.
    The last 10 years of conflict have taken a toll on our 
forces, and in particular those who serve in our military 
health care system. The constant demand on the system and the 
successes that we have seen both on the battleground and back 
home here in the States have been remarkable and a testament to 
your leadership.
    General Green, welcome back to you, sir. With the departure 
of General Schoomaker and Admiral Robinson, of course, you 
would be the most senior Surgeon General and I look forward to 
continuing to work with you.
    While I suspect that the majority of this hearing will 
focus on the Department of Defense's health care proposals that 
were included in the budget, this hearing will probably be one 
of the only hearings on health care that we will have prior to 
the subcommittee and committee markup.
    So as such, it is important that members of the 
subcommittee have an understanding of all the challenges that 
the military health care system is facing, not just the 
budgetary constraints. Our military personnel and their 
families are under constant pressure and challenges. And access 
to quality health care should not be on that list of concerns.
    I look forward to your testimony on how we are caring for 
our injured, ill, and wounded and what can be done to continue 
to improve the military health care systems.
    Thank you, Mr. Chairman.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 42.]
    Mr. Wilson. Thank you, Mrs. Davis.
    We have five witnesses today. We would like to give each 
witness the opportunity to present his testimony and each 
Member an opportunity to question the witnesses. I would 
respectfully remind the witnesses that we desire that you 
summarize to the greatest extent possible the high points of 
your written testimony in 3 minutes. I assure you that your 
written comments and statements will be made part of the 
record.
    And, of course, first we want to welcome the Honorable Dr. 
Clifford L. Stanley, the Under Secretary of Defense for 
Personnel and Readiness [P&R], Dr. John Woodson, Assistant 
Secretary for Defense for Health Affairs and this--Doctor, I 
know it is your first appearance so we are delighted to have 
you here. And Lieutenant General Eric Schoomaker, the Surgeon 
General of the Department of the Army and General, thank you 
for your distinguished career. And this is your last appearance 
and we just wish you well in your future career.
    And Vice Admiral Adam Robinson, the Surgeon General of the 
Department of the Navy and indeed General Robinson, thank you. 
This, too, I can see the big smile on your face which means 
this is your last appearance here. And we appreciate your 
service and thank you for in every way, for your service. And 
then soon to be the senior Surgeon General amazingly enough, 
Lieutenant General Charles Bruce Green, the Surgeon General of 
the Department of the Air Force.
    And at this time, Dr. Stanley, you may begin.

 STATEMENT OF HON. CLIFFORD L. STANLEY, PH.D., UNDER SECRETARY 
             OF DEFENSE FOR PERSONNEL AND READINESS

    Secretary Stanley. Good morning and thank you, Mr. Chairman 
and members of the committee, I really do appreciate this 
opportunity to appear before you today to discuss the future of 
the Military Health System, particularly our priorities for the 
coming year.
    Dr. Woodson, the Surgeon Generals and I look forward to 
discussing our health care plans for 2011 and 2012. At the 
outset, I just want to acknowledge the performance and courage 
of our military medical professionals serving in combat 
theaters. For service members wounded in combat, their 
likelihood of survival after a medic arrives remains at 
historic and unmatched levels.
    For those seriously wounded service members who require 
months, years and sometimes a lifetime of medical 
rehabilitation and treatment, we are committed to ensuring that 
they and their families receive the finest evidence-based 
medical services available in this country. And we are working 
ever more closely with our colleagues in the Department of 
Veterans Affairs [VA] to ensure our activities are better 
coordinated to include the disability evaluation process, the 
sharing of personnel and health information and collaboration 
on our future electronic health record.
    In addition to the efficiencies that we will discuss today, 
I have asked the former Governor and former Representative John 
Balucci--Baldacci, excuse me, from Maine to help us work in a 
deep dive review of health care and wellness. Dr. Woodson and 
our Assistant Secretary of Defense for Health Affairs ensures 
that the military health care system runs smoothly every day.
    But I have asked the Governor to pursue a four azimuth deep 
dive approach which is focusing on readiness, improve health 
population, patient experience and care and lastly, cost. And 
with that, I would turn to Dr. Woodson. Before I do that, I 
would like to also thank the subcommittee for the tremendous 
support you provide the Department for our service members and 
their families, particularly the Military Health System. Thank 
you.
    [The joint prepared statement of Secretary Stanley and Dr. 
Woodson can be found in the Appendix on page 44.]
    Mr. Wilson. Next, we have Dr. Woodson.

 STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT SECRETARY 
                 OF DEFENSE FOR HEALTH AFFAIRS

    Dr. Woodson. Mr. Chairman, Ranking Davis and members of the 
committee, thank you so much for this opportunity to appear 
before you today. I will briefly elaborate on Dr. Stanley's 
opening statement. I have had the privilege of serving the 
Military Health System both in uniform as an officer and 
physician and in my current role as senior medical advisor to 
the Secretary of Defense.
    This system has shown time and again that it is a vibrant, 
learning organization capable of self-improvement and rapid 
incorporation of lessons learned into both our combat and 
peacetime endeavors.
    In our combat theaters, Dr. Stanley has already noted the 
historic rates of survival among those who are injured. I would 
also point out the reductions in disease and injuries through 
improved public health and preventative medicine strategies. 
Thanks to the ongoing support of Congress, we are continuing to 
invest deeply in medical research and development on the most 
challenging medical issues we are confronted with from the war.
    We are accelerating the delivery of our scientific findings 
from the laboratory to the bench--to the battlefield to include 
prevention, diagnosis, and treatment for both visible and 
invisible wounds of war. We are also making important 
investments in how we deliver care to all of our beneficiaries. 
The Patient-Centered Medical Home is a transformative effort 
within our system.
    We have enrolled more than 655,000 beneficiaries to date, 
with promising results in the use of preventive services, 
reducing emergency room [ER] use, and provision of more timely 
care. In addition to our investments in readiness, improved 
population and improved service to our patients, we also have 
proposed some changes that will allow us to more responsibly 
manage our cost.
    Our efficiency initiatives share the responsibility for 
cost controls among all of the participants including us 
internally at Health Affairs and TMA [TRICARE Management 
Activity], among provider communities and with our 
beneficiaries for whom we propose a very modest change to 
select out-of-pocket costs.
    Throughout our proposals, we have taken steps to protect 
those who are enrolled in existing programs or who have special 
circumstances that must be considered and protected. Our 
proposed budget helps keep fidelity with our core principles. 
We will never lose our focus on our commitment to all the men 
and women who serve our Armed Forces, their families, those who 
have served in the past and present, and those will serve in 
the future.
    We are proud to represent the men and women who comprise 
the Military Health System and we look forward to your 
questions this morning.
    [The joint prepared statement of Dr. Woodson and Secretary 
Stanley can be found in the Appendix on page 44.]
    Mr. Wilson. Thank you very much.
    And General Schoomaker.

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

    General Schoomaker. Chairman Wilson, Ranking Member Davis, 
distinguished members of the committee, thanks for permitting 
me to talk with you today about the dedicated men and women of 
the Army Medical Department who bring value and inspire trust 
in Army Medicine.
    Despite over 9 years of continuous armed conflict, for 
which Army Medicine bears a heavy load, every day our soldiers 
and their families are kept from injuries, illnesses, and 
combat wounds through our health promotion and prevention 
efforts; and are treated in a state-of-the-art fashion when 
prevention fails; and are supported by an extraordinarily 
talented medical force including those who serve at the side of 
the warrior on the battlefield.
    We are a member of this Military Health System team 
committed to partnering with soldiers and families, and 
veterans to achieve the highest level of fitness and health for 
all. And we have been leaders in innovation for trauma care and 
preventive medicine that have saved lives and improved the 
well-being of our warriors and improvements that have really 
changed even clinical practices in the civilian sector. We are 
focused on delivering the best care at the right time and 
place.
    I would like to talk about our work through the lens of the 
five E's: Enduring, Early, Effective, Efficient, and an 
Enterprise fashion. We have an enduring commitment to care 
through initiatives such as the Warrior Care and Transition 
Plan and the Soldier Medical Readiness Campaign Plan.
    We have an enduring responsibility alongside our sister 
services in the Department of Veteran Affairs to provide care 
and rehabilitation for wounded, ill and injured for many, many 
years to come. We have a warrior transition command in the Army 
Medical Department under the leadership of Brigadier General 
Darryl Williams, many of you have met him. He is a key in our 
provision of care and provides a centralized oversight for the 
Army's Warrior Care and Transition Program.
    Our focus is on investing soldiers and families with 
dignity, respect, and self determination to successfully 
reintegrate them either back into the force or into the 
community. Since we stood up the first warrior transition units 
in June of 2007, more than 40,000 wounded, ill, and injured 
soldiers and their families have either progressed through or 
are currently in care, and we have returned over 16,000 
soldiers to the force.
    We have also created a Soldier Medical Readiness Campaign 
that has been brought about because of the rising cost of 
health problems in our force, especially within the Reserve 
Components. Among its many goals under the leadership of Major 
General Rich Stone, a mobilized Reserve Component physician 
from Michigan there to identify the medically non-ready soldier 
population and implement medical management programs to reduce 
this medically non-ready population with an ultimate end state 
of a deployment of healthy, resilient, and fit soldiers, and 
increase Army medical readiness.
    Those soldiers that can no longer meet retention standards 
have to navigate our physical disability evaluation system. 
Assigning disability has long been a contentious issue. DOD and 
VA have jointly designed a new disability evaluation system 
that integrates the DOD and VA processes with a goal of 
expediting the delivery of VA benefits to service members. This 
pilot, called the Integrated Disability Evaluation System or 
IDES, began in late 2007 at Walter Reed. It is now in 16 of our 
Army Medical Treatment facilities.
    And it will be the DOD and VA replacement for the legacy 
Disability Evaluation System. But even with this improvement, 
disability evaluation remains complex and adversarial. Our 
soldiers still undergo dual adjudication where the military 
rates only on fitting condition and the VA rates all service-
connected conditions.
    Dual adjudication is confusing to soldiers and leads to 
serious misperceptions about the Army's appreciation of the 
wounded, ill, and injured soldiers' complete medical and 
emotional situation. And IDES has not changed the fundamental 
nature of the dual adjudication process. Under the leadership 
of the Army Chief of Staff and the Army G-1, we continue to 
forge the consensus necessary for a comprehensive reform of the 
Physical Disability Evaluation System in which the Army and the 
DOD only determines fitness for duty, and the VA determines 
disability compensation.
    Our second strategic aim is to reduce suffering, illness, 
and injury through early prevention. Army public health 
protects and improves the health of the Army community through 
education and promotion of healthy lifestyles, and disease and 
injury prevention. The health of the total Army is essential 
for readiness and prevention is the key to health.
    The examples of this are the promotion of healthy 
lifestyles, of achieving the highest measures of population 
health measured by [inaudible], the implementation of Patient-
Centered Medical Home that you have heard about already, and I 
hope you will hear more about, and the focus on, for example, 
body mass index, and childhood obesity.
    The Army is leading the way also in the recognition and 
treatment of mild traumatic brain injury [TBI] or concussion 
through an ``Educate, Train, Treat, Track'' strategy. Vice 
Chief of Staff of the Army Pete Chiarelli has led personally in 
this and we have refined this through General Richard Thomas, 
my Assistant Surgeon General for Force Projection. We fielded 
this program, which some have called the ``CPR for the brain,'' 
increasing the awareness and screening of concussive injury and 
leading to a decrease of the stigma associated with seeking 
care.
    The use of evidence-based practices are aimed at the most 
effective care for us, is our third strategic aim. For example, 
we have harvested the lessons of almost a decade of war and now 
strengthen our soldiers' and families' behavioral health and 
emotional resiliency through a campaign that aligns all of the 
behavioral health programs within this human dimension of the 
Army's Force Generation cycle. We call this the Comprehensive 
Behavioral Health System of Care. We have got now outcome 
studies that demonstrate the profound value of using multiple 
touchpoints in assessing and coordinating health and behavioral 
health for soldiers and families across this cycle.
    Coupled with the major advances in battlefield care under 
the Joint Theater Trauma System which was birthed in the Army's 
Medical Research and Materiel Command and the Army's Institute 
of Surgical Research, we have made great strides in preventing 
and managing physical and emotional wounds of war.
    Additionally, we have launched a comprehensive pain 
management strategy to address chronic pain that our soldiers 
are focused, it is holistic, multidisciplinary, multimodal. 
Utilizes art--the state-of-the-art care, and it is focusing on 
non-pharmacologic practices such as incorporating complementary 
and alternative therapies, like acupuncture, and massage 
therapy, movement therapy, yoga, and other mind-body medical 
practices.
    Our fourth strategic aim is optimizing efficiencies that 
you have alluded to. We do that through leading business 
processes and partnerships with the other services and veterans 
organizations. Ultimately, I would like to say that the 
principal efficiency and cost saving step in health care is the 
maintenance of health, promotion of good health, and the focus 
on good clinical outcomes and evidence-based practices.
    But we are also working with the DOD and the VA to create a 
single electronic health record, seamlessly transferring 
patient data between and among the partners to improve 
efficiencies and continuity of care. We share a significant 
amount of health information today. No two health organizations 
in the Nation share more non-billable health information than 
the DOD and the VA.
    The Departments continue to standardize this sharing 
activity and are delivering information technology solutions 
that will significantly improve the sharing of appropriate 
electronic health information.
    Our fifth aim is an enterprise approach. We have 
reengineered Army Medicine. We have created a Public Health 
Command. And we have reengineered our regional medical commands 
to align with the TRICARE regions so that we can more 
efficiently provide health care in a seamless way through our 
TRICARE partners.
    We also have at each regional medical command, a deputy 
commander who is responsible for readiness and can reach out 
even to our Reserve Component elements within their area of 
responsibility to ensure that all medical and dental services 
are being provided and our Reserve units are optimally ready.
    This is my last congressional hearing cycle as the Army 
Surgeon General and the Commanding General, The Army Medical 
Command. I would like to thank the committee for the 
opportunities that I have been given to highlight the 
accomplishments we have made, the challenges that we face, to 
hear your collective perspectives regarding the health of our 
extended military family and the health care we provide.
    I have appreciated your tough questions, your valuable 
insights, the sage advice you have offered and the deep 
commitment you have all demonstrated to our soldiers and their 
families. On behalf of over 140,000 dedicated soldiers, 
civilians, contractors that make up my command in Army 
Medicine, I would like to thank also the Congress for your 
continued support in providing the resources we need for 
delivering leading edge health services, and build healthy and 
resilient communities.
    Thank you.
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 59.]
    Mr. Wilson. General Schoomaker, thank you very much. And 
thank you for being so candid.
    And Admiral Robinson, again, I am so grateful for the 
briefing you provided at your very historic office. And so, 
thank you for coming by today.

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

    Admiral Robinson. Thank you very much, Mr. Chairman.
    Chairman Wilson.
    Congresswoman Davis.
    Distinguished members of the subcommittee, I am pleased to 
be with you today. And I want to thank the committee for the 
tremendous confidence and unwavering support of Navy Medicine, 
particularly, as we continue to care for those who go in harm's 
way, their families, and all beneficiaries.
    Force Health Protection is the bedrock of Navy Medicine. It 
is what we do and why we exist. It is our duty, our obligation, 
and our privilege to promote, protect and restore the health of 
our sailors and marines. This mission spans the full spectrum 
of health care, from optimizing the health and fitness of the 
force, to maintaining robust disease surveillance and 
prevention programs, to saving lives on the battlefield.
    I along with my fellow Surgeons General traveled to 
Afghanistan last month and again witnessed the stellar 
performance of our men and women delivering expeditionary 
combat casualty care. At the NATO [North Atlantic Treaty 
Organization] Role 3 Multinational Medical Unit, Navy Medicine 
is currently leading the joint and combined staff to provide 
the largest medical support in Kandahar with full trauma care.
    This state-of-the-art facility is staffed with dedicated 
and compassionate Active and Reserve personnel who are truly 
delivering outstanding care. Receiving 70 percent of their 
patents directly from the point of injury on the battlefield, 
our doctors, nurses, and corpsmen apply the medical lessons 
learned from 10 years of war to achieve a remarkable 97 percent 
survival rate for coalition casualties.
    The Navy Medicine team is working side by side with Army 
and Air Force medical personnel and coalition forces to support 
U.S. military coalition forces, contractors, Afghan nationals, 
police, army and civilians as well as detainees. The team is 
rapidly implementing best practices and employing unique skill 
sets such as an interventional radiologist, pediatric 
intensivist, hospitalist and others in support of their 
demanding mission.
    I am proud of the manner in which our men and women are 
responding--leaving no doubt that the historically 
unprecedented survival rate from battlefield injuries is the 
direct result of better trained and equipped personnel, in 
conjunction with improved systems of treatment and casualty 
evacuation.
    We spend a lot of time discussing what constitutes world 
class health care. I would like to be clear that there is no 
doubt in my mind that the trauma care being provided in theater 
today to our casualties is truly world class as are the men and 
women delivering it. Their morale is high and professionalism 
unmatched.
    We also had the opportunity to visit our Concussion 
Restoration Care Center [CRCC] at Camp Leatherneck in Helmand 
Province. The center which opened in last--which opened last 
August, assesses and treats service members with concussion or 
mild TBI, mild traumatic brain injury, and musculoskeletal 
injuries, with the goal of safely returning to duty many 
service members as possible to full duty following recovery of 
cognitive and physical function.
    The CRCC is supported by an interdisciplinary team 
including sports medicine, family medicine, mental health, 
physical therapy, and occupational therapy. The CRCC, along 
with other programs like OSCAR, our Operational Stress Control 
and Readiness program, in which we embed full-time mental 
health personnel with deploying marines, continues to reflect 
our priority of positioning our personnel and resources where 
they are most needed.
    We have no greater responsibility than caring for our 
service members, wherever and whenever they go. We must 
understand that preserving the psychological health of service 
members and their families is one of the greatest challenges we 
face today. We recognize that service members and their 
families are resilient at baseline but the long conflict and 
repeated deployments challenge this resilience.
    We also know that nearly a decade of continuous combat 
operations has resulted in a growing population of service 
members suffering with traumatic brain injury. We are forging 
ahead with improved screening, surveillance, treatment, 
education, and research. However, there is still much we do not 
yet know about these injuries and their long-term impact on the 
lives of our service members.
    I would specifically point out that the issuance of the 
directive type memorandum in June 2010 has increased line 
leadership awareness of potential traumatic brain injury 
exposure and mandates post-blast evaluations and removal of 
blast-exposed warfighters from high risk situations to promote 
recovery.
    We also recognize the important of collaboration and 
partnerships, and our efforts include those coordinated jointly 
with the other services, the Department of Veterans Affairs, 
the Centers of Excellence, as well as leading academic and 
research institutions.
    Let me now turn to patient- and family-centered care. 
Medical Home Port is Navy Medicine's Patient-Centered Medical 
Home model, an important initiative that will significantly 
impact how we provide care to our beneficiaries. Medical Home 
Port emphasizes team-based comprehensive care and focuses on 
the relationship between the patient, their provider and the 
health care team.
    Critical to its success is leveraging all of our providers 
and supporting information technology systems into a cohesive 
team that will not only provide primary care but integrate 
specialty care as well. We continue to move forward with the 
phased implementation of Medical Home Port and our medical 
centers and family-practice teaching hospitals, and the initial 
response from our patients is very encouraging.
    Both force health protection and patient and family-
centered care are supported by robust research and development 
capability and outstanding medical education programs. These 
are truly force multipliers. The work that our researchers and 
educators do is having a direct impact on the treatment we are 
able to provide our wounded warriors and helping to shape the 
future of military medicine.
    Finally, I would like to address the proposed Defense 
Health Program cost efficiencies. Rising health care costs 
within the MHS continue to present challenges. The Secretary of 
Defense has articulated that the rate at which health care 
costs are increasing and relative proportion of the 
Department's resources devoted to health care cannot be 
sustained. He has been resolute in his commitment to implement 
systemic efficiencies and specific initiatives which will 
improve quality and satisfaction while more responsibly 
managing cost.
    The Department of the Navy fully supports the Secretary's 
plan to better manage costs moving forward and ensure our 
beneficiaries have access to the quality care that is the 
hallmark of military medicine.
    In summary, I am proud of the progress we are making, but 
not satisfied. We continue to see ground-breaking innovations 
in combat casualty care and remarkable heroics in saving lives, 
but all of us remain concerned about the cumulative effects of 
worry, of stress and anxiety on our service members and their 
families brought about by a decade of conflict. Each day 
resonates with the sacrifices that our sailors, marines, and 
their families make quietly and without bravado.
    It is this commitment, this selfless service that helps 
inspire us in Navy Medicine. Regardless of the challenges ahead 
I am confident that we are well-positioned for the future. 
Since this is my last cycle of hearings, I too would like to 
extend my sincere appreciation to the committee, to the Members 
and the professional staffers for all of the support, the 
insights and the advice being given; it has been a true honor 
being before you and actually working with you.
    I appreciate the opportunity to be here today and look 
forward to your questions. Thank you very much.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 82.]
    Mr. Wilson. Admiral, thank you very much.
    And General Green.

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

    General Green. Good morning, Mr. Chairman, Representative 
Davis, and distinguished members of the committee, I appreciate 
the opportunity to meet with you today representing the men and 
women of the Air Force Medical Service.
    We cannot achieve our goals of better readiness, better 
health, better care and best value for our heroes and their 
families without your support, and we thank you.
    Military Health System achievements have changed the face 
of the war. We deploy and set up hospitals within 12 hours of 
arrival anywhere in the world. We move wounded warriors from 
the battlefield to an operating room within minutes and have 
achieved and sustained less than 10 percent died-of-wounds 
rate.
    We move our sickest patients in less than 24 hours of 
injury and get them home to loved ones within 3 days to hasten 
recovery. We have safely evacuated more than 85,000 patients 
since October, 2001, 11,300 in 2010 alone, many of them 
critically injured.
    The Air Force Medical Service has a simple mantra: Trusted 
Care Anywhere. This fits what we do today and will continue to 
do in years ahead. It means creating a system that can be taken 
anywhere in the world and be equally as effective whether in 
war or for humanitarian assistance.
    Medics at Air Combat Command have now developed an EMEDS 
[expeditionary medical support] deployable hospital that is 
capable of seeing the first patient within 1 hour of arrival 
and performing the first surgery within 3 to 5 hours. These 
systems are linked back to American quality care and refuse to 
compromise on patient safety.
    Providing trusted care anywhere requires the Air Force 
Medical Service to focus on patients and populations. Patient-
centered care builds new possibilities in prevention by linking 
the patients to provider teams that both the patient and the 
provider can be linked to an informatics network dedicated to 
improving care.
    Efficient and effective health teams allow recapture of 
care at our medical treatment facilities to sustain currency 
and continually improving our readiness insures patients and 
warfighters always benefit from the latest medical technologies 
and advancements.
    The Air Force supports the DOD strategy to control health 
care costs, and believes it is the right approach to manage the 
benefit while improving quality and satisfaction. By the end of 
2012, Air Force Patient-Centered Medical Home will provide 1 
million of our beneficiaries new continuity of care via single 
provider led teams at all of our Air Force facilities.
    We will do all in our power to improve the health of our 
population while working to control the rising costs of health 
care.
    The Air Force Medical Service treasures our partnerships 
with OSD [Office of the Secretary of the Defense], the Army, 
Navy, Veterans Administration, civilian, and academic partners. 
We leverage all the tools you have given us to improve 
retention and generate new medical knowledge. We will continue 
to deliver nothing less than world-class care to military 
members and their families, wherever they serve around the 
globe.
    Thank you and I look forward to answering your questions 
this morning.
    [The prepared statement of General Green can be found in 
the Appendix on page 109.]
    Mr. Wilson. Thank you very much, General.
    And as we begin questions I want to make it clear, we are 
going to have a 5-minute rule and first of all it applies to 
me. And we have someone very impartial who is going to be 
observing this and monitoring it, Jeanette James.
    And so, Ms. James, on the mark, get set, go.
    With this in mind and to you, Dr. Stanley, knowing your 
background, your military background and medical, and Dr. 
Woodson, I have faith in both of you and I have faith in both 
of you as to the oversight of military health care. And so, it 
was a real surprise to me that out of the blue, last week, 
there would be a military health care czar appointed, Governor 
Baldacci, a former governor of Maine. And I understand he is to 
conduct a 1-year review.
    I truly believe that is a duplication and the General 
Accountability Office just 2 weeks ago said that our government 
suffers from duplication, overlap, fragmentation; and then in 
light of that, a new position is created at a time where we are 
all concerned about efficiencies and now we are adding a new 
job, I believe, a $163,000 a year. That just doesn't seem right 
to me.
    And then I am also concerned and in light of this study, 
why should Congress enact what you are proposing which are the 
defense health cost efficiencies, if this work could be 
overturned by another major reform by another party.
    Secretary Stanley. First of all, Congressman and Chairman, 
I thank you first of all for your confidence because the 
efficiencies that we are talking about today and specifically 
are de-coupled and are not directly related to what Governor 
Baldacci is going to be doing.
    His charge, by me, because I asked him--first of all, I 
wanted to have an objective, outside look. I have looked at GAO 
reports; my charge from Secretary Gates when I first joined the 
Department last year was to look at P&R a little differently.
    We have not really been as open as I think we should have 
been with VSOs [veteran service organizations], I don't think 
we have been as open as we should have been in terms of 
following some of the things that have been laid out before in 
terms of recommendations and I needed an outside look and I had 
a Member of Congress as well a former governor now who served 
two terms to help with not only the Guard, Reserve issues but 
also looking at the holistic viewpoint of readiness, of 
wellness, of looking at how we are going to do, you know, 
patient satisfaction and then cost was the last piece.
    So the duplication is not what I actually see right now, 
actually I am asking Dr. Woodson to work very closely with him 
as we look at the objectives assessment of this.
    Mr. Wilson. And Dr. Woodson.
    Dr. Woodson. Thank you for that question. I think in part 
with the delay in my confirmation and sort of the inconsistent 
leadership within health affairs there was a need to in fact 
look at how business was conducted within health affairs.
    I do not see the governor's mandate as interfering with my 
statutory authorities and the efficiencies that we need to roll 
out. To the extent that Governor Baldacci conducts his studies 
and produces products that informs me in terms of what 
additional reforms need to made, I look forward to his work.
    Mr. Wilson. I am concerned too and I am glad you brought up 
about confirmation. I don't believe this position goes through 
confirmation; that concerns me.
    General Schoomaker, real quickly with the--it is so 
important about the Walter Reed Bethesda what I consider to be 
merger, but I am very concerned about the level of support 
provided for the wounded warriors. Will it be equal to what we 
know is world class currently at Walter Reed?
    General Schoomaker. Sir, we have worked--I think all the 
services have worked very, very hard to ensure that that is 
going to occur. We have had some very, very tight schedules and 
some unexpected hurdles that we are going to have to overcome.
    I feel that I should say, honestly, that there are going to 
be some patients and some clinical situations in a new system 
that is going to be, who are going to be facing unfamiliar 
terrain. We are going to have a new physical plant, a new 
organizational arrangement and a new virtual space, that is the 
Electronic Health Record to deliver that care. But I can say 
that we are working as hard as we can to meet those, both the 
deadlines as well as the standards of high-quality care.
    Mr. Wilson. Thank you, and with the 5-minute rule, Mrs. 
Davis.
    Mrs. Davis. Thank you.
    Dr. Stanley, I understand that the Department analyzed a 
number of options before it considered what proposals to put 
forward to try and address the growing health care budget. So I 
wondered if you could share with the subcommittee what other 
proposals were considered and subsequently rejected by the 
Department?
    Secretary Stanley. Yes, Congresswoman Davis. The Department 
did, in fact, look at other options, everywhere from curtailing 
certain studies, doing curtailment on research, dealing with 
not only cancer research but looking at a whole range of 
options that I know that I am going to ask Dr. Woodson to help 
with some of this but the bottom line is, is that over the 
years, before I came, there were actually higher costs looked 
at which were rejected not only by this body but also 
internally looking at ways to be more efficient but also having 
minimal impact or effect on our troops and affecting our Active 
Duty Component.
    So we looked at things that will have minimal impact on 
Active Duty and at the same time not really affecting even our 
retirement community or Reserve and Guard significantly, just 
looking at ways to manage costs but still deliver quality care. 
And that is the side, that is where we came down with these 
minimal efficiencies that we are looking at.
    Mrs. Davis. Dr. Woodson.
    Dr. Woodson. Thank you very much for that question. 
Producing efficiencies and reduction in costs in health care is 
an ongoing effort, both within the Military Health System and 
within civilian sector as well.
    Since 2007 $1.65 billion have been saved in the Military 
Health System by introducing mail-order pharmacy products, 
going after Federal price ceilings, using outpatient 
perspective payment systems, enhanced fraud detection, and 
standardizing medical supplies and equipment.
    And of course I would remind the committee that the factors 
that are influencing the rise in health care include the fact 
that we have an increased number of users, new products and we 
have growing pharmacy use and growing utilization of health 
care resources.
    Now we have endeavored to streamline our practices and 
produce efficiencies. We mentioned Patient-Centered Home as a 
method for particularly managing chronic disease which reduces 
cost but also improves quality of care. We have undergone 
consolidation and initial outfitting and transition of 
equipment efficiencies. We have centralized procurement of 
medical equipment and devices. We have also reduced service 
contracts and we continue to look at this as a source of 
efficiencies and as you know we are undergoing an efficiency 
evaluation to reduce 780 FTEs [full time equivalents] from 
Health Affairs and TRICARE Management Activity.
    We streamlined TMA, TRICARE Management Activity operations 
and expanded the use of urgent care and nurse advice lines to 
produce better quality of care and more efficient care.
    So there have been a number of initiatives that have been 
implemented and continue to be implemented, and again I would 
remind the committee that between 2001 and 2008, the rise in 
cost of health care was about 11.8 percent per year. We are 
really desperately trying to bend that curve and produce all 
sorts of efficiencies, and that is why we have considered for 
fiscal year 2012 a really balanced approach to bending that 
cost curve. Thank you.
    Mrs. Davis. I appreciate, you know, your response. And one 
of the things I was wondering about this, Surgeons General, 
could you just talk a little bit about the engagement of you 
all and whether you felt that there was adequate opportunity 
for people to weigh in on these issues?
    Admiral, did you want to----
    Admiral Robinson. Yes, Congresswoman Davis. I think that 
the Surgeon Generals, all of us have been brought into the 
whole efficiency movement. I think that coming from Health 
Affairs, we have all been tasked to look not only at what we 
are doing externally with the five efficiencies that have been 
named, but also the internal approach.
    And it has been through, in my opinion, the Medical Home 
where all three services leverage some of the efficiencies that 
are occurring in terms of access to care for primary care, 
integration of specialty care, having a real provider-patient 
relationship 24 hours, 7 days a week, decreasing urgent and 
emergency room visits, and having the ability to emphasize 
prevention rather than disease care.
    So, in the Medical Home Port model, what the Navy calls, 
the same model that, the Medical Home is what Air Force and 
Army uses also--I think that it is going to be one of those 
major efficiency moves in terms of quality of care.
    Yes, ma'am.
    Mrs. Davis. I think my time is up. General, perhaps later 
we will have a chance for your response.
    Mr. Wilson. And thank you very much.
    Congressman Jones of North Carolina.
    Mr. Jones. Mr. Chairman, thank you very much. And my 
question will be directed to Admiral Robinson and General 
Schoomaker. I want to thank you first for your service, and the 
many times you have testified, and the fine work you have done 
for our military.
    I, like most Members of Congress, I have visited Walter 
Reed and Bethesda on a regular basis. And I make reference to 
this article of March 9th report reveals steep increase in war 
amputations the last fall.
    And it seems like the last year that I have had the 
privilege to visit the heroes at Walter Reed and Bethesda, that 
the severity of the wounds are deeper or more severe than ever.
    One being a kid that lost most of his lower body parts, the 
other being a sergeant first class who on a fourth tour in 
Afghanistan as he told me that day that he has always told the 
young marines to walk in the boot print in front. He did and it 
blew his leg off and other parts of his lower body were 
injured.
    My concern for those who are still in the military who are 
severely wounded as well as when they leave the military, but 
this panel today, and that is why I have to single out the 
admiral and the general for this answer, are you satisfied that 
we are where we need to be as it relates to psychiatrists in 
the Army and the Navy?
    Do we have an issue there that the government needs to 
really reach out and try to encourage those who are graduating 
from the schools, who are getting degrees in psychiatry, to 
look more at trying to come into the military? Or do you feel 
like the numbers are where they need to be?
    My concern is--I am going to let you answer in one sec--my 
concern is not only the young injured, but if they have a mom 
and dad or if they have a wife and children. My concern is that 
I want to make sure that they get the mental health care as 
well as the physical health care.
    General, I would go to you first and then the admiral 
second.
    General Schoomaker. Well, mindful of the time, sir, I am 
going to say two things real quickly. First of all, not to 
minimize or in any way to marginalize the interest that you 
have in this complex injury pattern that you have seen, we have 
recognized the same thing.
    In fact, I have started up a task force a month or so ago 
to look in greater detail under the leadership of Brigadier 
General Joe Caravallo from the Southern Regional Medical 
Command and Brooke Army Medical Center.
    He has pulled a team together to look at the data and look 
at the magnitude of the injuries that we are now seeing. We are 
seeing a larger number as you have seen of complex injuries 
from dismounted operations in Afghanistan with more multiple 
limbs lost, and higher limbs with abdominal and genital 
injuries as well.
    We think this is the dark side of a good story. Soldiers 
and marines are surviving even more than they have in the past. 
The battlefield medicine is improving in all facets.
    But what we get is a soldier, marine, sailor, airman who is 
very, very severely injured. And we are focusing now on what we 
need to do for them.
    As far as psychological care, this is a moving target. We 
have seen as Dr. Woodson talked about it, increasing 
utilization especially in behavioral health across all of our 
units and families.
    We have increased the number of behavioral health 
specialists, not just psychiatrists, but social workers, 
psychologists, our nurse psychiatric workers as well as our 
enlisted.
    The Army has allowed us to put more of them down into 
battalions and brigades. We continue to chase that; we are not 
satisfied as you pointed out. The need is still there.
    Mr. Jones. Admiral.
    Admiral Robinson. The entire nation has a real challenge 
with behavioral health needs. The military certainly has an 
even increased challenge. I would say that what General 
Schoomaker said is correct. I would ditto everything that he 
has said.
    We don't have enough psychiatrists, psychologists, social 
workers, or nurse practitioners in the sense that I can always 
use more. If we look at the retention rates particularly with 
psychiatry, we are probably in the Navy at 72 percent.
    With that said, we have spent about $240 million in 
contracts. We have now about 144 more behavioral health 
contractors at 14 of our MTFs [military treatment facilities].
    We have billeted for an increase in social workers from 35 
to about 86, which is a substantial increase. We are looking at 
each facet of behavioral health, who we have, where they are 
located, and how we use them. We also put them and we embed our 
mental health professionals with our operational stress 
control, our OSCAR teams, we put them with the deploying units 
so that we can get care to people that they need immediately.
    On the home front, we have FOCUS--or Families OverComing 
Under Stress. It is a focus, the program is called, in which we 
look at families and their behavioral health needs and the 
needs of the children and spouses, et cetera.
    So we are putting together, I think, across the Military 
Health System a comprehensive look. Is it enough? It is all 
that we have now. We can always do better. And this is the 
major challenge as I said in my opening statement, a continuing 
major challenge. It really is a moving target.
    We are trying to stay with it. And we will never leave 
those men and women behind.
    Mr. Jones. Thank you, sir. Thank you, Mr. Chairman.
    Mr. Wilson. Thank you.
    And it is a good story. In January, I visited a young 
injured marine, Corporal Kyle Carpenter. And Kyle has had 
dozens of operations. He was gruesomely injured.
    And he--last week it was on the front page, the newspapers 
across South Carolina appearing at the South Carolina Senate 
where he was on the floor. And all the members of the Senate 
welcomed him and shook his hand. And he was given a hero's 
deserved welcome.
    Congresswoman Niki Tsongas of Massachusetts.
    Ms. Tsongas. Thank you all for being here. And I have to 
say I share Congressman Jones' concern. But I too have a good 
story.
    Last week, I visited a young first lieutenant in the Army 
who had been injured by an IED [improvised explosive device] in 
Afghanistan. He had sadly lost the lower portion of his leg. 
But he was on a good recovery, yet another example of a very 
determined young man who wants to make the best of his service 
to our country and to the life that lies before him.
    So, I thank you all for the great work that you are putting 
in, in challenging times. But I will also wanted to start out 
by commenting on the Uniformed Services Family Health Plan 
[USFHP]. The USFHP had its genesis 30 years ago when the direct 
care system needed help to meet the health care needs of our 
military personnel, retirees, and dependents.
    And since then, as you all know, they have become the 
highest rated health care program in the Military Health System 
based on beneficiary satisfaction with a 90.4 percent 
satisfaction rate in 2009.
    Their approach to patient care management with the focus on 
prevention and a continuum of care has improved clinical 
outcomes, decreased emergency room visits and hospital 
admissions.
    This health plan is a model for what we have been aiming to 
do as we all struggle with the rising cost of health care. So, 
I would urge that as a body, we give careful analysis to the 
impact of your proposals to shift its cost to Medicare for 
retirees. Simply a statement of concern.
    But I have a question, Secretary Stanley and Dr. Woodson. 
Secretary Gates has stated that, ``Healthcare costs are eating 
the Defense Department alive.'' And according to the US News & 
World Report, ``Healthcare cost as part of the Defense budget 
have gone from $19 billion in 2001 to about $55 billion now, 
about a 10th of the total.''
    Currently the over 2 million military retiree families 
enrolled in the lifetime health insurance system, TRICARE, pay 
$460 per family per year for health insurance. And an 
individual pays $230 per year. As we all know, these fees have 
not been raised in 15 years.
    With this in mind, I do believe that Congress needs to take 
on the difficult task of reviewing this fee structure. It is an 
issue that will have to be dealt with because of the massive 
strain which has been placed on the defense budget by rising 
health care cost.
    However, I believe it must be done in such a way as to 
minimize its impact. It would be inexcusable to deprive our 
retired heroes of the health benefits they have earned.
    For Active Duty personnel, the Department has different 
annual deductible rates for TRICARE Extra and TRICARE Standard 
on the basis of pay grade. For example, under TRICARE Standard, 
the deductible is $150 per individual or $300 per family for 
beneficiaries at E5 and above and $50 per individual or $100 
per family if the beneficiary is under E5.
    Retirement benefits vary greatly depending on how long a 
person served and at what rank they retired.
    One of the most significant changes made by the National 
Defense Authorization Act for Fiscal Year 2000 was a lifting of 
the 75 percent cap used in the calculation of retired pay for 
members eligible for service retirement.
    Under this calculation, a retired O10 with 45 years of 
service could earn over $210,000 per year before taxes in 
retirement. But an E5 with 20 years of service would earn only 
around $17,000 in annual retirement pay before taxes.
    Keeping this great gap in benefits in mind, I would like to 
ask, has the Department seriously reviewed any proposals for a 
stepped increase of TRICARE Prime fees determined on the basis 
of rank at the time of retirement and retiree benefits earned.
    Secretary Stanley. Congresswoman Tsongas, thank you very 
much for the question.
    I am not aware of stepped increase look. The amount that 
was chosen was considered really a minimalist approach to 
addressing probably a longstanding issue of prices just not 
changing, or cost or charges being, you know, put onto the 
beneficiaries.
    If Dr. Woodson, I am not sure if you have heard anything on 
that. I haven't.
    Dr. Woodson. Thank you, Dr. Stanley.
    Thank you for the question. I agree that we haven't looked 
at the step-wise increases because we have introduced very 
modest changes. And as an administrative process, it becomes 
more difficult to assess income and who should have the step-
wise increase because of that.
    Even an enlisted person who retires after 20 years may 
actually enter a very good-paying job. And so what they 
actually make may not always relate just to their retirement 
pay.
    And I would just remind the committee members to reflect on 
the fact that our proposals suggest modest increases for 
working-age retirees. And so, we would probably have to means-
test against the issue of what their total salaries are; it is 
conceivable that following retirement, as talented as our men 
and women are who serve, they contribute greatly, get advanced 
degrees, and may be doing quite well.
    So, administratively, it would be very tough to means-test. 
If we were proposing large fee increases, I would agree with 
you strongly.
    Ms. Tsongas. Thank you.
    Mr. Wilson. Thank you, Ms. Tsongas.
    And we are very grateful to have distinguished freshmen on 
the committee. The first is Dr. Joe Heck of Nevada. He is 
actually a staff alumnus of the Uniformed Services University 
of Health Sciences.
    Dr. Heck. Thank you, Mr. Chairman.
    And Dr. Stanley, Dr. Woodson, Surgeons General, thank you 
for being here today and thank you for your commitment to our 
service men and women's health and the health of their 
families.
    I am going to refer to the joint written statement of Dr. 
Stanley and Dr. Woodson specifically, Reserve health readiness. 
You have referenced the individual medical readiness metric 
that has been developed. And in your statement you quote--
``Within the Reserve Component, medical readiness is below our 
benchmarks.''
    And of course this is an area of great concern for me. And 
it raises several issues that I would like to bring up 
revolving primarily around the LHI [Logistics Health 
Incorporated] contract and how that service has currently 
performed for the Army Reserve.
    You know, as you well know, we have units in the Army 
Medical Reserve, MSUs, Mobilization Support Units, whose job it 
is to accomplish the medical aspect of soldier readiness 
processing when they get mobilized to their support base.
    However, they are prohibited from performing that very same 
service for their own Reserve counterparts on a BTA [battle 
training assembly] weekend.
    In your notes, you mentioned issues with minor dental 
procedures and immunizations being an issue that can be readily 
fixed in pre-mobilization or pre-deployment mobilization. Yet, 
in my unit, I have dentists that on a BTA weekend can go out 
and provide services to homeless people as a community service, 
but can't examine the reservists that are in their own unit 
because it is prohibited because of the LHI contract.
    In immunizations, every fall, our immunization readiness 
plummets because a new flu vaccine comes out and everybody's 
compliance falls off until everybody gets their flu vaccine. 
You would think that in a medical unit full of doctors, nurses, 
and medics, we could immunize each other. But we can't even get 
the vaccine because we have to put in a voucher for LHI to come 
and do the immunizations.
    The issues here are multiple. One, as you well recognize, 
it impacts our medical readiness. Two, it impacts our ability 
to perform real world training. Certainly, our doctors and 
nurses are doing that in their day job. But my 68 Whiskeys, my 
combat medics, they could be a janitor, they could be garbage 
man, they could be a schoolteacher, and we are taking away an 
opportunity for them to actually do their medical training on a 
drill weekend.
    We send people to a PHA [periodic health assessment]. We 
send soldiers that are well and they come back to us broken. 
They go in well and they come back with a P3 profile. They are 
now medically non-deployable. And it takes us 6 months or more 
to backtrack and get that profile lifted because the folks 
doing these physicals don't understand what the profile process 
is.
    I am encouraged by Major General Kasulke at AR-MEDCOM [Army 
Reserve Medical Command] who is starting a pilot project to 
review all these things and trying to find a way to take care 
of these mis-profiles. But the answer is not to have the person 
come back broken to begin with.
    So my questions are: I understand that the LHI contract is 
up for renewal. I would like to know who has the formal 
approval authority for that contract? Is the Army considering 
any other options or modifications to the contract? What is the 
overall cost? And how can we document whether or not the LHI 
contract has provided any value-added service to our medical 
readiness?
    Dr. Woodson. Thank you, Congressman, for that very good 
question. And I would like to take that one for the record and 
get back to you with the substantive facts and answer you 
specifically. I think that probably it is time for review as we 
look at individual medical readiness and seeing how we can get 
added value out of all of the contracts that we employ.
    [The information referred to can be found in the Appendix 
on page 131.]
    Dr. Heck. I appreciate that. And I think it is critical 
that we also look at the opportunities to allow--I mean, back 
in the old days--and I guess, for the record, I should probably 
disclose that the Honorable Woodson used to be my rater when he 
was Brigadier General Woodson at AR-MEDCOM. And I thank you for 
all those good ratings, sir.
    But, you know, we need to get back to the point where our 
Army Reserve medical personnel can do medical stuff on BTA 
weekend and maintain their skills. In the old days, we used to 
do all the physicals. And then all of a sudden there was an LHI 
contract and we were prohibited from doing those same things 
that we did for decades.
    So, I look forward to the answers for the record, sir. 
Thank you.
    General Schoomaker. And, Congressman, if I could just make 
one comment. I think what you described also is why we stood up 
the Soldier Medical Readiness Campaign under mobilized 
reservist Rich Stone. And I would welcome the opportunity to 
have him come out and talk to you about that and what we are 
trying to do in partnership with both the Guard and Reserve.
    Dr. Heck. Okay, thank you, General. I appreciate that.
    Mr. Wilson. Thank you very much. And the issues that we are 
dealing with are so important for our service members, 
families, and veterans. In consultation with the ranking 
member, we will do a second round of one question each. But at 
this time, we immediately, of course, go to Ms. Pingree of 
Maine.
    Ms. Pingree. Thank you very much, Mr. Chair, Secretary 
Stanley, Dr. Woodson and all of the Surgeons General. I really 
appreciate your service to our country, your testimony this 
morning and so much of what you have been talking about are 
things that I appreciate hearing about, whether it is how you 
treat traumatic brain injury or using alternative methods of 
care to find more ways to heal our soldiers, talking about the 
medical home concept.
    There are so many good things that you are doing. And I 
appreciate it, and I appreciate all the work that you have 
done. And I understand Chair Wilson's concern about the recent 
appointment of the governor from my state, Governor Baldacci, 
and his interest in making sure we are doing everything that is 
as cost effective as possible.
    But I do want to say that Governor Baldacci has a great 
work ethic. He is very devoted to our military. He has worked 
very closely with the National Guard in our state to improve 
many of the practices in our state. So I look forward to him 
looking for some of the efficiencies that could be found.
    But I want to reiterate some of what my colleague from 
Massachusetts talked about earlier. It is a deep concern for 
me. I represent the state of Maine, and I am proud to represent 
many Active Duty members and their families as well as military 
retirees and their families. I have over 34,000 military 
families and retirees that are fortunate to have access to 
outstanding health care provided by U.S. Family Health Plan at 
Martin's Point Healthcare in Maine.
    I visited their facility. I have seen their use of the 
Medical Home model of care. The beneficiaries tell me how much 
they like this health care option. I mean, it has been said 
many times. This is exactly where we want to go with health 
care with our military retirees. And they are very happy, very 
satisfied about it.
    In March, I sent a letter to you stating my unequivocal 
support of how this program currently works and suggesting that 
I would oppose any changes that would negatively impact the 
ability of them to provide care to beneficiaries, including 
those aged 65 and over who have earned their health benefits 
through their service to our Nation.
    I am sorry to say, General Stanley, and with all due 
respect, I wasn't completely pleased with your response. And 
now the fiscal year 2012 President's budget request includes a 
proposed legislative provision that future enrollees would not 
remain on the plan upon reaching age 65. I am concerned about 
this proposal, that it would eliminate access for those in 
greatest need of care and their ability to receive what is the 
highest rated health care plan in the military.
    Let me just shorten up some of my conversation here because 
I know you know exactly what my concerns are and what I am 
talking about. But I want to reiterate that I am sure you know 
by law, the government cannot pay more for the care of a U.S. 
Family Healthcare Plan enrollee than it would if that 
beneficiary were receiving care from another government 
program.
    So I have a hard time seeing this as anything but a cost 
shift over to Medicare while destabilizing what is already a 
very successful program. So I guess I would like to hear you 
address that and also address my concerns that the 
destabilization of this program, in my opinion, isn't 
consistent with DOD's stated priorities of improved health 
management and the continuity of care.
    I am just not pleased about what we are doing here in the 
budget. I understand the importance of cost efficiencies, but, 
to me--and I guess it is a little smoke and mirrors and maybe 
not going to be good for the long-term health care of the 
people of my state.
    Secretary Stanley. Thank you for the question, 
Congresswoman Pingree. I think, as we look at what we are 
proposing, that each hospital that we are working with 
particularly with the Family Health Plan that we are going to 
be working very closely with them because the changes first of 
all may be minimal in some cases or almost barely perceptible 
initially as we work, as we look at how the Medicare, you know, 
the funding is worked out because you really don't want to just 
unplug and move right into something that becomes a cost shift.
    At the same time, we are trying to address something that 
had not been addressed for a number of years in terms of how 
we, you know, work with the cost and everything. So the bottom 
line is we are going to work with them.
    And I hear your concern and I recognize your concern. And 
we are going to do our very best to work with them. I am going 
to ask Dr. Woodson to address this also.
    Dr. Woodson. Thank you very much for that very important 
question. I think the issues that we need to remind ourselves 
of is that this is not about taking a beneficiary away from 
their doctor. They can continue to see their doctor. They can 
continue to go to the same hospitals. But we pay about $16,000 
per member per year in capitated fees to the Uniformed Services 
Family Health Plans.
    And it is important to note that their plan is not just 
about hospital fees, but it is about the money that is also 
paid to their primary care physicians, whereas, the cost to the 
government for, let's say, TRICARE Prime is about $4,500 and 
for TRICARE Standard is about $3,500. Just good business 
practice in this day and age would suggest that we have to get 
better value for the dollar.
    Now, I want to say up front that we consider all of these 
facilities and providers that are in the Uniform Services 
Family Health Plan as great partners. We don't want to lose 
them. I just think that in these tough times of budget 
constraints and rising health care cost, we look at contracts 
everywhere and say how can we get the best of value.
    The proposal actually will save the entire Federal 
Government about $300 million over about 10 years because right 
now, of course, we pay about 42 percent higher in cost than we 
would pay under Medicare fees. I remind you also that most of 
the individuals that are Medicare eligible actually have taken 
already on part B.
    Ninety percent or so all ready have part B because if they 
were to move or circumstances in their life cause them to shift 
to other doctors, if they don't take it on at age 65, they pay 
severe penalties. So the impact to any individual patient is 
likely to be not that dramatic as well.
    So it is about being good stewards of public money. It is 
about preserving money for the future and making sure that the 
Military Health System and the provisions under TRICARE remain 
strong in the future for those who might serve in the future 
and bringing equity, if you will, to the benefits for all 
Medicare eligible beneficiaries as well as equity in terms of 
how we pay all of our providers and hospitals that may serve 
our men and women who have served.
    So there are multiple reasons to really consider this. And 
I think again, it is one of those modest changes that on the 
balance says that we have looked at a number of initiatives to 
produce efficiencies.
    Ms. Pingree. My time is up, but thank you. I am sure----
    Mr. Wilson. And, Ms. Pingree, we will get back to another 
question, too. So thank you so much, very good question.
    And as we conclude this first round, it is very fitting 
that we have another distinguished freshman, Colonel Allen West 
of Florida, who himself has had an extraordinary record of 
military service.
    Colonel West.
    Mr. West. Thank you, Mr. Chairman, also Madam Ranking 
Member, the Honorable Stanley, Honorable Woodson, General 
Schoomaker, General Green, and Admiral Robinson. Thank you so 
much for appearing here today.
    We talked about the visible injuries that we see coming out 
of the combat theaters of operation in Iraq and Afghanistan, 
but one of my concerns is the unseen injury and, of course, 
that is traumatic brain injury, TBI.
    I have had the opportunity to visit with a gentleman by the 
name of Dr. Ray Kraul down at South Florida who has been 
offering hyperbaric oxygen treatments to several returning 
veterans. I have had the chance to sit down with three of them 
and we have seen some noticeable improvements.
    About 3 weeks or so ago, I had the opportunity to sit down 
and have lunch with Vice Chief of Staff General Chiarelli, and 
we talked about the opportunities and the options of the 
hyperbaric oxygen treatment. One of the things he said is that 
there are some obstacles out there to the implementation of 
this as a viable treatment for returning veterans.
    And so I would like to know what are those obstacles that 
are out there and how can this committee help to, I guess, 
eradicate some of those obstacles so we can facilitate taking 
care of our veterans?
    General Schoomaker. Well, I don't think there is anything 
that the committee can necessarily do for this, Congressman. 
Thanks for that question. Hyperbaric oxygen is currently an FDA 
[Food and Drug Administration] regulated treatment. It is not 
currently approved by the FDA for treatment of either 
concussive brain injury or for post-traumatic stress disorder.
    We have offered through your generous funding any and all 
investigators out there who are administering hyperbaric oxygen 
to design and administer protocols that would test and 
demonstrate the utility of this. We finally undertook those 
investigations ourselves. We have currently three projects. One 
has been completed at the LDS Hospital in Salt Lake City by an 
international expert in hyperbaric medicine, Dr. Lin Weaver.
    Its results on a non-randomized and uncontrolled study show 
that hyperbaric oxygen appears safe at this point for patients 
with moderate and stable brain injury. We currently are 
awaiting the results of an Air Force School of Aerospace 
Medicine study that has just been concluded that is controlled 
and sham controlled so that we can see what the effect of the 
hyperbaric oxygen is against a semblance of that administration 
of oxygen, but without it. We have yet to see what the results 
of that. And we are awaiting a more definitive study that will 
be overseen by the Army's Medical Research and Materiel Command 
that will include four or five sites across the country, 
military and non-military.
    So the summary of all of this is that despite a series of 
published and unpublished anecdotes, there really remains no 
medical evidence that hyperbaric oxygen has a therapeutic role 
in the relief of symptoms of--or brain dysfunction for warriors 
with post concussive syndrome, or mild traumatic brain injury, 
or posttraumatic stress disorder.
    And until we have that, we just can't in good conscience 
provide care which is quite expensive without knowing its 
ultimate safety and its utility.
    Mr. West. Well, I guess the thing is when you sit down and 
you do speak to some of these young men as I have that say that 
it has made a difference, I think that is some pretty good 
anecdotal evidence for myself.
    But, you know, perhaps, Mr. Chairman, we ought to look at 
seeing if we do need to send a letter over to the FDA and ask 
what impediments that they are making. But we cannot, you know, 
take too much time because every day some soldier, sailor, 
airman, marine is going through an IED blast. And these IEDs 
continue to cost much injury as far as TBI. So, hopefully, we 
can put a little bit more emphasis and a little bit more speed 
to this.
    Thank you very much and I yield back.
    Mr. Wilson. Thank you, Congressman. I look forward to 
working with you in a joint letter or whatever. And I 
appreciate your promotion of this issue.
    We will now have a second round with everyone, a single 
question. And, for me, so often we hear the bad, but there is 
so much good. And military medicine really has been the best in 
the world providing for care of people with brain injuries and 
trauma injuries. And this applies to the civilian world of auto 
accidents and these who are people who are injured in sports 
injuries, additionally, prosthetics, truly the best in the 
world now, our American military medicine and available to the 
civilian population.
    With this, I would like to know from each of the Surgeons 
General what you have done in regard to cost efficiencies. Can 
you give us an example of a cost efficiency on behalf of the 
taxpayers of our country. And we will begin with General 
Schoomaker, the senior person and then we will end up with the 
junior general.
    General Schoomaker. Sir, what we have focused on a lot 
within Army Medicine is standardization of practices, both 
administrative and clinical practices. It has been widely 
discussed both in the private sector as well as in government 
medicine that elimination of unwarranted variation in 
practices--clinical practices and administrative practices--
will squeeze out a lot of waste in the system.
    We have focused very hard on that. We have also used a 
business case model for all of our hospitals and clinics in 
which commanders are encouraged to target health promotion and 
health improvement as a way of preventing preventable 
hospitalizations, ER visits and the like.
    And, finally, I would say that all of us here--and we 
commend the Air Force for their lead on this--have embraced the 
Patient-Centered Medical Home, which we think is going to be 
transformative in bringing into the primary care sector both 
ready access continuity, because many of our patients seek 
continuity where we think they are looking for access alone, 
and a fusion site for behavioral health, for pain management 
and many of the other things that we are doing that will 
ultimately result I think in better and healthier people, 
better and healthier communities and reduction and cost over 
all.
    Mr. Wilson. Thank you.
    Admiral.
    Admiral Robinson. Thank you very much for the question. In 
addition to what General Schoomaker said--I am not going to 
repeat that--many of the Navy initiatives are along the same 
line. We have also taken some internal looks. And partnering 
with the Applied Physics Lab at Johns Hopkins and also the 
Center for Naval Analyses, we have come through and looked at 
business practices and also clinical practices in our medical 
treatment facilities across the enterprise.
    We are taking an enterprise approach, having industrial 
engineers come through, look at the orthopedic departments and 
how we have patient flows at Balboa or Camp Pendleton, how we 
have access to care for the patient, how we then work them 
through our system, how we could do that more efficiently, not 
only from a patient perspective, but also from a provider 
perspective.
    I am talking about from the corpsman, from the nurses, from 
the physicians, from everyone on that team. So we are trying to 
take an enterprise look at how we can implement that across the 
board and doing what Eric said in terms of the standardization 
of practice so that we can reduce the variation.
    Additionally, in the financial world and I, not being a 
financial expert, am blessed to have a really excellent Navy 
Medicine controller who has instituted a great deal of effort 
at standardization of how we in fact do our financial 
accounting, how we do our audits and how we look at the 
financial program's execution. He has been sensational and 
there is so much more that I can't describe, but he has been 
sensational and has become a real best practice for not only 
the Department of the Navy but also the Department of Defense. 
So he is being utilized and a lot of his programs are being 
utilized there.
    Those two business practices, that industrial engineering 
and the way we do our financials across the gamut within Navy 
Medicine have produced efficiencies and savings that have 
really made a much better enterprise approach to the way we do 
Navy Medicine.
    Mr. Wilson. Thank you, and General.
    General Green. We have looked at several different things. 
We actually decreased our headquarters manning to increase the 
manning back to the hospitals trying to recapture care. We have 
looked at standardizing our practice. Part of the Medical Home 
was to basically look at support staffing ratios and put some 
of the nursing staff back into hospitals again, based on 
business case analysis to bring the care back in.
    We have had systems looking at our ORs [operating rooms] 
and at our emergency rooms basically trying to maximize the 
efficiency to increase access. We have seen at some of our 
bases as much as a 40 percent increase in the surgical cases 
that can go through our ORs by recapturing care. Under the 
Patient-Centered Medical Home, the satisfaction is up, the 
continuity jumps from about 40 percent to 70 percent, and we 
end up encouraging the providers to work at the top of their 
license based on changes to their practice.
    I would tell you that the partnerships that we are doing 
are based on bringing care back into the direct care 
facilities, both for currency and to decrease cost in terms of 
what is going to the private sector. And finally, the efforts 
in disease management and case management across all three 
services are reducing care cost. In fact, in one case out at 
Hill Air Force Base we have saved probably $400,000 in reduced 
utilization by diabetics based on the output and the efforts to 
try to case manage.
    Mr. Wilson. Thank you all very, very much, and Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman. One thing that I would 
like to mention is I hope that we will have an opportunity to 
look at mental health issues overall, whether or not we are 
providing the support to encourage people to go into those 
fields and also a look at some of the research and development 
that has been done, and whether or not we are utilizing those 
dollars well and coordinating those efforts in a way that we 
really do know what has happened over the last number of years, 
because we have certainly put a lot of effort into that and I 
would like to take a look at that and see how it is really 
affecting our service members and their families.
    But I wanted to go back to Ms. Pingree's question, I think 
generally because the new proposal really could have an impact 
on our Active Duty members and because there is in the proposal 
we are reducing possible payments to Sole Community Hospitals, 
and those hospitals may of course decide to limit TRICARE 
participation due to the reduced rates. And so I am wondering, 
and this goes really I think to General Green, whether or not 
the Air Force has particularly engaged with Sole Community 
Hospitals outside of Air Force bases to assess the impact of 
this proposal on the beneficiaries in those communities, and if 
you are confident that the proposal will not severely impact 
them.
    In addition to the concerns that I think a lot of our 
Members are going to have because there are certain Members, 
communities that are more affected by this than others, we also 
know that those hospitals that have many cases of 
disproportionate share hospitals also even in urban communities 
might be affected by this. So I am wondering if you could 
address it, General Green and perhaps others quickly. What do 
we know about that and what can we anticipate could be the 
impact on our beneficiaries?
    General Green. Eight of the 20 hospitals that have over 5 
percent of their income based on admissions are from Air Force 
areas and so, when you look at those, about 4 of those 
facilities actually are in the 10 percent to 15 percent range 
for us. We are not the highest, but it is a concern.
    The reality of the implementation is that we have had 
longstanding partnerships with these organizations. We believe 
that the care will still continue to go to these organizations. 
As you change the payment and bring it in line with payment 
elsewhere in the country in terms of how we receive care, we 
believe that the implementation is conservative enough in terms 
of the basically bringing online over a 4-year period that we 
can look at it, work with the local facilities and if 
necessary, work with Health Affairs in terms of any type of 
transitional changes in payments to make certain that this is 
sustainable.
    Our belief is that this is a reasonable approach to try and 
bring this back in line with what is going on elsewhere in the 
Nation and obviously remains to be seen, particularly with 
these hospitals where it is a large portion or a larger portion 
of their income.
    There should be no effect on our beneficiaries because 
their care would still go to the same areas. They just would be 
at the rate of payment that is provided at every other site 
where they might go and seek care if they were out of that 
area. And so the question is going to be does it end up 
affecting the facilities to the point where despite the long-
term partnerships, they feel they have to change the mix of 
patients, and so we will be watching that very closely.
    General Schoomaker. Yes, I would echo those comments. Two 
of the 20 are Army-centric including a hospital in the 
community that our Secretary of the Army represented at one 
point, and I think everything that General Green said applies 
to the Army as well and we have been reassured by Dr. Woodson 
that the financials of this will be looked at very carefully 
and that we won't erode the relationship that we have with 
these hospital systems.
    Dr. Woodson. Thank you for that question. I think I want to 
emphasize that we are willing to reach out proactively to these 
hospitals to look at their revenue streams and how they will be 
impacted. We do have the ability as the law is allowed to pay 
Medicare rates when practicable and if it turns out in a 
situation that there is hospital that is providing needed 
services and there are no other hospitals, adjustments can be 
made. So I want to emphasize that in fact we are going to be 
proactive about this. We want to be fair about this. But again, 
we need to in this day and age, make sure that all of our 
contracts are really looked at carefully and add value and--as 
well as quality in terms of the care that is provided.
    Mr. Wilson. Thank you very much. We now go the Mr. Jones.
    Mr. Jones. Thank you, Mr. Chairman. And my question in just 
a moment would be for you Admiral Robinson. I appreciate the 
question by Congressman West. I remember 10 years ago I think I 
was briefed by Dr. Harch from LSU about hyperbaric oxygen as a 
treatment for head wounds. And I know I had a conversation a 
couple of years ago, I cannot remember the Air Force officer, 
about where the research is going and I appreciate your 
statement, General Schoomaker, that my concern or interest is 
this--Admiral Robinson, I know that--and I want to thank 
Admiral Mullen.
    Quite frankly, I brought this up at a full hearing about a 
year ago about hyperbaric chamber down at Camp Lejeune. We do 
have one at Camp Lejeune. And I believe that they are in the 
process now preparing to be part of a pilot program to treat 
marines down at Camp Lejeune which I am grateful for.
    Help me understand when--I understand the need for studies, 
please understand I do realize they are very, very important. 
But when would the military get to a point after the study by 
the Air Force, maybe the Army, I don't know that. Maybe the 
Navy as well. When did you get to a point that the studies say 
and I will tell you why, then I am going to let you answer, I 
have called numerous moms and dads whose sons and a couple of 
daughters had been in the hyperbaric chamber for treatment. 
What really sticks with me and I want to use this before and 
then you answer please, sir.
    I called Colonel Bud Day who won the medal of honor in 
Vietnam, and he told me that his grandson had a severe brain 
injury from Iraq I believe at that time, and he was just not 
satisfied with the treatment, and at his own expense, he sent 
his grandson to LSU to Dr. Harch and I know I will never forget 
what Colonel Day said to me. He said that, ``I will go anywhere 
I need to go to testify that this treatment has given my 
grandson a quality of life that he would never have had if he 
had not had the hyperbaric treatment.''
    So now this--was the question--I just remember. When do we 
get to the point that we say, meaning Department of Defense, 
that this protocol does help, it does work?
    Admiral Robinson. Congressman Jones, thanks for the 
question. This has been for me as a Surgeon General of the Navy 
a 4-year question. We have looked at hyperbaric oxygen and Dr. 
Harch who has been at several meetings and I have met him many 
times and looked at his results.
    We have invited him to come through and participate 
firsthand in our double-blinded studies so that we can get away 
from the anecdotal results of individual patients, families, 
and other anecdotal lessons, and we can get down to what we 
have to have from an objective and a definitive way so that we 
can base clinical practice guidelines both for the Military 
Health System and also for the private sector. We need to base 
those therapies on objective clinical data that cannot be 
influenced by opinions of people who have benefited, but we 
can't prove that benefit in a scientific way. So we need to 
employ a scientific method.
    What we have done, and I can say that after in my fourth 
year as Surgeon General, we now have studies--we are now 
beginning to produce data from competent studies that look at, 
number one, hyperbaric oxygen seems to be safe, so I think that 
that is a clear improvement in terms of our knowledge. And now 
we need to go and look more deeply at the Air Force study and 
that study has been completed, but the analysis has not been 
done. So I think we are very, very close to getting more data.
    I think when we can get some studies on the record that 
actually look at the efficacy of hyperbaric oxygen therapy, I 
think at that point we can simply say, that is an effective 
treatment, it is not an effective treatment, but it is a 
treatment that can be utilized in complementary medical ways so 
that people who may benefit from it can use it, it certainly 
not going to harm them. We will have an array of answers.
    I think we are literally months away from getting there, 
but it normally takes--and this is one of the issues with 
medicine--it normally takes time to get to where we need to be 
and we have to base it on a scientific method unless, in order 
to keep from having everything become a clinical practice 
guideline, things that are not proven. So the scientific method 
is being utilized in this way.
    Mr. Jones. Thank you, Admiral. Thank you, Mr. Chairman.
    Mr. Wilson. Thank you and next we go to Ms. Pingree of the 
great state of Maine.
    Ms. Pingree. Thank you, Mr. Chair. Thanks for the 
opportunity to discuss these issues with you again in a second 
round. And I just want to say again, I understand how well you 
are all doing your job and the importance of all of you looking 
for cost efficiencies in what you do as we face a difficult 
time with the budget deficit. And also where there is a lot of 
examination of the military budget and looking for places where 
we can cut.
    And maybe my first comment really is more to my fellow 
committee members than to all of you, but I might see more 
places to cut the fat in the military budget than others of my 
colleagues, but I am deeply concerned that we are going after 
medical care for both our Active Duty personnel and our 
retirees when I think there are other places to make more 
effective cuts. So I know you have to do your job and look for 
those cuts, but almost everything that is before us today, 
either myself or one of my colleagues has mentioned a concern 
about, whether it is the changes to TRICARE, how we are going 
to deal with some of our Sole Community Hospitals. I have two 
in my district, there are four in our state of only 1.2 million 
people in a state where we have almost a fifth of our citizens 
are either Active Duty or retired military.
    So there is a very big dependence on this system in our 
state and I am worried about that particular program. So for 
me, many of the efficiencies that you are talking about are 
going to reduce the level of medical care to the people who 
have served us, to whom we have made a huge promise. And there 
is going to be, I think, a reduction in the services that they 
receive, so I just--I know you have to do your job, but I don't 
like it and I don't think it is all necessarily good.
    And the only other program that hasn't been brought up 
today but I might ask you to comment on is the pharmacy co-pay. 
I have seen a little bit about that and know that some of the 
co-pays will be reduced through using mail order pharmacies. I 
have concerns about that as well because I do believe that 
people get better care when they go directly to a pharmacist in 
their community, that is where we catch a lot of redundancies 
or problems with the medications that people are taking, 
particularly with retirees.
    So, in my opinion, having to go to mail order to get your 
pharmaceutical products is not necessarily always good 
treatment or good service. And one of the things I might ask is 
how much the Department is doing to negotiate for better prices 
with the pharmaceutical companies and bringing costs down in 
that way as opposed to this other option? That was my question, 
if you have got any comments about that.
    Dr. Woodson. We continue to have efforts to negotiate with 
pharmaceutical companies. I think in fact that the mail order 
advances care because there is a large percentage of retail 
prescriptions that are never picked up and there are breaks in 
terms of the supply of medications.
    Our proposal not only reduces the cost, but it ensures 
timely supply of medicines and, of course, linked with our 
concept of the Patient-Centered Home, they have a team of 
health care providers that can counsel, coach, monitor their 
medicines. We have new electronic databases that highlight 
medication to medication interactions and notify practitioners 
of medications that may be unsafe.
    So, I think there are a number of things that we are doing 
that are going to enhance the quality of care while reduce the 
costs and provide a better service for the beneficiaries.
    Ms. Pingree. I appreciate your perspective on that. That is 
useful information in thinking about the program. Back to the 
question of negotiating, is that an active activity that goes 
on today, to negotiate for cost-cutting? We still continue to 
pay some of the highest prices in the world in this country for 
prescription drugs and I know the military has done a better 
job of bringing down the costs, but I just--I wonder how 
engaged we are in the process and how much resistance there is 
to it?
    General Schoomaker. Ma'am, I am told that is a commodity 
that is managed through the Defense Logistics Agency and the 
center in Philadelphia. And I am told that the Department of 
Defense has some of the most favorable cost profiles of any 
organization in the United States because of our--because of 
leveraging volume.
    Ms. Pingree. Great. I will take up that issue with them. 
Thank you again for your answers today.
    Mr. Wilson. Thank you and I share your appreciation of 
local pharmacists too. We will conclude with Dr. Joe Heck.
    Dr. Heck. Thank you, Mr. Chairman. And not to belabor the 
issue, but I am going to go back to TBI. First, I appreciate 
the Surgeons General and the academic rigor with which their 
reviewing the HBOT [hyperbolic oxygen therapy] issue and 
please, I encourage you and implore you to keep that academic 
rigorous approach before we make a determination on its 
application.
    No matter how that turns out and no matter what treatment 
process we have in place for TBI, my biggest concern is 
identifying the soldier, sailor, airman, marine who has TBI. 
Based on my deployment to Iraq, when young guys were getting 
their bells run so many times that they had the MACE [Military 
Acute Concussion Evaluation] card memorized, it no longer 
became a valid screening tool because they knew the answers 
before I asked them.
    When I came back, it spurred me to write my joint forces 
staff college paper on TBI entitled ``Re-thinking the Treatment 
Paradigm'' and that was 3 years ago last month. I don't think 
we have come that far in 3 years, as far as we should have, in 
being able to recognize folks suffering from MTBI [mild 
traumatic brain injury].
    I know there was an initiative underway that everyone pre-
deployment was supposed to get cognitive assessment, the ANAM 
[Automated Neuropsychological Assessment Metric] or equivalent. 
Where are we in that process in making sure that everybody 
before they deploy has a baseline cognitive assessment done so 
that we can find the small changes when they come back.
    And then specifically going back to my heart of hearts in 
the Reserve side of the house, it seems it is the reservists 
that are getting lost to the follow-up. They get home, get 
irritable. The spouse or family member saying, ``Well, he is 
just reintegrating. We got to, you know, this is his re-
acclimation process.'' Three months later, he is still 
irritable and then somebody starts to think, ``Well, maybe it 
is something more than just he has been gone for a year.'' But 
by that time, we have lost 3 months of intervention.
    So again, the status of the cognitive assessment pre-
deployment and what are we doing to make sure we don't lose 
reservists to follow-up or it just gets brushed aside as they 
are just getting reintegrated or re-acclimated.
    General Schoomaker. Let me take a stab at this if I might, 
Congressman. First of all, I think we have come a long way in 
the last few years especially with the publication as was 
referred to earlier of the decision type memorandum.
    Early in the war as you may recall, we had clinical 
practice guidelines in the battlefield, but they were not 
mandatory in their application and we failed to recognize that 
the soldier, the marine, the sailor, the airman who was 
actively engaged in battle and was part of the team was very 
reluctant to leave formation, and would celebrate their 
survival of an IED but then would go right back in the fight.
    We now have a mandatory screening tool down range. In our 
recent trip to Afghanistan, we looked at its application and 
how well we are complying with it. We are seeing very good 
acceptance by combatants, by their small unit leaders, all the 
way up to General Petraeus himself. And with resiliency centers 
such as the one that Admiral Robinson mentioned, and we have 
seven in eastern Afghanistan and southern Afghanistan, we are 
seeing rapid turnaround.
    So, we have mandatory screening of a clinical diagnosis 
only, as you know, at this point and then we apply tools like 
the ANAM, the Automated Neurocognitive Assessment Module, to do 
longitudinal tracking of whether they are recovering. We have 
done studies now with the ANAM down range with fresh casualties 
to be able to know that as a screening tool, it is insensitive 
and nonspecific. It misses about a quarter to a third of those 
who are concussed and it includes about 50 percent of people 
who aren't concussed.
    We are doing a head to head evaluation between the ANAM and 
the impact tool that the National Football League uses and so 
many high schools use right now. But you are absolutely right. 
Right now, we have no single definitive test for the diagnosis 
other than the clinical diagnosis of concussion. But we are 
being very much more aggressive. And right over the horizon we 
see biomarkers and other tools that we think will be useful.
    Dr. Heck. Thank you very much. Admiral, did you want to 
answer that?
    Admiral Robinson. I think that General Schoomaker was very 
comprehensive. I will add one piece. We also have the NICOE 
[National Intrepid Center of Excellence] and the Defense Center 
of Excellence that is devoting a great deal of research efforts 
both in the basic science areas and in the areas of trying to 
understand how we can diagnose and then how we can assess and 
treat traumatic brain injury.
    Now, I am not going to mix the two, but PTS is also there 
and it is on the continuum. But I am going to stay with the 
TBI. So I think that we are not only doing the in-theater 
assessments, we are reporting the data, we are actually 
compiling data, reporting it. I think that General Schoomaker 
has emphasized the concussion part because concussion as a 
clinical diagnosis is at least something we can diagnose and 
follow as opposed to just TBI which becomes a little bit more 
difficult to define and understand.
    But with the ANAM and with the MACE, with our professionals 
trained, with the Uniformed Services University deployment 
psychology group training our professionals, just in time 
training as they go over into theater, and with adequate data, 
having the concussion restoration centers, multicomprehensive 
teams, I think we are going to get at least a look at who has 
been involved, how we can do a longitudinal look at them and 
make sure that we can at least follow them even if we can't do 
a lot in terms of understanding how it works now. We don't 
understand this completely, but we are not going to let it go.
    Mr. Wilson. Thank you and I would like to again point out 
how much we appreciate all of you being here today, 
particularly General Schoomaker, Admiral Robinson. We want to 
wish you Godspeed in your future endeavors and again, I think 
it has been so illuminating and we want the best for our 
military, military families and veterans.
    At this time, we are adjourned.
    [Whereupon, at 11:48 a.m., the subcommittee was adjourned.]



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                            A P P E N D I X

                             March 15, 2011

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             March 15, 2011

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


              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             March 15, 2011

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              RESPONSES TO QUESTIONS SUBMITTED BY DR. HECK

    Dr. Woodson. The contracting authority for the contract is the U.S. 
Army Medical Research Acquisition Activity; the office of the Deputy 
Assistant Secretary of Defense for Force Health Protection and 
Readiness administers the contract. (The Reserve Health Readiness 
Program (RHRP) is a Department of Defense (Health Affairs) program 
developed by Force Health Protection and Readiness, and executed by its 
contractor, Logistics Health Inc. (LHI).)
    Unless the Service Components request new services (for example, 
mental health assessments) to augment their readiness, we do not plan 
to modify or re-compete this contract at this time. The Reserve Health 
Readiness Program (RHRP) contract for medical and dental readiness 
services was awarded to Logistics Health Inc. in September 2007, after 
a full and open competition, for a base year and four option years. The 
contract is currently in its third option year. The fourth option year, 
if exercised, will conclude at the end of September 2012.
    The contract for the five-year period is capped at $790,295,941(the 
total value of the orders against the contract cannot exceed that 
amount).
    We can and have documented such value added.
    According to the most recent data from the Office of the Surgeon, 
U.S. Army Reserve Command, readiness rates have never been higher. From 
October 2008 to March 2011, the percentage of Army Reserve soldiers 
with a current Periodic Health Assessment (PHA) has risen from 45 
percent to 88 percent; achieving dental readiness rose from 53 percent 
to 75 percent; and current immunizations increased from 34 percent to 
79 percent. The percent that are medically ready to deploy immediately 
or within 72 hours has similarly risen from 24 percent to 64 percent.
    Overall, the RHRP contract provides a broad array of services in 
response to requests by the Service Components to assist them in 
achieving medical readiness. The contract provides the PHA, Post-
Deployment Health Reassessment, Mental Health Assessment, dental exam, 
dental treatment, and other Individual Medical Readiness services that 
satisfy key deployment requirements and supplement the Services' own 
efforts. Services are provided at the request of the Reserve Components 
and implemented per their guidance. The annual dental examinations, 
annual PHAs, and current immunizations for each Service member are 
required Department of Defense elements for medical readiness.
    For Fiscal Year 2010, RHRP providers addressed approximately 
650,000 reservists and guardsmen across all Military Services--
conducting 218,000 dental examinations, 255,000 PHAs and 372,000 
immunizations. Each of these adds value to medical readiness. [See page 
21.]
?

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


              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             March 15, 2011

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

      
                   QUESTIONS SUBMITTED BY MRS. DAVIS

    Mrs. Davis. Several of the reserve components continue to see 
issues with medical readiness of its force. To ensure the readiness of 
its force, the Air Force National Guard and Reserve requires its 
personnel to be medically ready or they are not allowed to participate 
in drill or training exercises. Should this requirement be extended to 
the Army, Navy and Marine Corps? If not, what efforts should be 
undertaken to ensure the medical readiness of the reserve component?
    Secretary Stanley. No, not at this time and we do not recommend any 
change to the current policy. Preventing service members from attending 
drill or AT may compound the problem. Many commanders use these active 
duty periods for readiness activities that include medical and dental 
appointments. There are also certain aspects, such as annual preventive 
health assessments (PHA), which require members to meet face-to-face 
with military health providers.
    Mrs. Davis. If not, what efforts should be undertaken to ensure the 
medical readiness of the reserve component?
    Secretary Stanley. The instructions may be drafted to ensure 
members can drill or be placed on orders to complete their medical/
dental requirements, but will not drill for training until the issues 
are resolved.
    Reservists may be placed on military orders for the purpose of 
receiving military medical/dental evaluation, or examination. 
Reservists receiving medical/dental care during a tour of duty will be 
voluntarily retained on Active Duty orders to continue treatment. 
Reservists not on military orders may be placed on invitational travel 
orders when directed by appropriate military medical authority to 
receive an examination or evaluation by military medical/dental 
facilities to meet military requirements. Invitational travel orders 
may also be issued to those reservists receiving military medical/
dental care at military medical treatment facilities for the purpose of 
medical/dental appointments.
    Reserve or Active Duty medical units do not extend, authorize the 
extension of, or issue military orders, or invitational travel orders. 
Order issuance or an extension is the responsibility of the commander.
    Mrs. Davis. Can you explain what impact the current continuing 
resolutions are having on the Military Health System and on your 
particular Service?
    Dr. Woodson. While the Department worked vigorously to ensure that 
such stopgap funding measures would not directly impact patient care, 
the resolutions create inefficiencies hinder effective planning efforts 
and exacerbate the operational challenges associated with supporting 
mission requirements. For example, to limit the level of expenditures 
during the continuing resolution periods, the MHS undertook several 
actions including delayed hiring actions, restricted acquisitions, 
deferred life cycle replacements of medical equipment, and limited 
supply replacements.
    Mrs. Davis. Health care costs of the Department continue to grow, 
and is a concern both to the Department and the Congress. Can you break 
down for the subcommittee, the cost growth figures over the past ten 
years? For example, could you determine how much of the health care 
cost growth is due to the increase in end strength for the Army and 
Marine Corps over the past several years, vice an increase in health 
care utilization among the population vice an increase in eligible 
beneficiaries returning to the system? If so, would you please provide 
that information to the subcommittee?
    Dr. Woodson. Excluding Overseas Contingency Operation (OCO) 
funding, health care costs for the Department grew approximately $30 
billion from Fiscal Year (FY) 2000 to FY 2010.
    Generally speaking, 35 percent of that increase was due to medical 
inflation; 36 percent was due to congressionally mandated benefits 
(with TRICARE For Life being the major contributor); 10 percent was due 
to the higher percentage of retirees and their families who are now 
using the Military Health System (MHS) as their primary coverage; and 
20 percent was due to higher utilization and greater intensity of care 
among beneficiaries using the MHS.
    Over that ten-year period, the number of beneficiaries unrelated to 
OCO funding has remained relatively stable or slightly declining, so 
the effect of total population was a small (less than 1 percent) 
reduction. However, the reduction would have been greater if the Army 
and Marine Corps end strength had not increased. Those increases have 
returned 1 to 2 percent of the population to the overall growth.
    Mrs. Davis. What are the strategic issues that the subcommittee 
should be looking at to ensure the success of the military health 
system?
    Dr. Woodson. The leadership of the Military Health System (MHS) has 
developed a strategic framework around which we assess our performance 
across four critical priorities: Readiness, Population Health, Patient 
Experience and Cost.
    For each of these priorities, we have developed a series of 
specific goals, metrics and measures. At the center of our framework is 
readiness--our primary mission and obligation. There are two core 
questions pertaining to this priority: (1) Are the members of the Armed 
Forces medically ready to engage in combat (or non-combat) operations? 
(2) Are the medical forces ready to provide the full-spectrum of 
medical operations worldwide?
    Based on our experience this past decade, we believe the answer is 
``yes'' to each of these questions. We recognize that sustaining top 
performance requires continuous investment in medical research, 
technology, education and information, modernization and human capital 
management.
    Our other strategic issues--population health, patient experience, 
and responsibly managing the cost of care--are interdependent 
priorities. We measure performance against ourselves over time and 
against leading civilian standards in each of these areas. 
Fundamentally, we must improve the health of our population in order to 
better manage costs. Cost control is nearly impossible with a 
population engaging in unhealthy behaviors, and we are seeking to 
change behaviors for all 9.6 million of our beneficiaries.
    Mrs. Davis. Nearly two years after the original protest was filed, 
the Department recently announced the T3 award in the South, which has 
been protested again. What efforts is the Department taking to ensure 
that lessons learned from T3 are not repeated in T4, and can we expect 
that all of the T3 contracts to be successful resolved before the 
Department engages in T4?
    Dr. Woodson. Lessons learned are collected and documented in the 
final phases of the acquisition process. The documented lessons learned 
from previous acquisitions become key inputs to the planning phase for 
subsequent acquisitions. In other words, lessons learned from the 
original T-1 TRICARE contracts influenced the TNEX acquisition strategy 
which, in turn, influenced the T-3 strategy. Lessons learned from the 
TNEX acquisition were collected by a consultant contractor through a 
process that included surveying, interviewing participants and 
publishing a final report. TMA has hired a consultant contractor to 
perform an after-action review of the T-3 source selection evaluation 
process, and may seek a final report comparable to the TNEX product. 
All of this information and the Government Accountability Office (GAO) 
decisions will be provided to the T-4 acquisition strategy team. That 
team will develop an acquisition plan for T-4 that incorporates all the 
lessons learned and GAO findings. In addition, one of the objectives of 
the Peer Review process required by OUSD(AT&L)/DPAP policy is to 
facilitate the sharing of lessons learned and best practices across the 
Department of Defense. All the T-3 and T-4 acquisitions are subject to 
the Peer Review process.
    The first T-3 contract award for the North region included health 
care delivery options through March 31, 2015 and the ability to add 
another calendar year of performance. The South and West regions will 
include option periods that run through at least March 31, 2017. The 
re-evaluation of the West will take a minimum of six and half months, 
but will be accomplished well before the T-3 NORTH contract expires. 
There should also be ample time to accommodate any directions from the 
on-going GAO review of the South region award.
    Mrs. Davis. Several of the reserve components continue to see 
issues with medical readiness of its force. To ensure the readiness of 
its force, the Air Force National Guard and Reserve requires its 
personnel to be medically ready or they are not allowed to participate 
in drill or training exercises. Should this requirement be extended to 
the Army, Navy and Marine Corps?
    Dr. Woodson. No, not at this time and we do not recommend any 
change to the current policy. Preventing service members from attending 
drill or AT may compound the problem. Many commanders use these active 
duty periods for readiness activities that include medical and dental 
appointments. There are also certain aspects, such as annual preventive 
health assessments (PHA), which require members to meet face-to-face 
with military health providers.
    Mrs. Davis. If not, what efforts should be undertaken to ensure the 
medical readiness of the reserve component?
    Dr. Woodson. The instructions may be drafted to ensure members can 
drill or be placed on orders to complete their medical/dental 
requirements, but will not drill for training until the issues are 
resolved.
    Reservists may be placed on military orders for the purpose of 
receiving military medical/dental evaluation, or examination. 
Reservists receiving medical/dental care during a tour of duty will be 
voluntarily retained on Active Duty orders to continue treatment. 
Reservists not on military orders may be placed on invitational travel 
orders when directed by appropriate military medical authority to 
receive an examination or evaluation by military medical/dental 
facilities to meet military requirements. Invitational travel orders 
may also be issued to those reservists receiving military medical/
dental care at military medical treatment facilities for the purpose of 
medical/dental appointments.
    Reserve or Active Duty medical units do not extend, authorize the 
extension of, or issue military orders, or invitational travel orders. 
Order issuance or an extension is the responsibility of the commander.
    Mrs. Davis. Can you explain what impact the current continuing 
resolutions are having on the Military Health System and on your 
particular Service?
    General Schoomaker. The numerous continuing resolution (CR) 
extensions caused a general disruption of operations across the command 
this year. Despite ASD (HA) and OSD (Comptroller) efforts to respond to 
OMB's numerous data calls to validate Service Medical Department 
requests for exception apportionment, the temporary, short-term budgets 
caused activities to defer spending to preserve resources for must-fund 
bills like payroll. Although clinical service delivery was not 
compromised at any time, it appears that this behavior did contribute 
to a slow-down in the growth rate of program improvement required to 
meet the demands of a larger Army with increased benefits, utilization, 
and Wounded, Ill, and Injured workload.
    CR limitations and associated administrative processes have had the 
following impact:

      Slowed down program improvements in access initiatives 
designed to match capacity to escalating demand resulting from 
increased end strength, rising utilization, benefit enhancement, and 
increasing level of effort to manage and process Wounded, Ill, and 
Injured.
      Strained internal compliance with BRAC-directed project 
milestones and/or validation of BRAC-related ``incidental'' costs at 
several locations due to artificial budget execution masking actual 
conditions.
      Delays in the augmentation of Occupational Health/
Industrial Hygiene capability to address previously neglected remote 
area services for the Army's at-risk civilian workforce.
      Delays in Initial Outfitting and Facility transition of 
medical treatment facilities generated by extensive investment in 
MILCON and renewal projects in previous years.
      Delays in implementation of the enhanced, integrated 
Disability Evaluation System designed to streamline disability 
processing of separating service men and women.
      Delayed full-scale implementation of the Comprehensive 
Pain Management Plan.

    Mrs. Davis. Given the reductions in the Services recruiting and 
retention budgets, how are you ensuring that we continue to recruit and 
retain the qualified medical providers that are necessary to support 
the military health care system?
    General Schoomaker. The mission to recruit our military health care 
providers rests with United States Army Accession Command. To date, we 
have received no indication of any significant funding constraints 
placed upon them that would affect recruitment of health care 
professionals. We have no indication that there will be any reduction 
in the number of health care recruiters in the field or that the 
funding to support them will be significantly decreased.
    The Office of The Surgeon General is working diligently to maintain 
the level of funding support for the health professions officer special 
pays that are critical to the recruiting and retention efforts of the 
past years. As the Assistant Secretary of Defense for Health Affairs 
converts the Services programs from the legacy Special Pays to the 
Consolidated Special Pays, we do not anticipate any support for growth 
within these pays; however, we believe that in the near term we will be 
able to maintain the status quo. This includes support for the Health 
Professions Officer Accession and Retention Bonuses for Clinical 
Psychologists, Clinical Social Workers, Physician Assistants, and 
Veterinarians, as well as the Critical Wartime Skills Accession Bonus 
for Physicians and Dentists.
    Mrs. Davis. As your Services move toward the Patient-Centered 
Medical Home (PCMH) concept, how will deployments of providers impact 
this process? Will PCMH providers need to be civilian or contract 
providers in order to maintain continuity of care?
    General Schoomaker. By limiting the size of our PCMH teams to 3-5 
Primary Care Providers and ensuring a variable mix of military, 
civilian and contract providers, the Army decreases the impact of a 
military provider's deployment and relies upon the PCMH team to provide 
the patients with continuity of care. One of the core principles of the 
PCMH model is to ensure that there is a standardized, consistent and 
continuous relationship between the patient and the PCMH team which 
includes the assigned provider as well as the designated support staff. 
Under this model, providers deploy with the units to which they are 
assigned, providing Soldiers continuity of care before, during, and 
after the deployment. The Army does have a number of providers who will 
deploy with other units and in these situations other providers in the 
PCMH provide coverage during the deployment.
    Mrs. Davis. Where are [we] on the transition and closure of Walter 
Reed, and is the Army, Navy, and the Joint Task Force on National 
Capitol Region Medical (JTF CAPMED) prepared to ensure an orderly 
transition by September of this year?
    General Schoomaker. The majority of the medical Base Closure and 
Realignment (BRAC) construction at both the Bethesda and Fort Belvoir 
sites is complete. Current progress indicates that they will be 
finished in time to transition patients and clinical functions from 
Walter Reed Army Medical Center (WRAMC) by September 15, 2011. The 
Army, JTF CapMed, and the other Services are working together to ensure 
an orderly transition. Patient care and patient safety remain the top 
priorities related to the move and all stakeholders continue to pay 
close attention to the timeliness and milestones necessary to achieve 
the final moves.
    Mrs. Davis. The U.S. Olympic Committee's Paralympic Military 
Program provides our wounded warriors the ability to compete in several 
adaptive sports. However, I understand that funding challenges may 
affect the future of this program. What efforts, if any, are the 
Services taking to ensure that such opportunities continue for our 
wounded warriors?
    General Schoomaker. The Army leverages the U.S. Olympic Committee's 
(USOC) Paralympics' Military Program as a critical complement in our 
efforts to improve the quality of life of our injured Soldiers while 
they are on active duty and during their transition to civilian life. 
The Army is addressing the future funding challenge by pursuing funding 
through the Defense Health Program for Adaptive Non-Clinical 
Reconditioning Activities (ANCRA). ANCRA includes Warrior Games 
participation and associated costs, pre-Warrior Games clinics and 
training camps, adaptive adventure training, the Army Center for 
Enhanced Performance (ACEP) trainers, and adaptive equipment. The goal 
is to instill ANCRA into the warrior care rehabilitation process.
    Mrs. Davis. The Integrated Disability Evaluation System (IDES) 
started as a pilot program, and has recently been expanded across the 
country. While the program goals are to reduce the time wounded 
warriors spend going through the disability process, I understand that 
timelines have actually increased. What are the challenges each of your 
medical systems have been seeing as the IDES program has been 
implemented? What improvements have been made under the program? What 
challenges still remain under the program?
    General Schoomaker. The Army population that requires entrance to 
the physical disability evaluation system continues to grow and 
challenge our capacity to process them in a timely manner. The Army 
continues to take the necessary steps to address the challenges of the 
IDES program and has implemented numerous practices and process 
improvements to improve physical disability evaluation processing 
times. These improvements include: the development and implementation 
of a new IDES Narrative Summary format; implementation of the Medical 
Evaluation Board (MEB) processing guidance to standardize the MEB 
processes; assignment of dedicated MEB Physicians; improving staffing 
shortages; the implementation of the electronic Medical Board (eMEB) in 
July 2010; and the development of the IDES Implementation Plan that 
requires Senior Commanders play a central role in certifying that a 
IDES site is fully resourced, staffed, trained and ready to meet 
processing standards prior to Initial Operating Capability date. The 
major challenge is that the disability evaluation system remains 
complex.
    Mrs. Davis. Can you explain what impact the current continuing 
resolutions are having on the Military Health System and on your 
particular Service?
    Admiral Robinson. We continue to face challenges associated with 
operating under a potential continuing resolution for the remainder of 
the year, particularly in the areas of provider contracts and funding 
for facility special projects. The Defense Health Program (DHP) has 
taken specific actions as a result of the continuing resolution 
including: reducing the number of hours for patient care provider 
contracts; limiting medical facilities sustainment/maintenance 
contracts to only ``life safety'' implications; deferring life cycle 
replacement of medical equipment; maximizing utilization of existing 
inventory of supplies and medicines; and limiting quantity of 
replacement pharmaceuticals. We continue to work with ASD (HA) to 
mitigate adverse effect on the quality and timeliness of healthcare 
provided to military members, retirees, and their families.
    Mrs. Davis. Given the reductions in the Services recruiting and 
retention budgets, how are you ensuring that we continue to recruit and 
retain the qualified medical providers that are necessary to support 
the military health care system?
    Admiral Robinson. Navy active duty (AC) medical recruiting has been 
successful in attaining overall accession goal in FY09 and FY10, and 
retention has been relatively stable across all health professions. 
Recruiting is projected to meet most FY11 goals for active component 
Medical Corps officers; however, direct accession physicians and 
dentists present challenges. Recruiting medical and dental students for 
the Health Professions Scholarship Program (HPSP) is the most vital 
contributor to Navy physician and dentist inventory, accounting for 
more than 80 percent of active duty accessions into the Medical and 
Dental Corps. Medical and dental HPSP accessions have been successful 
over the past two years due, in large part, to a $20,000 signing bonus.
    Targeted special and incentive pays and bonuses are offered at 
critical career points to incentivize retention behavior. Medical 
Special and Incentive pays are critical to maintaining Navy Medicine 
professional inventory--doctors, dentists, nurses, psychiatrists, 
clinical social workers, and other providers.
    Direct appointment recruiting of physicians and dentists for both 
active and reserve forces remains a challenge, primarily because these 
healthcare professionals have well-established medical practices and 
are very well compensated in the civilian market. Interrupting their 
civilian medical careers is often personally and financially 
unattractive to many private medical providers. In the case of both AC 
and RC Physician and Dentist recruiting, a credible recruiting bonus is 
critical to attracting these professionals.
    We continue to evaluate the financial incentives within budgetary 
constraints to target specific communities that are, and will remain, 
critical to our mission.
    Mrs. Davis. As your Services move toward the Patient-Centered 
Medical Home (PCMH) concept, how will deployments of providers impact 
this process? Will PCMH providers need to be civilian or contract 
providers in order to maintain continuity of care?
    Admiral Robinson. As Navy continues to implement the Patient-
Centered Medical Home (PCMH) model, we are seeking to structure the 
teams in a way that sustains deployment of military providers in 
support of operational commitments, while ensuring continuity of care 
for Navy beneficiaries assigned to the PCMH team.
    Navy's approach has been to build PCMH teams that have both 
military and civilian (civil service and contract) assets integrated. 
Ideally, 50 percent of staffing on a Navy PCMH team is civilian, 
ensuring stability within the team that can withstand deployments, 
supports continuity while providing patient and family-centered care.
    When an active duty PCMH provider deploys, Navy Medical Treatment 
Facilities (MTFs) are encouraged to use a strategy successfully applied 
at other sites. A contract provider is hired to cover the deployed 
provider's panel of patients (in a locum tenens type arrangement) and 
works within the PCMH team during the provider's absence. This allows 
the patient to keep the same primary care manager (PCM) during the 
deployment, but have identified coverage during their PCM's absence; 
patients can be notified of their PCM's pending deployment, length of 
absence and the provider providing temporary coverage using blast 
secure patient messaging.
    When the deployed provider returns to the MTF, patient's can once 
again be notified regarding their pending return using secure 
messaging; the contract provider can then be utilized elsewhere in the 
MTF to cover another provider's practice while they deploy.
    Mrs. Davis. Where are [we] on the transition and closure of Walter 
Reed, and is the Army, Navy, and the Joint Task Force on National 
Capitol Region Medical (JTF CAPMED) prepared to ensure an orderly 
transition by September of this year?
    Admiral Robinson. Navy is committed to the successful transition of 
the new Walter Reed National Military Medical Center (WRNMMC) onboard 
the campus of the National Naval Medical Center, Bethesda. This 
realignment is significant and we are working diligently with DoD's 
lead activity, Joint Task Force Medical--National Capital Region, NSA 
Bethesda and WRAMC staff to ensure we are on track to meet the Base 
Realignment and Closure (BRAC) deadline of 15 September 2011.
    Mrs. Davis. The U.S. Olympic Committee's Paralympic Military 
Program provides our wounded warriors the ability to compete in several 
adaptive sports. However, I understand that funding challenges may 
affect the future of this program. What efforts, if any, are the 
Services taking to ensure that such opportunities continue for our 
wounded warriors?
    Admiral Robinson. All Service components collaborate with 
organizations outside the United States Olympic Committee (USOC), 
including Paralyzed Veterans of America, Challenged Athletes 
Foundation, Team Semper Fi (which supports Sailors, as well as 
Marines), Disabled Sports USA and the Lakeshore Foundation. These, 
along with numerous other adaptive sports organizations, offer 
competition opportunities and training in adaptive athletics for 
wounded warriors. Additionally, Navy Safe Harbor has appointed an 
Adaptive Athletic Program Manager and Headquarters Transition 
Coordinator, to include adaptive athletics opportunities in the 
rehabilitation plans of Sailors. In FY11, Safe Harbor has executed two 
adaptive athletic training camps at Naval Base Port Hueneme, CA.
    Mrs. Davis. The Integrated Disability Evaluation System (IDES) 
started as a pilot program, and has recently been expanded across the 
country. While the program goals are to reduce the time wounded 
warriors spend going through the disability process, I understand that 
timelines have actually increased. What are the challenges each of your 
medical systems have been seeing as the IDES program has been 
implemented? What improvements have been made under the program? What 
challenges still remain under the program?
    Admiral Robinson. The IDES process is achieving the primary goals 
that were intended when this process was designed in 2007. Most notable 
of these goals is that our Sailors and Marines receive both their post-
service military and Veterans Administration benefits on the first day 
authorized by law. This eliminates the ``benefits gap'' experienced 
under the previous DES system. To achieve this significant benefit, the 
IDES process has the secondary impact of keeping our service members in 
uniform for a longer period of time. This is a concern because the 
length of time needed to process cases has direct proportional adverse 
impact on the services' readiness for their military mission. Those in 
the IDES spend longer in uniform which, for any given end-strength, 
reduces the number of active duty available for unrestricted 
assignment. Therefore, in the near term a principle focus must be on 
reducing the amount of time consumed by the process itself without 
debasing what we do for our Wounded, Ill and Injured (WII) service 
members.
    The simplest and most direct means of monitoring the IDES process 
is through the observation of case flow--the time service members' 
cases spend transiting the IDES' waypoints. Tracking and evaluating 
process time brings clarity for resourcing decisions and process 
improvements. To this end, based on a review of data from IDES 
operations over the past six months (period ending March 31, 2011), we 
would like to reduce the average time taken by the Medical Evaluation 
Board (MEB) Phase of the IDES by approximately 100 days. However, since 
some of the processing events occurring within this phase are 
controlled by the Military Treatment Facilities (MTFs) and some are 
controlled by the Veterans Administration, reducing the average MEB 
Phase time requires both Departments to ensure resources and internal 
processes are aligned to support timeliness goal.
    To significantly reduce the overall processing time, Navy Medicine 
has implemented four main improvement initiatives. Navy Medicine has 
highlighted MTF MEB timeliness as a Strategic Goal, providing increased 
awareness by reviewing monthly metrics. Development of a SharePoint 
tool will allow for enhanced program management of data between the MTF 
and Veterans Tracking Application data. Thorough evaluation of MTF 
business practices and throughput has allowed for identification for 
appropriate resourcing to address areas of need. Additionally, 
innovations to leverage existing programs, technologies, and resources 
are ongoing, such as the use of Armed Forces Health Longitudinal 
Technology Application (AHLTA) electronic medical record vice narrative 
summaries. Finally, the Department of the Navy has recommended specific 
changes to ``remodel'' the IDES. This IDES Remodel allows us to keep 
what is good about the current IDES process while making needed 
improvements and renovations. The recommended IDES Remodel can be 
implemented under current laws, avoids any post-service benefit gap, 
maintains the service member's due process rights and can be completed 
in significantly less time required by the current IDES process. This 
remodel is currently under review by both DoD and the VA for possible 
near-term implementation. By seizing process design change 
opportunities, properly resourcing the processes we decide to deploy 
and better leveraging existing capabilities, both the WII service 
member and readiness for our military mission will benefit.
    Mrs. Davis. Can you explain what impact the current continuing 
resolutions are having on the Military Health System and on your 
particular Service?
    General Green. Contracting: The Air Force Medical Service (AFMS) is 
holding $62M in contracting actions until we have an approved budget. 
The more we delay passing an appropriations act, the more pressure and 
undue burden is placed on the Air Force Base Contracting Office to get 
the contracting documents processed once a full budget is received.
    Restoration and Modernization (R&M): The AFMS programmed $61.4M for 
R&M projects. Under the numerous FY11 Continuing Resolutions (CRs), the 
AFMS has only released $34M for emergency military treatment facility 
repairs or time sensitive facility renovation. Additionally, the AFMS 
has approximately $120M in estimated R&M projects that still need to be 
completed. If full year funding is not received in FY11, the AFMS will 
be forced to put R&M projects at risk to fund higher priority issues. 
Withheld R&M funds will be used to offset lack of funding for patient 
care and other urgent bills. If CRs continue, the AFMS may not be able 
to fund R&M in FY11. The lack of FY11 funding will simply push the 
requirement into FY12 at a potentially higher cost.
    Medical Equipment: The AFMS has minimized medical equipment 
purchases to emergency items only during the numerous CRs. AFMS 
programmed $75M and have currently only funded $2M for emergency 
equipment buys to prevent mission stoppage and prevent patient safety 
issues.
    Administrative: The numerous CRs place an exorbitant amount of 
extra work to process documents. It is comparable to having six fiscal 
year closeouts in one year.
    Mrs. Davis. Given the reductions in the Services recruiting and 
retention budgets, how are you ensuring that we continue to recruit and 
retain the qualified medical providers that are necessary to support 
the military health care system?
    General Green. Reductions in the recruiting and retention budgets 
for the Services add to a challenging environment for accessing and 
retaining health care professionals. Air Force (AF) recruiting is 
limited by many of the same shortages the Nation faces in health care 
professions such as: nursing, general surgery, family practice, 
psychology, and oral maxillofacial surgery. Our recruiting difficulties 
lie in accessing fully qualified professionals, not our training 
pipelines. We face keen competition for fully qualified specialists 
from the private sector and other Federal agencies where multiple 
deployments are not an issue, such as the Department of Veterans 
Affairs hospitals and the Public Health Service. Also, there are 
significant pay disparities between military and private sector 
employers, especially those surgical specialties crucial for wartime 
support. These disparities hinder our ability to retain experienced 
providers. The changing demographics of health professions with 
increased numbers of women entering the profession, who may be less 
inclined to choose military service, provide a challenging environment 
in which to recruit. Additionally, current data suggests less than 7 
percent of eligible graduates consider entering military service.
    Using feedback from exit interviews and informal counseling as well 
as our experiences with various incentives, the Air Force Medical 
Service (AFMS) confronts the recruiting and retention challenges in a 
three-pronged approach addressing: (1) education, (2) compensation, and 
(3) quality of life.
    (1)  Education: Due to historical difficulties recruiting fully 
qualified specialists, the AFMS deliberately places increased emphasis 
and funding into educational scholarship opportunities rather than 
continually focusing on a manpower intensive program that has shown 
only moderate success. With this change, we have found great success in 
``growing our own,'' either through the scholarship programs or through 
training in the Uniformed Services University of Health Sciences 
(USUHS). Historically the highest retention occurs when we control the 
educational environment and service obligations associated with these 
advanced training programs. The Health Professions Scholarship Program 
(HPSP) is a resounding success with over 1,400 students currently 
enrolled, projected to be 1,568 by the end of this fiscal year. As 
reflected in the DOD budget for FY13, AF has a programmed budget to 
support an ultimate increase to 1,666 students. We have also optimized 
our enlisted commissioning programs, such as the InterService Physician 
Assistant Program (37 graduates per year) and the Nurse Enlisted 
Commissioning Program (50 graduates per year). Additionally, the AF 
receives small numbers of new health professionals through other 
training venues, such as the Airman Education Commissioning Program, 
Reserve Officer Training Corps, and United States Air Force Academy. 
The Nurse Transition Program is a robust recruiting tool. It provides 
an incentive for new graduates to consider AF nursing as a career 
option upon graduation. However, there are various limitations with our 
training programs. As a result of fiscal guidance from AF and Congress, 
under Section 2124 of Title 10, HPSP enrollment DoD-wide is capped at 
6000 students. USUHS programs have physical constraints of the facility 
and academic accreditation constraints of oversight committees. Third, 
enlisted commissioning programs are constrained by the number of 
training-years programmed and funding against all enlisted training. 
Even with these limitations, education has proven the most successful 
avenue of accession and retention of health professionals.
    (2)  We also seek to entice fully qualified specialists into the AF 
and retain them through competitive compensation using accession 
bonuses and other financial incentives. Under the auspices of Health 
Affairs, the AF has funded accession bonuses and incentive pays to 
target fully qualified specialists in selected areas. For FY11, the AF 
has sufficiently budgeted $13M towards accession bonuses for personnel 
in fully qualified critical specialties based on historical rates of 
accession. Historically, as outlined in the first paragraph and under 
section (1), above, our physician and dental specialist accession 
bonuses have been of limited success due in part to statutory bonus 
restrictions, as section 301d and 301e of Title 37 are mutually 
exclusive of section 302k and 302l of Title 37. Because these accession 
bonuses cannot be taken with a multiyear special pay, only 2 of 22 
fully qualified physicians entering in FY10 took the accession bonus. 
Our dental officer recruiting had limited success with 10 of 14 fully 
qualified dentists accessed in FY10; however, none of them took the 
accession bonus due to the statutory restrictions. In contrast, with 
new accession bonuses and incentive pays, our nursing program had great 
success with 296 selected out of 290 requirements. Overall, we have 
found compensation helps, but does not entirely ease the burden of 
multiple deployments. As we migrate our compensation portfolio under 
the new pay authority of section 335 of Title 37, we will be able to 
initiate specialty pays for the mental health care providers and other 
critical wartime or shortage specialties that previously were excluded 
from accession and incentive pays. We feel this move will be of great 
benefit to the Air Force and military health care in general, allowing 
targeted accession bonuses, incentive pays, and retention bonuses to 
address the manning shortages in the health professions. Due to the 
complexity of medical specialty and incentive pays and entitlements, 
the scheduled migration of these contractual agreements under the 
Assistant Secretary of Defense, Health Affairs, will take time to fully 
implement. In general, recruiting success of many fully qualified 
specialists without accessions bonuses is extremely limited.
    (3)  Finally, no recruit enters, and few medical providers stay in 
the military, without discussing quality of life issues, whether this 
is family services, medical practice, educational or leadership 
opportunities, or frequency of moves and deployments. We address many 
of these issues amongst the AF agencies. Ongoing AFMS projects include 
the Family Health Initiative, which is a medical model that better 
leverages our personnel. In addition, we are building force sustainment 
models in collaboration with AF Manpower and Personnel, evaluating 
promotion opportunities, and developing a more proactive approach to 
provide additional opportunities for advancement. In specialties with 
increasing wartime deployments, we are better able to distribute the 
deployment requirements more evenly among our members. Restructuring of 
our medical groups and the deliberate force development of our 
personnel allow increased opportunities for all health professions to 
become leaders in the AF.
    We remain committed to providing the best in health care for our 
Nation' s military and their family members through enhanced recruiting 
and retention efforts maximizing the tools provided for education, 
compensation and creative quality of life efforts of new health 
professionals.
    Mrs. Davis. As your Services move toward the Patient-Centered 
Medical Home (PCMH) concept, how will deployments of providers impact 
this process? Will PCMH providers need to be civilian or contract 
providers in order to maintain continuity of care?
    General Green. PCMH providers do not need to be civilian. In the 
Air Force Medical Service most of the PCMH providers are active duty 
and roughly 10% of these providers are deployed at any given time. In 
the past year, we have averaged 32 family physicians deployed, with 
overlap of rotations transiently raising this level as high as 40-45 
for periods of 1-2 months. With a current workforce of 299 family 
physicians in clinical billets, this is over a 10 percent loss of 
family physicians. This loss is compounded by the fact that our current 
fill rate for active duty family physician billets is 78.6 percent.
    Hiring of replacements for these deployed providers with overseas 
contingency operations (OCO) funding has met with varied success 
depending on location. At locations where hiring has occurred, the 
impact on PCMH has been lessened. The presence of these civilian 
providers who fill in for the deployed provider decreases the impact, 
but there is still an impact on continuity. At locations where hiring 
has not occurred, these deployments cause not only loss of continuity, 
but also some diminution in access to care.
    While the use of civilian and contract providers in Air Force 
military treatment facilities (MTFs) is and will continue to occur, we 
have a large number of Air Force MTFs in locations where hiring of 
quality civilian providers has consistently been difficult. As such, we 
will continue to balance the use of active duty providers in addition 
to civilian and contract providers.
    Mrs. Davis. The U.S. Olympic Committee's Paralympic Military 
Program provides our wounded warriors the ability to compete in several 
adaptive sports. However, I understand that funding challenges may 
affect the future of this program. What efforts, if any, are the 
Services taking to ensure that such opportunities continue for our 
wounded warriors?
    General Green. We budgeted approximately $85K to support the 2011 
Warrior Games to cover coaching support and travel expenses for our 
athletes attending the two Air Force training camps.
    With the help of OSD, we have funded adaptive equipment for 
archery, track and field, aquatic lifts for swimming pools, basketball, 
volleyball, and a variety of cardio equipment for our wounded warriors 
and customers with disabilities. In addition, we send 20 Air Force 
personnel each year to Penn State University to received training on 
inclusive recreation. Penn State University provides them with 
fundamental skills sets which allow them to offer programs and services 
to meet the needs of Air Force community members with disabilities. We 
will continue to support programs serving our wounded warriors.
    Mrs. Davis. The Integrated Disability Evaluation System (IDES) 
started as a pilot program, and has recently been expanded across the 
country. While the program goals are to reduce the time wounded 
warriors spend going through the disability process, I understand that 
timelines have actually increased.
    General Green. The legacy Disability Evaluation System (DES) which 
includes a separate Department of Defense (DoD) and Veterans Affairs 
(VA) process, takes 500 days to completely process a service member's 
case through the DES. The estimated timeline for processing cases 
within the IDES is 295 days however, the Air Force is currently 
processing cases within 340 days; a 160 day improvement from the legacy 
DES. While the IDES timeline has drastically decreased to less than a 
year, the AF is committed to continue and improve the IDES process. We 
expect the timeline for the IDES process to continue to decrease as we 
implement ``lessons learned'' from the other sites during the rollout 
process.
    Mrs. Davis. What are the challenges each of your medical systems 
have been seeing as the IDES program has been implemented?
    General Green. Within the Air Force Medical Service (AFMS), the 
greatest challenge is completing the Medical Evaluation Board (MEB) 
package that is ultimately submitted to the Informal Physical 
Evaluation Board (IPEB). There are several variables affecting the 
completion of the MEB package. They are:

      Completion of the Compensation and Pension (C&P) 
examination from the VA:
        Predominantly, these exams are complete, but there are 
        instances when a health condition has not been thoroughly 
        evaluated and/or another condition is identified requiring 
        further examination before the MEB Narrative Summary (NARSUM) 
        can be written.
      Military Treatment Facility (MTF): Continuity of care is 
sometimes a challenge. For example, if a physician deploys or changes 
duty stations before completing a NARSUM, a new physician must be 
assigned the case and allowed time to become familiar with the medical 
history before writing the NARSUM.
      Unit Commander: The MEB package must include input from 
the Airman's unit commander. The Commander's letter provides the IPEB 
with insight on the Airman's health condition such as, how it affects 
his or her ability to perform duties, and the impact on the 
distribution of workload within the unit. If the Commander's input is 
not received in a timely manner, the Physical Evaluation Board Liaison 
Officer (PEBLO) must track it down before forwarding the MEB package.
      Line of Duty (LOD) determinations: For Reserve Component 
members, the health conditions that caused the MEB referral must be 
accompanied by a LOD determination to determine if the injury or 
illness was incurred in the LOD and was not as a result of negligence 
or misconduct. Delays in completing the LOD determination will 
inadvertently delay the MEB package.

    Mrs. Davis. What improvements have been made under the program?
    General Green. Within the AFMS, PEBLOs are being encouraged to be 
more proactive in securing the NARSUM from military physicians and to 
engage the Medical Director's for assistance before the MEB becomes 
late. For MTFs with increasing MEB workload, additional PEBLOs are 
being hired or other assigned personnel from within the MTF are being 
directed to assist with case management and/or administrative 
requirements. Additionally a comprehensive training website is already 
available for the PEBLOs. The website includes MEB guidance, training 
slides, and other tools. Lastly, training for physicians involved in 
the MEB process has also been developed. Physicians may access 
pertinent information under the AFMOA SGH Link on the Knowledge 
Exchange, which is a separate location from the PEBLOs.
    Mrs. Davis. What challenges still remain under the program?
    General Green. The main challenge is the time it takes to process 
Airmen through the IDES. Although the IDES has drastically improved its 
timeline, the overall IDES process remains cumbersome and lengthy. To 
improve the overall IDES process, OSD (P&R) directed a working group 
comprised of all the Services, in collaboration with the VA, to focus 
on reducing the IDES timelines. Other improvement objectives are to 
properly resource activities and better leverage existing capabilities 
to ensure Airmen with service-incurred or service-aggravated 
disabilities are expeditiously processed through the IDES.
    Mrs. Davis. Your testimony indicates that the Air Force will begin 
to add 36 full-time Special Needs Coordinators at 35 medical treatment 
facilities to assist families with a special needs child. Since these 
coordinators are not expected to be brought on-board until October of 
this year, what is currently in place to assist families with special 
needs?
    General Green. There are currently Special Needs Coordinators 
appointed by the Medical Treatment Facility (MTF) Commanders at each 
MTF available to assist sponsors and special needs family members. 
These have traditionally been Mental Health officers who performed this 
role as an additional duty. Given the increased demands now seen for 
Mental Health, Air Force (AF) determined additional manning is needed 
to provide dedicated support to uniformed personnel who have a special 
needs child or spouse. Additionally, AF is incorporating the use of 
existing Health Care Integrators, Case Managers or Utilization Managers 
to provide specific support to families with special needs until the 
new coordinator being brought on board is in place and to provide 
support at those installations that will not receive a full-time 
Special Needs Coordinator.
                                 ______
                                 
                    QUESTIONS SUBMITTED BY DR. HECK
    Dr. Heck. Who is the formal approving authority for the LHI 
Contract?
    Dr. Woodson. The contracting authority for the contract is the U.S. 
Army Medical Research Acquisition Activity; the office of the Deputy 
Assistant Secretary of Defense for Force Health Protection and 
Readiness administers the contract. The Reserve Health Readiness 
Program (RHRP) is a Department of Defense (Health Affairs) program 
developed by Force Health Protection and Readiness, and executed by its 
contractor, Logistics Health Inc. (LHI).
    Dr. Heck. Is the Army considering any other options or 
modifications to the contract?
    Dr. Woodson. No. Unless the Service Components request new services 
(for example, mental health assessments) to augment their readiness, we 
do not plan to modify or re-compete this contract at this time. The 
Reserve Health Readiness Program (RHRP) contract for medical and dental 
readiness services was awarded to Logistics Health Inc. in September 
2007, after a full and open competition, for a base year and four 
option years. The contract is currently in its third option year. The 
fourth option year, if exercised, will conclude at the end of September 
2012.
    Dr. Heck. What is the overall cost of the contract?
    Dr. Woodson. The contract for the five-year period is capped at 
$790,295,941 (the total value of the orders against the contract cannot 
exceed that amount).
    Dr. Heck. How can we document whether or not the LHI contract has 
provided any value added service to our medical readiness?
    Dr. Woodson. According to the most recent data from the Office of 
the Surgeon, U.S. Army Reserve Command, readiness rates have never been 
higher. From October 2008 to March 2011, the percentage of Army Reserve 
soldiers with a current Periodic Health Assessment (PHA) has risen from 
45 percent to 88 percent; achieving dental readiness rose from 53 
percent to 75 percent; and current immunizations increased from 34 
percent to 79 percent. The percent that are medically ready to deploy 
immediately or within 72 hours has similarly risen from 24 percent to 
64 percent.
    The Reserve Health Readiness Program (RHRP) contract provides a 
broad array of services in response to requests by the Service 
Components to assist them in achieving medical readiness. The contract 
provides the Periodic Health Assessment (PHA), Post-Deployment Health 
Reassessment, Mental Health Assessment, dental exam, dental treatment, 
and other Individual Medical Readiness services that satisfy key 
deployment requirements and supplement the Services' own efforts. 
Services are provided at the request of the Reserve Components and 
implemented per their guidance. The annual dental examinations, annual 
PHAs, and current immunizations for each Service member are required 
Department of Defense elements for medical readiness. For Fiscal Year 
2010, RHRP providers addressed approximately 650,000 reservists and 
guardsmen across all Military Services, conducting 218,000 dental 
examinations, 255,000 PHAs, and 372,000 immunizations. Each of these 
adds value to medical readiness.
    The Army Reserve leadership uses the RHRP almost exclusively for 
its medical readiness services. According to the most recent data from 
the Office of the Surgeon, U.S. Army Reserve Command, its readiness 
numbers have never been higher. From October 2008 to March 2011, the 
percentage of Army Reserve soldiers with a current PHA has risen from 
45 percent to 88 percent, achieving dental readiness rose from 53 
percent to 75 percent, and current immunizations increased from 34 
percent to 79 percent. The percent that are medically ready to deploy 
immediately or within 72 hours has similarly risen from 24 percent to 
64 percent.

                                  
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