[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 114-84]
MILITARY TREATMENT FACILITIES
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON MILITARY PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
FEBRUARY 3, 2016
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
U.S. GOVERNMENT PUBLISHING OFFICE
98-912 WASHINGTON : 2016
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SUBCOMMITTEE ON MILITARY PERSONNEL
JOSEPH J. HECK, Nevada, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
JOHN KLINE, Minnesota ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice JACKIE SPEIER, California
Chair TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
Jeanette James, Professional Staff Member
Craig Greene, Professional Staff Member
Colin Bosse, Clerk
C O N T E N T S
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Page
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman,
Subcommittee on Military Personnel............................. 1
WITNESSES
Freedman, CAPT Rick, USN, Commanding Officer, Naval Hospital Camp
Lejeune, United States Navy.................................... 5
Heimall, COL Michael S., USA, Chief of Staff, Walter Reed
National Military Medical Center, Defense Health Agency........ 3
Littlefield, Col Douglas M., USAF, Commander, 19th Medical Group,
Little Rock Air Force Base, United States Air Force............ 7
Place, COL Michael L., USA, Commander, Madigan Army Medical
Center, Joint Base Lewis-McChord, United States Army........... 4
APPENDIX
Prepared Statements:
Freedman, CAPT Rick.......................................... 59
Heck, Hon. Joseph J.......................................... 37
Heimall, COL Michael S....................................... 39
Littlefield, Col Douglas M................................... 70
Place, COL Michael L......................................... 49
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Dr. Heck..................................................... 83
Mr. MacArthur................................................ 83
Questions Submitted by Members Post Hearing:
[There were no Questions submitted post hearing.]
MILITARY TREATMENT FACILITIES
----------
House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Wednesday, February 3, 2016.
The subcommittee met, pursuant to call, at 2:03 p.m., in
room 2212, Rayburn House Office Building, Hon. Joseph J. Heck
(chairman of the subcommittee) presiding.
OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM
NEVADA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL
Dr. Heck. I will go ahead and call the hearing to order.
Good afternoon, everyone.
Today's subcommittee meets to hear testimony on military
treatment facilities, or MTFs, which are the medical centers,
hospitals, and clinics that are owned and operated by the
Department of Defense and the military services.
For decades, military treatment facilities have been
recognized as the foundation of military medical care. They are
the primary location for Active Duty military to receive
treatment and are the training and education platforms for
medical providers worldwide.
Every member of the military healthcare team, me included,
has spent time in MTFs. If you have served in the military,
chances are you have received care in an MTF for everything
from immunizations, to routine health screenings prior to
deploying, to witnessing the birth of your child. Depending on
the size and location, MTFs provide a wide range of medical
services to Active Duty, Active Duty family members, retirees,
and retiree family members.
However, military health care, alongside civilian health
care, has evolved, and we have seen many changes to MTFs. The
certainty that a military installation will have a full-service
medical facility is a thing of the past. For example, in 1989,
there were more than 500 military medical facilities worldwide,
168 military hospitals and hundreds of clinics. Today, there
are 55 hospitals and 360 clinics, for a total of 415 MTFs.
Large medical centers, such as Fitzsimons Army Medical Center,
once considered an enduring capability, have closed.
The reasons for some of these changes are varied. Health
care has largely shifted from an inpatient focus to outpatient
settings such as ambulatory surgery and care models such as
patient-centered medical homes. Another reason unique to
military medicine is the realignment of troop units and closure
of military installations, which has shifted the need for
medical care among different locations.
So the question we now ask is: What is the future of
military treatment facilities? How do they maintain the primary
mission of readiness of the force and ready medical
professionals? Are MTFs currently situated to support the
readiness mission along with the mission to provide care to
their beneficiaries?
I am interested to hear from our witnesses about the
challenges of running an MTF. How are MTFs different than
civilian medical facilities? How does MTF leadership balance
readiness requirements and the needs of the beneficiary
population, including service members, family members, and
retirees?
And, finally, what can we do to ensure the Military Health
System has trained and ready providers to support the readiness
of the force and provide a valued health benefit to our
beneficiaries?
With that, I want to welcome our witnesses, and I look
forward to their testimony.
Before I introduce our panel, I would like to offer
Congresswoman Susan Davis, our ranking member from San Diego,
an opportunity to make her opening remarks.
[The prepared statement of Dr. Heck can be found in the
Appendix on page 37.]
STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL
Mrs. Davis. Thank you, Mr. Chairman.
I also want to welcome our witnesses, and thank you very
much for joining us today.
You know, over the past several months, we have met with
senior leaders in military medicine who have discussed the
policies of providing health care to the force and their
families, and we have also heard from beneficiary organizations
that represent those on the receiving end of healthcare
services.
So today we have this unique opportunity to meet with the
four of you, the military treatment facility commanders, three
words, but they are all really important, all separate--who
execute the policies, interact with the military providers as
well as the beneficiaries affected by those policies and
healthcare services.
So I look forward to our discussion and hearing from each
of you how you balance the requirements of maintaining medical
readiness for your providers while providing access to quality
health care for your beneficiaries and what can we do to help
you in that endeavor.
Thank you all so much for being here.
Dr. Heck. Thank you, Mrs. Davis.
We are joined today by another outstanding panel.
Given the size of our panel and our desire to give each
witness the opportunity to present his testimony and each
member an opportunity to question the witnesses, I respectfully
remind the witnesses to summarize, to the greatest extent
possible, the high points of your written testimony in 5
minutes.
The lighting system before you, when you have 1 minute
left, it will turn yellow. When you are out of time, it will
turn red. I assure you that your written comments and
statements will be made part of the hearing record.
So let me welcome our panel: Colonel Mike Heimall, United
States Army, Chief of Staff, Walter Reed National Military
Medical Center--in the interest of disclosure, I was on staff
at Walter Reed from 1998 to 2001; Colonel Mike Place,
Commander, Madigan Army Medical Center at Joint Base Lewis-
McChord; Captain Rick Freedman, United States Navy, Commanding
Officer at Naval Hospital Camp Lejeune; and Colonel Douglas
Littlefield, United States Air Force, Commander of the 19th
Medical Group at Little Rock Air Force Base.
Colonel Heimall, you are recognized for 5 minutes.
STATEMENT OF COL MICHAEL S. HEIMALL, USA, CHIEF OF STAFF,
WALTER REED NATIONAL MILITARY MEDICAL CENTER, DEFENSE HEALTH
AGENCY
Colonel Heimall. Thank you, Chairman Heck. And I was also
on staff at Walter Reed 1998 to 2001. So it is great to have
another alumnus of the Georgia Ave. campus.
So, sir, Ranking Member Davis, and distinguished members of
the committee, Mr. O'Rourke, it is great to see you again, sir,
thank you for the opportunity to discuss the role our military
treatment facilities play in supporting military readiness and
how we care for our beneficiaries.
I am the Chief of Staff at Walter Reed National Military
Medical Center, and, until this past Monday, I served as the
Center's interim director. I would like to take a moment to
highlight what we at Walter Reed are doing to ensure our staff
are well prepared for future deployments and how we are
enhancing access for our patients across the National Capital
Region [NCR] while we continue to care for America's heroes
from around the world.
Walter Reed is the largest MTF in the National Capital
Region enhanced multiservice market. Together with the Fort
Belvoir Community Hospital and 9 smaller MTFs, we are
partnering to improve access to care for more than 245,000
TRICARE Prime enrollees across the National Capital Region.
Today, providers from Walter Reed are seeing patients in
nearly every one of those MTFs across our market in order to
make care more convenient for our patients, eliminating the
hassle of having to fight beltway traffic to come to Bethesda.
We are also streamlining functions like appointing and referral
management to gain efficiencies and improve access.
My written testimony highlights several of the programs
which Walter Reed-Bethesda is internationally renowned for. The
Military Advanced Training Center for amputee rehabilitation,
the National Intrepid Center of Excellence for traumatic brain
energy and psychological health, and the Murtha Cancer Center
continue to lead our Nation in developing evidence-based
innovations that serve both a critical military medical need
but also critical needs within American medicine.
Our co-location with the Uniformed Services University of
Health Sciences and the National Institutes of Health allow us
to develop partnerships that better integrate education and
research into patient care. These partnerships also afford us
the opportunity to collaborate with renowned leaders in trauma
care, cancer care, and infectious diseases, improving care for
our patients today while preparing our team for the deployments
of the future.
And we are also expanding this partnership to include our
local and regional Veterans Administration medical centers so
we can improve access to care for our veterans. Our veterans
are as much a part of the military family as anyone who comes
to us for care, and it is a privilege to care for them.
These veterans are also often our most critically ill and
complex patients, which exercises and strengthens the same
critical care skills our entire team--providers, nurses,
technologists, medics, and corpsmen--all need to care for a
critically ill or injured service member on the battlefield, en
route to a higher level of care, or back home at our MTFs.
Thank you again for the opportunity to discuss these
efforts with you, and I look forward to your questions.
[The prepared statement of Colonel Heimall can be found in
the Appendix on page 39.]
Dr. Heck. Colonel Place.
STATEMENT OF COL MICHAEL L. PLACE, USA, COMMANDER, MADIGAN ARMY
MEDICAL CENTER, JOINT BASE LEWIS-McCHORD, UNITED STATES ARMY
Colonel Place. Chairman Heck, Ranking Member Davis, and
distinguished members of the subcommittee, thank you for the
opportunity to represent Madigan Army Medical Center and Army
Medicine today.
Since 1944, Madigan has been a provider of world-class
patient care, an unparalleled education facility, and a state-
of-the-art research platform. Madigan cares for over 100,000
beneficiaries with around 5,000 staff members; supports over
250,000 beneficiaries as the tertiary referral hospital for the
Puget Sound enhanced multiservice market.
Madigan supports Joint Base Lewis-McChord, one of the
Nation's premier power projection platforms, home to 1st Corps,
7th Infantry Division, 1st Special Forces Group, the 62nd
Airlift Wing, and a variety of smaller units. Our forces are
aligned to the U.S. Army Pacific and are integral to supporting
partnerships and exercises in the region as well as operations
around the world.
Madigan has a two-fold readiness mission: to ensure our
service members are medically ready to deploy; and generating
and maintaining ready medical forces.
By collaborating closely with our line commanders, as well
as unit medical and dental providers, we have increased the
available rate for soldiers in 1st Corps to nearly 91 percent.
We will continue to work with our senior mission commander,
Lieutenant General Lanza, to identify means to continue to
improve the readiness of our soldiers, such as by increasing
the availability of physical therapists for injury prevention
or through implementation of the Army's Performance Triad.
As an academic medical center and one of only two
designated Level II trauma centers in the Army, Madigan plays
an important role in ensuring we have ready medical forces. In
2015, Madigan trained 319 individuals in graduate medical
education [GME] in 33 distinct training programs. Our residency
programs boast a 95 percent 3-year, first-time board pass rate,
readily exceeding the national average of 87 percent. Madigan's
orthopedics, neurology, and radiology programs' in-service
examination performance this year places them in the top 10
percent of the Nation. And our emergency medicine residency
remains one of if not the top in the country.
Most importantly, our graduates are prepared through a
unique military curriculum which provides them the tools to
successfully transition to serve as surgeons in maneuver units
or to serve in forward surgical teams or combat support
hospitals.
As a hospital commander in Afghanistan, I witnessed
firsthand how our GME and related medical training programs
provided the capability to achieve our unprecedented 92 percent
survival rate despite the increasing severity of injuries
sustained in modern combat.
However, the Army cannot focus exclusively on sustainment
of trauma skills and surgical capabilities alone. My experience
in supporting the 75th Ranger Regiment in Operation Uphold
Democracy in Haiti and as a medical task force commander during
the Kosovo air campaign shows that Army Medicine must be
prepared to support a wide range of crises, from peacekeeping,
to disaster relief, to humanitarian assistance.
Military treatment facilities like Madigan are vital to
ensure our medical teams are trained, ready, and relevant to
provide care globally. Our partnerships with the VA [Department
of Veterans Affairs] and the civilian community strengthen our
programs by providing a diverse and complex mix of patients to
hone our skills for our entire medical team.
I am personally committed to improving the readiness of our
soldiers and our medical teams so they can best serve our
Nation. On behalf of Team Madigan and Army Medicine, I want to
thank Congress for your continued support. I look forward to
your questions.
Thank you.
[The prepared statement of Colonel Place can be found in
the Appendix on page 49.]
Dr. Heck. Captain Freedman.
STATEMENT OF CAPT RICK FREEDMAN, USN, COMMANDING OFFICER, NAVAL
HOSPITAL CAMP LEJEUNE, UNITED STATES NAVY
Captain Freedman. Chairman Heck, Ranking Member Davis,
distinguished members of the committee, thank you for providing
me the opportunity to share my perspectives as Commanding
Officer, Naval Hospital Camp Lejeune, on the role that military
treatment facilities have in providing medically ready service
members and ensuring an operationally ready medical force. We
in Navy Medicine are privileged to care for those entrusted to
our care.
Naval Hospital Camp Lejeune is a family medicine teaching
hospital located in eastern North Carolina, providing medical
support to forces stationed on and around Marine Corps Base
Camp Lejeune, to include members of the 2nd Marine
Expeditionary Force and members of the Marine Corps Special
Operations Command.
The primary reason we exist is to build and sustain medical
readiness. At Camp Lejeune, readiness takes three distinct but
equally important components.
First, readiness means that we as medical professionals who
wear the cloth of our Nation are ready at a moment's notice to
deploy in support of our Navy and Marine Corps team. We must be
physically, professionally, spiritually, medically,
administratively ready to move out at a moment's notice. Our
MTFs are the reservoir of forward-deployable expeditionary
medical support for our combatant commanders. Nowhere is that
better understood than aboard Marine Corps Base Camp Lejeune,
where it is common knowledge that no marine has ever taken a
hill without a United States Navy corpsman.
Second, readiness means that we ensure our marines and
sailors are ready to be the first to fight in any theater of
operation and we understand their demanding mission. Several of
our clinics are located around the base and are staffed jointly
with medical personnel assigned to both hospital and assigned
to operational units. This initiative improves access,
continuity and quality of care, and provides expanded
capabilities for our teams to collaborate during real
scenarios, as demonstrated during our recent successful
response to two recent mass casualty events following training
mishaps.
A third but equally important mission is caring for our
families because our team understands there is no surer way to
make a combat marine, soldier, sailor, airman, guardsman more
ineffective than to have them worry about their family. Family
readiness supports force readiness.
We at Camp Lejeune are committed to being leaders in
quality, safety, access, and service. NHCL [Naval Hospital Camp
Lejeune] is proud to be among the first to employ available
technologies to increase how our patients communicate with our
providers. From our patient smartphone application, to 100
percent primary care manager use of secure messaging, to strong
support of our nurse advice lines, we are ensuring patients
have 24/7 access.
Another of our access initiatives is launching our tele-ICU
[intensive care unit] project, virtually connecting our
intensive care unit with that of Naval Medical Center San
Diego; use of digital radiology and telepharmacy throughout our
multiple clinics spread out over the 246 square miles of Marine
Corps Base Camp Lejeune.
We are proud to note that we have implemented the Centering
in Pregnancy Program that offers mothers-to-be a unique group
prenatal care model that promotes education and peer-group
connections. It has been extremely popular with many of our
patients, particularly those lacking built-in support systems,
a deployed spouse, or other challenges associated with military
service.
It is critical to note the importance of our hospital given
the location in eastern North Carolina and the vital role we
play in a medically underserved area of our country. There are
wonderfully talented and dedicated civilian medical partners in
Jacksonville and the surrounding areas; however, our community
does not have the medical infrastructure which may exist in
other metropolitan areas.
Camp Lejeune's family medicine residency program has
received the highest level of certification by the ACGME
[Accreditation Council for Graduate Medical Education], has
grown by 50 percent, and achieved 4 years of unprecedented 100
percent board pass rate for our residents.
Their re-affiliation with our retired beneficiaries, who
have doubled in size in the last 2 years, has really improved
the acuity and complexity of cases for our interns and
residents and specialists and allowing our team to care for
those who have previously served and who deserve the best that
this Nation can offer.
An integral aspect of care which has no counterpart in the
civilian community is our Intrepid Spirit Concussion Recovery
Center. This center offers exceptional support for our service
members afflicted with traumatic brain injury [TBI]. A hallmark
of the Intrepid Spirit Center is a holistic, integrated,
interdisciplinary treatment approach that includes 10 different
specialties, to include complementary alternative medicine
techniques. Care is tailored to meet the unique needs of the
warrior athlete, and, to date, approximately 2,000 of our
warfighters have gone through the program, with over 90 percent
of them, at least from the standpoint of TBI, returned to full
duty.
In summary, we are a critical part of the greatest and most
highly capable Navy and Marine Corps team that the world has
ever known. Our hospital serves as a readiness platform for the
force and families stationed in the area. We will continue to
be a forward-deployable expeditionary medical capability while
maintaining the highest levels of readiness.
Thank you for your support of military medicine, and I look
forward to answering your questions.
[The prepared statement of Captain Freedman can be found in
the Appendix on page 59.]
Dr. Heck. Colonel Littlefield.
STATEMENT OF COL DOUGLAS M. LITTLEFIELD, USAF, COMMANDER, 19TH
MEDICAL GROUP, LITTLE ROCK AIR FORCE BASE, UNITED STATES AIR
FORCE
Colonel Littlefield. Chairman Heck, Ranking Member Davis,
and distinguished members of the committee, I too thank you for
the opportunity to come before you today on behalf of the men
and women of the Air Force Medical Service.
As commander of the 19th Medical Group in Little Rock,
Arkansas, my job includes leading a team of 350 dedicated
Active Duty, government service civilian, and contract
employees in supporting a population of 44,000 beneficiaries
within a 40-mile radius from our clinic.
Of those beneficiaries, approximately 14,000 are enrolled
directly to our clinic and receive care across our spectrum of
provided services, such as our family and women's health
clinic, flight medicine, optometry, and dental clinics.
Some of the more unique services include both public health
and bio-environmental sections as well as our aerospace
physiology and High Altitude Airdrop Mission Support team that
directly support a myriad of U.S. and coalition partners in
conducting operations in unpressurized aircraft between 10,000
and 35,000 feet in altitude.
Each day, we strive to provide trusted care to the
population we serve while continually looking for ways to
provide safer, more efficient care and remain in touch with our
patients' needs.
Supporting the mission is our first priority. It is why we
exist and where we focus our daily efforts. At Little Rock,
this means combat airlift anywhere, anytime. Our actions ensure
our Active Duty population are ready physically, mentally, and
emotionally to carry out their role in supporting the wing's
mission. It also means caring for family members, retirees, and
their dependents with the services that we provide. Ultimately,
military readiness is community readiness, and leading my team
to recognize the role they play in this priority has benefited
all involved.
The next priority we focus on is people. Our amazing
teammates are how we get this mission done. And we strive daily
to treat our patients, family members, community partners, as
well as each other with the utmost respect and professionalism.
We are committed to resiliency in every area of our lives,
which makes us more productive and better teammates. We also
look for opportunities within the clinic, wing, and community
to grow personally and professionally so that we can continue
to become better airmen.
Our final priority is communication. There is no substitute
for clear and concise communication at all levels, which allows
our team to function at its peak. We are always looking for
opportunities to improve our communication methods by listening
more than we speak and utilizing different sources of
information across our available spectrums to get pertinent
messages to those we support.
By focusing on these priorities, we are committed to
supplying safe and high-quality health care to all those we
serve. While the pursuit of this may look different at each
location, the Air Force Medical Service will provide trusted
care anywhere as we strive for peak readiness and the highest
reliability in all we do.
Thank you for the opportunity to speak on this matter and
for your continued support.
[The prepared statement of Colonel Littlefield can be found
in the Appendix on page 70.]
Dr. Heck. I thank you all for your testimony.
We will now move into rounds of questioning. Each member
will be limited to 5 minutes. We will go in the order of
arrival prior to gavel. Hopefully, because I know I have
several questions, we will have time for multiple rounds.
And I will start.
Colonel Heimall, you know, the interesting thing about
Walter Reed is that you are under the command of DHA [Defense
Health Agency] and not a service. Can you give some insight as
to how that works, answering to the Defense Health Agency as
opposed to a service sector? And, you know, do you see pros and
cons to having that type of an alignment?
Colonel Heimall. Sir, from a functional alignment, based on
my experience commanding within Army Medicine, DHA really
functions like a regional medical command or a regional health
command for us. That is where our resourcing comes from; it is
where our policy guidance comes from. And so it is really not
much of a different relationship between Walter Reed and the
National Capital Region Medical Directorate and the Defense
Health Agency.
I think some of the challenges with the way we are
organized is, within the National Capital Region Medical
Directorate, Defense Health Agency only operates two MTFs. And
so when we look at resourcing, when we look at allocation of
civilian hiring caps that are in place to allow us to bring
civilians on board, we don't have the degree of flexibility
that Army Medicine, Navy Medicine, or Air Force Medical Service
have, given the size and the scope of their regions.
We have about 4,500 civilian authorizations across the
National Capital Region Medical Directorate. I will compare
that to my time at William Beaumont Army Medical Center in El
Paso, when Western Regional Medical Command at the time had
over 11,000 authorizations. And so it makes flexibility in
hiring and shaping our workforce much more challenging.
Dr. Heck. Great. Thank you.
Colonel Place, you mentioned that Madigan was a Level II
trauma center, one of only two within the inventory. Are you
integrated into the civilian EMS [emergency medical system]
system, and do you receive civilian casualties from trauma into
your trauma center?
Colonel Place. Yes, sir, absolutely. We are part of the
Tacoma Trauma Trust. As that, we back up two civilian hospitals
downtown. We average about one or one and a half activations of
our trauma team every day. So we are basically the backup 365/
24 hours a day for anyone else.
Dr. Heck. And how critical would you say that that
integration with the civilian trauma center is in being able to
maintain the trauma skills of your staff members?
Colonel Place. Sir, I think it is enormously important. We
have only one Level I trauma center down in San Antonio. I
think it is important that we routinely see trauma in order to
maintain those skills for not just the surgeons, because they
are relatively easy to get to a trauma center to go do trauma,
but, as you know, it takes a lot more than just the doctor to
be able to do those things. You need to have the ER [emergency
room] trained well; you have to have anesthesia and the PACU
[post operative care unit] and the ICU. All of those need to
have training, the pulmonologists, you know, the respiratory
techs. Everybody needs to be part of that.
So if we don't see any trauma, that is a challenge for us.
And I personally would like to see more because I think that
adds to our capabilities when we go to war.
Dr. Heck. Could you summarize how that relationship was
established between Madigan and the civilian hospital system?
Colonel Place. So, sir, I am not familiar with the actual
history of that. I understand it was more than a few years ago
that that was put in place. So I can get back with you for the
details if that is important. But right now we are in
discussions with our counterparts down there to make sure that
we are all fulfilling our roles and responsibilities as part of
that.
[The information referred to can be found in the Appendix
on page 83.]
Dr. Heck. And as part of that relationship, do some of your
providers rotate out to civilian hospitals? Or is it all done
based on the trauma patients, civilian trauma patients, coming
to your facility?
Colonel Place. Yes, sir, we have some external resource
sharing agreements where we send some of our folks downtown.
Right now, probably the most dramatic is our cardiothoracic
surgeons. They go downtown to perform surgeries there to
maintain their skills. We don't have enough caseload within our
population to really allow them to maintain their skills, so we
let them go downtown, with preferential treatment of our
beneficiaries. But even so, we end up doing some VA cases and
things like that downtown.
Dr. Heck. Great. Thank you.
Since my time is almost up, I would rather not shoehorn an
answer into my next question, so I will wait for the next
round.
Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
And, again, thank you all for being here.
We have heard from a variety of sources, certainly, as we
have worked through this over the last number of months, that
access to healthcare providers is a challenge for some of the
MTFs. And I wonder if you could talk about how you monitor or
you balance the access to care for those depending on services.
And when you think about additional services that have to
be increased, in what area is there greatest demand? And how--
do you track that so you have a sense of where that healthcare
dollar is being spent?
As you may know, there was a study last year, a Shelton
study last year, that really looked at some of the contracted
services, and they were pretty high, 70 percent, versus the
MTF.
So can you talk a little bit about that? And how do you do
that? And what do you know about that, in terms of trying to
provide that additional resource?
Colonel Heimall. Well, ma'am, I can tell you within the
National Capital Region we look very closely at where our
patients are going to get their care and what we are paying for
in the private sector, with the intent of trying to recapture
as much of that care as we can.
Every time we treat a patient inside of our MTF, there is
value in maintaining the skill level of not just the physician
or the midlevel provider who is seeing that patient but the
entire care team around that provider.
Additionally, if we have the capacity to see the patient
and we send them downtown, the taxpayer has really paid twice
for that care. And, as a taxpayer, I don't like doing that, and
I am sure not many others do.
Within the National Capital Region, the needs really
revolve around access to services like dermatology,
gastroenterology, podiatry, and physical therapy. And I think
the rest of the members will say physical therapy has been a
challenge for most of us across the military services.
And so you look at innovative ways, now, how can I bring
that care back into the system. And, in many cases, what we are
doing at Walter Reed and Fort Belvoir is looking at how we can
take our providers to where the patient lives and works. And so
we have gastroenterology providers living and working at Fort
Belvoir and Fort Meade every day. The Air Force has assigned an
additional gastroenterology provider to Malcolm Grow who
actually works at Fort Belvoir Community Hospital every day so
that we can meet that demand.
And we are justifying additional resources in the market
not based on what we are doing at an individual facility but
what the market needs to be able to take care of the patients
that are enrolled to us.
Mrs. Davis. Thank you.
And how has that medical dollar been spent then as a result
of what you are trying to do? What have you seen that is
different?
Colonel Heimall. Well, I think one of the things we have
done in the last year in the National Capital Region is we have
lowered our per-member, per-month cost significantly, about $90
per patient per month. And that has really been a result of
trying to bring that care back in-house and better utilize the
capacity that we have.
I am interested to see what happens. We have just hired 11
physical therapists for the entire market, and we are placing
those physical therapists at the MTFs where that care is being
referred to. So it will be interesting to see how much care we
can recapture and whether or not we can make the care more
convenient for the patient.
It makes no sense for somebody from Pax River, for example,
to drive to Walter Reed for physical therapy three times a week
if we can provide that service much closer to Pax River.
Mrs. Davis. Great. Thank you.
Anybody else want to respond?
Captain Freedman. Congresswoman, I would like to say, too,
as Navy Medicine and the MHS transitions from health care to
health, access, service, these are indicators of health--very,
very important.
So we look at establishing that trust with the patient in a
patient-centered medical home model to ensure that it is easy
to get access. We monitor every single morning, making sure
that our templates are built for open access for our patients.
We are providing new and innovative ways for our patients to
contact us, through nurse advice line, through secure
messaging, through our patient smartphone application.
We want to make sure that we establish that, because if you
need to be seen today, our covenant is that we will see you
today. And that is the trust that you build into your patients
so they don't seek care in the emergency room. Not that that is
not good care, but that is not great primary coordinated care
that leads us to health.
We also work very closely with our managed care support
contractor who manages our network of facilities. And if we see
that there is an indication for additional resources to be
brought back to the direct care system, we work very closely
with them to do so.
Colonel Place. Ma'am, I would like to add, as well, yes, we
monitor all those things very, very, very closely. We have all
kinds of briefings related to that.
But I guess the take-home message, from my perspective, is
the metrics don't tell the whole story. If you call today at
Madigan, the average time until you are seen for an acute
appointment is .6 days. The metric that we use for third next
available appointment is 1.6 is what that comes out as. But if
you call today, most of the time we add you on. We just say,
come on in, we will take care of you. So that is really what I
want to get to in terms of access rather than how many
appointments do we have.
In terms of the whole dollar figure, we recently went
through and kind of reviewed how we do on 37 different kinds of
service lines, so gastroenterology, pulmonology, and so forth,
that we have. For the multiservice markets, the 250,000
beneficiaries, for 25 of the 37 service lines, more than 85
percent of the care we provide inside the direct care system.
So, yes, ma'am, we look at the value for healthcare
dollars. When it makes sense for us to do it inside, we make
that business case analysis and we try and provide it internal.
If not, if it is more cost-effective to do it through a network
provider, then we go that way.
Mrs. Davis. Okay. Thank you. My time is up.
Dr. Heck. Ms. Tsongas.
Ms. Tsongas. Thank you, Mr. Chairman.
And welcome.
As you all are speaking, I am reminded of I was a recipient
of treatment in a military treatment facility in my early
teens, as was one of my sisters. My father was a career officer
in the Air Force. And I have always appreciated the great care
we received for not insignificant problems. One was in an MTF
here in the United States, another when we were stationed
abroad. And in both places, we got such great care. So I thank
you for that, as a family member. And I am sure, as we
certainly hear from our military families, how important that
is.
I do have a question related to the fact, the ever-growing
numbers of women that are now currently serving in the Active
Duty. And I am curious, as this population is increasing, how
well able you feel you are able to serve them as they are in
this Active Duty status. And are there shortcomings and ways in
which we could be more helpful?
And I will start with you, Colonel Heimall.
Colonel Heimall. Ma'am, I think we have had about a 10-year
head start on some of the other Federal systems in how we
manage women's health. Within Walter Reed, we have a women's
health clinic, and there is a range of programs that are
available. But we also have the luxury of having an obstetrics
and gynecology residency program that allows us to provide a
higher level of care for women who are serving, as well as for
retirees and the veterans that come to us.
I think one of the gaps that we have right now--and it is a
matter of developing it, and we have just started developing
the program about 6 months ago at Walter Reed, is a trauma
program for women who are suffering from, and men--who are
suffering from sexual assault trauma. While trauma is the same
from an emotional standpoint, the way we manage that within
groups and the therapy we provide really needs a different
touch. And so creating an intensive outpatient program for
victims of sexual assault is really, I think, a needed service
as we go across MTF to MTF.
Ms. Tsongas. Is that a resource issue or an approach issue?
How would you define the shortcoming?
Colonel Heimall. I think it is multivariate. It is an issue
of recognizing the need, resourcing it, and then making sure
you have the people who have the experience to be able to
implement the program.
Ms. Tsongas. Thank you.
Would others like to respond?
Colonel Place. Ma'am, I agree. We have had a little bit
more experience with this, and as a former operational medicine
consultant to the surgeon general, I would say we have even a
lot of experience going to war with women, which has, I think,
given us some perspectives and some understanding of what those
challenges are.
I don't think we have it perfect. I think there are some
things that we can do. But I think they are more tweaks to the
system rather than big gaps that need resources or major
renovations of how we approach women's health.
Ms. Tsongas. And as women go to war, how would you describe
the challenges you have?
Colonel Place. So there are a number of things that we look
for in terms of hygiene, in terms of privacy, in terms of
making sure that we balance security with lighting systems and
so forth versus the risk of sexual assault and things like
that. There are a number of small factors that come up. But
those are things that we have to mitigate the risk against
rather than create new programs, I think, from my perspective.
We have a very active women's health service line at MEDCOM
[Medical Command] that helps us review these things and
implement new methodologies. Recently, I will just give you an
example from Madigan. An important women's issue is
breastfeeding, and we have actually purchased four pods for
breastfeeding within Madigan because we didn't have locations
that we thought were reasonable and accessible for women to
breastfeed in. So we purchased them, we sent them up, had them
advertised and so forth. And we are helping the rest of the
installation figure out where to put them, how to utilize them
to make them effective for our female soldiers as well as for
us, the patients that come there.
Ms. Tsongas. And we are glad to see Secretary Carter
recognize that this is something that has to be dealt with
across the services, not just in the MTF environment but in
general.
Colonel Place. Yes, ma'am.
Ms. Tsongas. Would others like to comment? I have just a
little time.
Captain Freedman. Congresswoman, we are proud at the Naval
Hospital Camp Lejeune to have many initiatives.
We have been designated, applied for and designated as a
three-star facility by the North Carolina Maternity Center for
breastfeeding-friendly institutions.
We have started a Centering in Pregnancy Program that I
talked about in my opening remarks; that, according to the
Centering Healthcare Institute, we have the most number of
participants in the Nation, not just in DOD [Department of
Defense], with 27 active groups that are going through this
group prenatal care program.
And I am blessed in leadership with a partner, my executive
officer, who is also a women's health nurse practitioner, to
make sure that we provide care for all our warfighters and
their families.
Ms. Tsongas. Thank you. My time is up.
Dr. Heck. Ms. Stefanik.
Ms. Stefanik. Thank you, Mr. Chairman.
Thank you to the panelists for your service today and the
sacrifice of your families.
On Fort Drum, which is an Army installation that I
represent in my district, we have a clinic as opposed to a
hospital on post. Guthrie Army Health Clinic and the MEDDAC
[Medical Department Activity] that oversees it supports over
14,000 Active Duty soldiers and 16,000 military family members.
Due to this unique relationship, the MEDDAC at Fort Drum
partners with the community to ensure that the highest quality
of care is provided to all patients.
So I wanted to turn to Colonel Littlefield.
What are some of the unique challenges you have faced while
partnering with civilian provider networks for services that
you are unable to provide? And would you consider a model
similar to what you have at Little Rock Air Force Base to be as
efficient as other installations that have full hospitals with
inpatient care on post?
Colonel Littlefield. Thank you, ma'am.
I think the opportunity is, or the word is ``balance,''
too. It is something, when we are looking at access, again, a
clinic compared to a bedded facility and what we offer, we are
in constant communication with our community partners. Some
people don't consider Little Rock as robust, but that is one of
the things that I have found. Their civilian network is quite
robust. Now, there are some specialty areas, particularly when
you get in the pediatric ranges, some of the mental health
services that need to be provided, there are long wait times
there. But, overall, I have been very pleased with the
availability of services.
But we partner with them. We do things from holding
provider collaborations every year to invite our partners in,
meeting with them, developing relationships. We have been able
to send some of our providers down to the Arkansas Heart
Hospital, seeing open heart procedures and those types of
events.
So we are always looking for opportunities to partner. And
I think with us being the only Active Duty facility in the
State of Arkansas, that is where we are headed, is that we need
that partnership for those things that we can't provide. We
will capture everything we can, bring it into our facility to
keep the skills up of our team members, but we rely on our
community partners.
Ms. Stefanik. Thank you for that.
Does anyone want to comment on that question?
Go ahead, Captain Freedman.
Captain Freedman. Thank you very much, Congresswoman.
We are blessed in eastern North Carolina to have a
fantastic, supportive community in Jacksonville and the
surrounding area, where they understand the importance of the
Marine Corps and the Navy team and what it does for the defense
of our Nation.
So our partner facilities in the civilian community have
been wonderful for us. We have expanded some enhanced resource-
sharing agreements with our local hospitals for a dual
diagnosis program for dependency and behavioral health. We have
our local hospital that provides operating room space for us as
we undergo renovation of our operating room spaces. We have a
great medical center in Vidant Medical Center that we have
entered into an agreement with to allow our corpsmen, our
nurses, and our physicians to be able to go up there and get
training that we may not see in our institution.
So it is a true community. And I think it's understanding
the mission. And I think no one does it better than
Jacksonville, North Carolina.
Ms. Stefanik. Thank you very much.
Any other comments?
Colonel Place. Ma'am, I would just offer that I think it
depends. You know, ``balance'' is a way to put it, but what we
would like to do, and I think we do a pretty good job of it, is
finding the talents and capabilities in the civilian community,
and if it makes good business sense to capitalize on, then
let's do that. If it doesn't, then let's do it inside the
facility with, you know, taxpayer dollars.
So if the capability is there and it is a high-quality
capability, then, by all means, we ought to do that.
Colonel Littlefield. Ma'am, I agree with what the other
panel members have said. I think you to have to look at, first,
is there a compelling readiness reason why I would want to
offer that service--inpatient care, complex surgeries,
intensive care, for example, the things that Guthrie gets from
the civilian community--in my MTF at a particular location. And
health care is still a very local phenomenon, so every base has
a different community and different assets in that community to
support them.
And so, if that case is there, we build it there. If that
case isn't there, then where can we get that in the civilian
community, and how can we build the partnership to make sure
that works smoothly.
Ms. Stefanik. I appreciate those comments. And we have had
success stories in the broader Fort Drum community, partnering,
for example, with River Hospital, with a very high-quality PTSD
[post-traumatic stress disorder] program. That is an example of
identifying a need and working with the experts and the
practitioners who are within the community.
So thank you for your testimony today, and thank you for
the thoughtful answers.
Dr. Heck. Mr. O'Rourke.
Mr. O'Rourke. Thank you, Mr. Chairman.
And I want to thank each of you for your testimony and your
answers to our questions.
And, Colonel Heimall, I would just like to thank you,
especially, for your service, because I am most familiar with
it, when you were the commander at William Beaumont Army
Medical Center. And during that time, when you were both
commander and I was the Representative for the area, I probably
had 40 public townhall meetings, you know, where everyone was
invited, no holds barred, any issue or topic, and you were
there at every single one of them, whether Army Medicine or
veteran care was the subject or not. And I think that sends a
very powerful message to the community about your interest and
involvement in the community at large, especially veterans'
care as connected to Active Duty military care.
And then, to that point, you did a tremendous job working
with our local VA, which is physically conjoined with William
Beaumont, while overseeing a billion-dollar construction
project for the new William Beaumont. So I can't thank you
enough for what you have done for our community, for the
veterans there, for the Active Duty military and their
families.
You mentioned in your testimony the need to ensure that
there is a continuum of care for Active Duty service members
into the transition to civilian life when they are veterans.
And, anecdotally, in El Paso, I will often encounter veterans
who served at Fort Bliss, which is served by William Beaumont,
who said that for their mental healthcare needs, while they
were Active Duty, they were met almost without fail, without
complaints. If their prescription for their PTSD required
seeing a therapist once a week, they were seen once a week.
And, by contrast, in the civilian world, treated by the VA,
maybe they get in to see a therapist, maybe they don't get to
see anyone at all. And we were later able to confirm that
through a survey that found that one-third of veterans in El
Paso could not receive mental health care despite trying.
So how do we fix this? If we are able to recruit and retain
or make use of mental healthcare providers who are in active
service and do so effectively, how do we ensure that there is
consistency and continuity in that care once that service
member becomes a veteran, at a time when we have, officially,
22 veterans a day taking their own lives? And I know for a fact
that that level of suicide is connected to care that is delayed
or denied at the VA. How do we fix this? What have you learned
at Walter Reed, at William Beaumont, in collaboration with the
VA, that would allow us to begin to be more effective in
combating this?
Colonel Heimall. Sir, first, I want to thank you for your
support and your district staff. The partnership we had there I
think made my 33 months there incredibly successful and really
helped me navigate a number of problems that could have
derailed a lot of what we were trying to do. And that was the
partnership that we had, I think, that really made that a
success.
Your question is very well put. Particularly in the area of
behavioral health, there are a number of areas where we have
the ability, I think, to help the VA with access to care. And
we certainly try to do that at Walter Reed every day. But, in
El Paso, one of the areas I struggled to be able to support the
VA was in primary care services and behavioral health. And I
think that is true at a number of our facilities and certainly
true at Walter Reed, though we do have a little more
flexibility with the inpatient capabilities that we have.
There is a national shortage of behavioral health
providers. It is not unique to the military, unique to the VA.
I believe, nationally, we are not filling all the residency
seats for psychiatry across the country. We are looking for
innovative ways to grow psychology programs, internship
programs, et cetera. And so we have to do something to address
the supply at the national level.
We are all competing for the same providers, and often what
happens is we wind up into a bidding war with the VA or with
our civilian counterparts over how we retain providers. In our
experience in El Paso, it was very common to have someone work
for us for 2 years and then slide over to the VA for a couple
of years and then come back to us 3 years later. And we have to
do something to increase the pool so that we can meet the
demands of our patients.
Mr. O'Rourke. And it sounds like there is going to be
another round, so I will ask this again, and we will include
the other colonels in the response. But I think my point is
that you were somehow able to figure that out.
And, you know, very often I heard the reverse of the
scenario you described, where it is DOD that is hiring away
from the VA, and the VA felt like it couldn't compete on salary
or price or benefits or retention bonuses or whatever is
provided.
So I understand there is a scarcity, but some are able to
receive care amidst that scarcity while others do not. And I
would just think that if we are treating the same person for
the same condition and we are able to do so successfully on
this half of the divide, there has to be some way, perhaps even
using the same providers, to continue that care once they are
on the other side of the divide.
So I am out of time, but I would like to come back to this
if there is another round. Thank you.
Dr. Heck. Mr. MacArthur.
Mr. MacArthur. Thank you, Mr. Chairman.
You each are overseeing facilities within one of the
branches of our Defense Department. And I am interested whether
that matters, that you stay within that particular branch, or
whether all healthcare facilities within the MHS [Military
Health System] could be managed together, which has been
recommended.
And I would like to know, beyond parochial concerns, I
would like to know why you think one or the other is more
effective for our primary objectives.
And we will start with you.
Colonel Littlefield. Yes, sir. Thank you.
I think, at the end of the day, I think my panel members
would agree, we are pretty much blind to who we are providing
care to, as far as our sister services. We treat, you know,
Marines, Navy, Army all across, even in our facility. And so I
think that is the bottom line, is the provision of care and
excellent care and how we do it.
Mr. MacArthur. What about on the other end? Does the
oversight within a particular branch matter?
Colonel Littlefield. Ultimately, I don't think so. I think
providing the care, maintaining the readiness for our members,
maintaining the readiness for our team members themselves, the
medics that need to go out and be ready, and maintaining the
care for our family members, dependents, and retirees is the
factor that we are looking into.
Mr. MacArthur. Okay. Thank you.
Captain Freedman. Congressman, thank you for that question.
In Navy Medicine, as we move forward with readiness,
jointness, and value, there are many initiatives that are
taking place where we are doing best practices and sharing of
resources. We started in Naval Hospital Camp Lejeune an Eastern
Carolina Healthcare Consortium, where we have brought together
the leaders from Womack Army Medical Center, Seymour Johnson
Air Force Base, their clinic there, as well as the VA, to see
what we can do to better coordinate care and share resources.
However, there are some service-specific things, and the
important part of that readiness mission can't be overstated.
We are embedded, and the Navy-Marine Corps relationship is so
strong. We go to combat together. We have to understand each
other's operations and missions, and we have to be trusted
partners in leadership.
And aboard Marine Corps Base Camp Lejeune, we are very
fortunate to have incredibly strong leadership, but bring us in
on a lot of decision-making that occurs right there on that
Marine Corps base, brings that Navy hospital, makes sure that
our training is together, our providers work together, they go
to war together, they come back together. And there are a lot
of specific service-related times where Navy Medicine is called
for the Navy-Marine Corps team.
Mr. MacArthur. So that service alignment matters is what I
hear you saying.
Captain Freedman. It does, sir.
Colonel Place. Sir, I think I am in a unique position. I am
in a multiservice market that has Army, Navy, and Air Force in
it. So Joint Base Lewis-McChord, ``McChord'' is for McChord
Airfield, so there is the 62nd Air Wing there, kind of an
important unit in the Pacific Northwest, as well as Naval
Hospital Bremerton and Naval Hospital Oak Harbor.
So I am the tertiary referral hospital for the two Navy
facilities and actually provide facility space and oversight
and IT [information technology] and logistics and so forth to
the Air Force facility that actually is part of a wing of a
clinic that we have up on McChord Field, on that side of the
base.
So I would answer it this way. The clinical care doesn't
matter. So when you look down from us, it doesn't matter. It is
doctors and nurses and so forth applying their skills. That is
consistent across all of us. We have the same measures for
quality and safety and so forth.
Where it gets a little bit unique is then, when we talk to
line commanders about, you know, what does readiness mean and
how do we get there and the nuances of the mission, that
becomes important, that we speak that language. And there is
some service identification with that.
The bigger challenge really, I think, for all of us is that
we need consistency from us up for policy funding, all the rest
of the things, that if they change a lot, that becomes a
problem. And there are some very unique things about each of
our services in how we receive that kind of guidance and
information.
So I think, from here up, it gets a lot more complicated,
but from where we are down, it is pretty straightforward. It is
clinical care. And we can do that regardless----
Mr. MacArthur. Just so we have time for the----
Colonel Heimall. Sir, my situation is a little bit more
complicated than Colonel Place's, in that we are a joint
facility, and I do not have any of the traditional command
authorities over the Army, Navy, or Air Force personnel that
work at Walter Reed on a daily basis.
And one of the things that I have learned is, as you get
more senior and your organizations get larger, you rarely have
all the authorities that you want to do your job effectively,
and the premium is built on relationship-building and
consensus-building to accomplish the mission.
And that is really what we have done, I think,
exceptionally well within Walter Reed and the National Capital
Region Medical Directorate, given the fact that, as a Defense
Health Agency subordinate, we don't have those traditional
authorities that my counterparts at the table do have.
Mr. MacArthur. Your dilemma sounds a lot like Congress.
I yield back.
Dr. Heck. Ms. Speier.
Ms. Speier. Mr. Chairman, thank you.
And thank you to our panelists.
Recently, there was a study that shocked me and probably
many of my colleagues, that the child abuse among members of
our military is much higher than the national average. We are
going to have a hearing on that, I believe.
But I am curious what is being done within the various
services in terms of providing specifically mental health
services in child abuse cases.
Colonel Place. So, ma'am, one of the things that we are
looking at at JBLM [Joint Base Lewis-McChord] is that very
fact. We actually have a higher-than-expected rate of domestic
violence in our units. So General Lanza has charged several of
us to figure out what to do about it and----
Ms. Speier. I am talking about child abuse.
Colonel Place. Yes, ma'am. I am talking about domestic
abuse of all sorts, both spouse as well as child.
Ms. Speier. Okay.
Colonel Place. And, with that, we use our Family Advocacy
Program principally in order to identify families and get them
into care.
We also have a Child and Family Behavioral Health System
that we use. We have resources specifically identified to
assist with that particular problem, along with all the other
behavioral issues that we have for young children.
Ms. Speier. Anything else?
Captain Freedman. Congresswoman, aboard Marine Corps Base
Camp Lejeune, we are a partner with the Marine Corps Community
Services [MCCS] that, in addition with our Navy Medicine
assets, provides training and resources so we can get to the
prevention of this problem.
We have embedded MCCS family life counselors that enter our
clinics, as well, to make sure there are seamless handoffs for
cases that are too significant or clinically important for the
Marine Corps Community Services to handle so there is a
seamless transfer there.
So there are training opportunities and, I would say,
embedded partnership with our other services.
Ms. Speier. I guess what I am asking is, to me, this is a
crisis. It appears that, if it is seven times higher, I forget
what the figure was, but I think it was something like seven
times higher than the national average, we have a problem, and
what we have in place isn't enough.
So I guess my question is more about are we redoubling our
efforts, are we doing anything differently than we have been
doing.
Colonel Heimall. Ma'am, I think we are always looking for
opportunities to change how we are doing and deliver the care
that is required to intervene in these cases better than we
have in the past.
And the parallels within our child and adolescent
psychiatry community, as well as the adult behavioral health
community for the offenders, is how do you develop programs
that meet the needs of the victim, change the behaviors of the
offenders, and get at the root causes of what is leading to the
abuse.
Some of it requires criminal prosecutions, and those are
run through our service-level detachments. Again, these
commanders have the authority to prosecute that within their
own ranks. We run ours through Army, Navy, and Air Force at
Walter Reed.
But my biggest concern in my current role is how do I get
the emotional and clinical support to the victims, to the
support system around the victims, and if the behavior from the
offender is related to something like a combat experience or
other traumatic experiences, how do we get help to the offender
as well.
Ms. Speier. The issue of chronic traumatic encephalopathy
[CTE] is real. I have been doing some work with Dr. Omalu, who
is the coroner who really exposed the issue and the impact that
it is having on football players. He has also now looked at the
brains of veterans and has developed a technology of being able
to do MRIs [magnetic resonance imaging] and do the screening on
living persons.
And it would appear that within the military we have a
serious issue relative to CTE. And I am wondering to what
extent we have done anything to start to screen those who are
serving who suffered sub-concussive or concussions and what
steps we are taking to try and address that.
I am running out of time, so maybe, if you can't answer it
in 21 seconds, you can do so----
Captain Freedman. Congresswoman, our Intrepid Spirit
Concussion Recovery Center has partnered with Team TBI
[traumatic brain injury] and the University of Pittsburgh to
share resources, to share data, to share best practices. So I
think this initiative may open up some doors to be able to help
our warfighters and then address this problem.
Ms. Speier. All right. I would like to talk to you further
about it at some point.
Thank you.
Dr. Heck. Okay. We will begin a second round of questions.
Understanding the importance of trying to recapture
beneficiary care into the MTFs from a maintenance-of-readiness
perspective for the healthcare provider so they have that broad
array of diverse cases, one of the things that we are wrestling
with is how do you incent the beneficiaries to come back into
the MTFs.
In other hearings that we have had with beneficiary
stakeholder groups, one of the concerns that was expressed is
that, you know, a beneficiary doesn't like necessarily having a
military medical provider, because when that person PCSes
[permanent change of station] or they get deployed, they are
starting over with another, you know, military healthcare
provider.
The other issue that was raised was the inability to get a
timely appointment at an MTF.
So how would each of you address those two issues? What do
you think it would take to incent beneficiaries to come back?
How do you address the issues with the relatively transient
nature of military healthcare providers and the capability
within the MTF to actually expand access if we get more
beneficiaries to come back in?
And I am going to start with Colonel Littlefield since we
always go this way and you tend to get left out.
Colonel Littlefield. Thank you, sir. I appreciate it.
Again, I have mentioned the word ``balance'' before, but
being a clinic, it is something that we always have to be
looking at. We work closely with my staff, my chief of the
medical staff in particular, to look at our patient balance;
how many retirees, what is the acuity and the complexity of
care that we can provide for the provider mix that I have in-
house too.
I think some of it is communication. That was one of the
priorities we mentioned. But talking to the community partners,
we go out to the chamber of commerce meetings, we go out in the
community, those provider collaborations, and talking to the
members that are out there and letting them know the services
that we have and can provide to allow them to come back in if
that is allowed.
So we maximize everything we can. We fill up our
appointments. But we also focus on the access to care and keep
that as a priority, to make sure we can get them in. It is not
good to advertise services and then not be able to get them to
that.
Captain Freedman. Chairman, I think that this is where the
MHS and Navy Medicine is particularly well-suited to take care
of this issue. The nature of our demographics, our
beneficiaries, they are transient, as well, as they change duty
sections or duty stations multiple times in a career. We are
blessed to have a system of care that may be unlike anything
else in civilian medicine. Our medical records systems talk to
each other. So even if they go to one service to another or one
institution or another, there is some continuity in that.
Patients want to come back to us because we are set up not
to produce health care but produce health. We are looking at
things differently. Our remuneration system is different so
that we are perfectly focused and aligned right now to be able
to look at outcomes. Patient-centered care is getting them to
partner in their own health care.
And then with generational challenges or generational
differences, looking at how access to care is different. What
does that mean to some of the millennials? We are using our
smartphone technology. We are using virtual messaging. We have
appointments that are booked on our providers' schedule that
are just talking to patients virtually. Evidence-based research
has shown that these cohorts of patients that are connected
with their doctors do better in many of our health metrics.
Our quality is great, and no one is going to care more than
our providers.
Dr. Heck. Colonel Place.
Colonel Place. Sir, I agree with the idea of what is
access. I think we have to broaden our horizons a little bit
and recognize that different people want different things, and
it all gets lumped into this concept of access. Some of them
want secure messaging. Some of them want to have a nurse advice
line; they don't want to come in at all. Others really want to
have that face-to-face, doctor-patient touch to happen for
them.
But I think the biggest thing is that our veterans, our
retirees, and our soldiers and their families, quite frankly,
want to be part of us. We are the same. You know, we are
brothers and sisters in arms. They are our families too. So
what I am trying to do and I think is most important for us to
do is to celebrate that, to change the culture from, you know,
it being difficult to get in to say more that we want them here
and we embrace each other.
You know, we have the opportunity--I tell my staff this all
the time--we have the opportunity to have the best job in the
world because we get to take care of America's sons and
daughters every day. And we get to work with people like us who
really care about them because most of them have some sort of
affiliation with the military in some way, shape, or form. Many
of them could probably make more money going to a different
civilian job rather than staying with us.
So I am really trying to change the culture to say, you
know what, this is a special place where we do special things
for special people that makes a difference to our country. And
once we start having those conversations, my experience has
been the retirees say, you know what, I will do it, I want to
come be part of that. And our staff actually celebrates when
they do and say, you know, ``Sergeant Major Retired Jones, we
are glad you are back with us today. We are happy to provide
you care.'' I think when we do that that a lot of those other
issues will really go away.
I was in with the other Representative Heck this morning,
and he told me, for us, essentially, our complaints about lack
of access have declined precipitously recently. And I hope that
is related to some of that culture that we are working on that
really changes the dynamic, I think, of those interactions.
Dr. Heck. Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
You know, I think you just sort of capped off, brought
together, I think, Colonel Place, I mean, you know, what is the
problem we are trying to solve here. We know that the
affiliation is critical and combined with culture and tradition
and a whole host of other things. And, at the same time, we
have a lot of stakeholders out there who do think that there
are some changes that should really be made. You have attacked
a number of those, I think, over the last, you know, few years,
and we have certainly seen changes as many of our men and women
have returned home. We are not in the same OPTEMPO [operational
tempo] that we were.
But, you know, if you could change something, if you really
felt that there is something there that does need to change,
not because people are critical or because, you know, you think
you just have to do it because somebody is asking for it, but,
you know, is there something that really is important? Because,
in many ways, I think, we come back to arguing the status quo a
little bit even though that status quo is changing somewhat; it
is being defined differently.
But, you know, is that important? I mean, do you think
there are some things that absolutely should change?
Colonel Place. So, ma'am, let me start this way. I have a
fair amount of operational background. I was at a combat
support hospital in Afghanistan. I was division surgeon, 101st,
at the start of the war in Afghanistan. So I have seen what
happens. I am enormously proud of my colleagues up here and all
that we represent to achieve that 92 percent survivability
rate. When I was in Afghanistan, 98 percent--98 percent of the
people that came to us alive left us alive. Enormously proud of
that, unprecedented in the history of war.
So I would just urge caution before we begin thoughts of
changing that system. I think it works pretty well.
Can it get better? Absolutely, ma'am. I believe that we do
need to have more trauma, more diversity, complexity, acuity in
our system. It is very hard to have complex surgical cases when
you have young, healthy people. So we need to figure out ways
to make that happen. But in terms of dramatic changes, no,
ma'am, I don't think at this point that I am convinced that
that kind of thing is necessary.
Do we have to have better access? Absolutely. We have two
community-based medical homes to try and get to where our
patients are. We are trying to expand physical therapy at those
locations to make it more convenient. We have school-based
medical homes, or school-based health clinics, rather, that we
are putting in the middle schools and high schools to actually
have the kids get care there so they don't have to come out of
school.
So I think those are all, you know, innovations that are
going to help us in this process. I think we can do those
without wholesale change of the system.
Mrs. Davis. Uh-huh.
Anybody else want to comment on that?
Just to follow up really quickly, whether or not we have
some more organized ways of helping, you know, for lack of a
better term, moonlighting for our men and women to have more
formalized connections within communities. There are plenty of
communities that do that, but it is more on the initiative of
the individual.
Colonel Place. Ma'am, do you want me to answer that or----
Mrs. Davis. Well, let me just make sure, if you want to
just----
Colonel Heimall. Ma'am, I think, you know, from a
moonlighting standpoint, that is really great for the physician
that goes out and is able to practice their trauma skills in a
Level I trauma center on a weekend or when they are taking
leave, but it doesn't exercise the team that takes care of that
patient when the surgeon finishes in the operating room. The
operating room nurses, the ICU nurses, the respiratory therapy
techs, the folks that manage the blood bank and have to get
blood into the operating room during that case don't get to
practice their skills.
I think a better model is bring as much of that trauma into
the doors of our major facilities as possible and co-locate our
deployable platforms, the combat support hospitals, forward
surgical teams, the Navy FRSSes [forward resuscitative surgery
system] at those locations where they can practice those skills
every day. But we have to be careful in how we do this.
And I think it gets to Chairman Heck's question, as well.
When we make that commitment to a community, whether it is to
take our surgical teams and embed them in a civilian hospital
or to promise to provide Level II, Level I trauma care inside
our facilities, the next time the kinetic activity in the
battlefield picks up, are we going to be able to sustain that
commitment to the community and to those retirees, family
members that we have brought back into our system? And we have
to be very, very careful that we do not overpromise, because
the first time we sever that relationship, we lose the trust of
those beneficiaries as well as that community.
Mrs. Davis. All right. Thank you. My time is up, so maybe
we will get back later.
Dr. Heck. Mr. MacArthur.
Mr. MacArthur. Actually, I want to give you a little more
time to unpack that, because I think that is an interesting
idea. And I agree with you, but there is a sort of unspoken
side to what you just said about beefing up these facilities,
these major care facilities, and getting all these disciplines
there, recapturing care. And the other side is the many, many
other facilities in the MHS that are not of that size.
And so what do you think has to happen to those? Do they
have enough critical mass, in your view, to provide value? Or
is there a different model that should be used in those non-
concentrated areas?
Colonel Heimall. Sir, I think we are already doing that. I
know the Army has gone through this recently, at looking at a
number of their smaller facilities. The MHS modernization
report, which I don't think any of us has seen, is still
working through staffing in the Department and is coming to you
for review shortly.
I think it really becomes location-dependent. Colonel Place
and I both served at Fort Campbell, Kentucky. I think we would
have the opportunity and the density to be able to do that at a
place like Fort Campbell. I think Lejeune is probably a similar
size, and so I will allow Rick to tell you whether or not he
could do that in his facility.
But I think there is a density and a size, and we have to
be able to look at that from a, first, is it sustaining the
readiness capability that we need at that location and with
those deployable forces, and then does it make good business
sense for us to be able to provide that there.
Mr. MacArthur. While you are talking, I want to follow up
on my prior question from the last round. And I heard different
perspectives from all four of you on how important it is for
individual facilities to be within a specific branch of the
Defense Department. You suggested that it is difficult because,
if you are in one branch or not, you are in a place where you
have to do a lot of collaborating with others, and you have to
focus heavily on the softer side of management, the
relationship building, the managing up and down and sideways,
to get things done that you may lack specific authority to get
done.
What qualities, what management qualities, would we need in
commanders of facilities that we are not--if they were moved--
and I am not implying we will, but if they were moved to a
combined medical command as opposed to being aligned within
each service, what qualities would you need in commanders that
have to navigate that world?
Colonel Heimall. Sir, I think you need the same skill set.
The premium placed on my soft skills, my negotiating skills,
consensus skills, that I have to use every day at Walter Reed
are really not much different at all than what I had to do at
William Beaumont or that I had to do at a much smaller MTF at
Fort Riley, Kansas, as the commander.
I think when you have reached the colonel-level command and
really some of the lieutenant colonel commands, you have got to
have those soft skills to be able to get done what you need to
get done.
Mr. MacArthur. Okay.
Switching to recapturing patients, particularly at some of
the facilities where there is enough critical mass to do it,
are there any specific--and I will look to others of you now--
are there specific incentives that we could offer that might
encourage people to access the MTF instead of private-sector
care?
Captain Freedman. Congressman, I think we are doing a lot
of those right now. And it may even be on the softer side, of
incentivizing. With the patient-centered medical home and
putting the patient in the center of the care, really
partnering with them and, as my colleagues were talking about,
having them being part of our mission, we have really brought
people back to our institutions, probably each one of us, in
unprecedented numbers. We have had a 30 percent increase in
enrollment at Lejeune. We have doubled the size of our retiree
beneficiaries, which has helped with acuity in our cases.
So I think really partnering with them and really
discussing the benefits of not a fee-based system and doing
health care, not just leaving with a prescription. There are
often questions about why don't we have a big billboard that
says, ``Four-minute wait in the ER.'' Now, that is because our
ER physicians are phenomenal and our ED [emergency department]
is great, but that is not patient-centered----
Mr. MacArthur. Could I ask you to follow up and show the
statistics that you are alluding to and then some of the things
you have done that you believe have caused that recapture.
Because that is at the heart of one of the things we are
looking at.
I yield back.
Captain Freedman. We would happy to share that,
Congressman.
[The information referred to can be found in the Appendix
on page 83.]
Mr. MacArthur. Thank you.
Dr. Heck. Mr. O'Rourke.
Mr. O'Rourke. Thank you.
I wanted to start this second round by just thanking
Colonel Place for your description of what you do, why you do
it, and who you do it for. When you finished, I wanted to work
for you. And I feel like we should approach recruitment for
these hard-to-recruit specialties--DOD, VA--with that spirit of
service and this really unique, extraordinary opportunity you
have to do something, you know, profoundly important for people
who are doing really important things for this country. And so,
anyhow, I thought that was great.
I wanted to continue with the question I asked and would
allow anyone who would like to answer it to do so. If a service
member prior to separation is seeing a therapist every 2 weeks
for his or her PTSD, is it possible to continue that regimen
once they separate? Is that already happening, perhaps? If not,
could it?
And then the second scenario is a veteran who is diagnosed
with PTSD after their service and is having a hard time gaining
an appointment at the VA or a community provider. What is the
opportunity to be seen at an Army medical or a military
treatment facility?
And so I will begin with Colonel Heimall, since you were
starting to answer that, and then anyone else.
Colonel Heimall. Sir, yeah, I was going to say, you know, I
am very proud of what we were able to do for our Active Duty
service members at Fort Bliss, from a behavioral health
perspective. And we had some phenomenal success. We fell well
short in what we were able to do for our family members and for
our retirees, and we had to lean very heavily on the civilian
community to be able to do that. And so what you saw from the
Active Duty side was not what we were able to provide for
everyone else.
I think we would like to get to a system where we could
have that continuity. I think the challenge becomes, does the
veteran stay in the community where they were receiving care
when they were on Active Duty? Increasingly, in your district,
that is happening, but in a lot of districts, there is an out
migration, as well, and so sustaining the continuity becomes a
problem.
Certainly if we had sufficient capacity at Walter Reed for
Active Duty family members, retirees, and veterans, we would be
reaching out to the VISN [veterans integrated service network]
five facilities and making sure that we were using that
capability well.
Mr. O'Rourke. Anyone else?
Colonel Place. Absolutely. So, sir, you are welcome to join
anytime. We will send you an application.
So this is a real problem for mental health in particular.
I have talked to our public health department in Pierce County,
and one of the concerns that they have is they have one of the
lowest per capita behavioral health; psychiatrists,
psychologists, inpatient beds, and so forth. They are trying to
fix that. And it is at the same time that I am opening a
residential treatment facility for substance abuse within
Madigan. So we are literally trying to get the same people to
come to work. And so I am a little concerned, and I have
expressed that concern, that we are in this competition
together.
Mr. O'Rourke. How about that specific scenario of a service
member being treated, they separate, they are still in the
community; could they go back and see the same, very same
psychologist that they saw at your military treatment facility?
Colonel Place. So I can't answer you right here, sir. I
would check with our managed care folks. And then probably I
think the way that I would have to approach that is see whether
or not we could do secretarial designee for them in order to
get them in for a short period of time until whatever the
crisis was----
Mr. O'Rourke. In other words, it is not a standard
operation procedure. It would----
Colonel Place. No, sir.
Mr. O'Rourke [continuing]. Be an exception.
Colonel Place. It would all be an exception of policy for
all of those.
Mr. O'Rourke. Yeah. And I guess my thought is, you know,
just using the El Paso anecdote again, if the service members
with whom I have spoken about this say, ``While I was at Fort
Bliss, I got excellent behavioral health care; if I was
supposed to see someone every 2 weeks, I saw them every 2
weeks; when I transitioned to the VA, I did not,'' if you are
able to serve, you know, 100 percent of the need in the Active
military and some percentage far short of that in the VA, could
you expand, stretch your capacity a little bit to ensure that
people are receiving their treatment? Or am I hearing you all
say that you are at capacity, you cannot spare additional
hours?
Captain Freedman. Congressman, I think that we talk about
relationships, and certainly I am proud of the relationships
that we have established with the VA in our local area. We are
partnered with the VA Medical Center in Fayetteville and the VA
Center in Wilmington.
We have actually embedded a community-based outpatient
clinic in one of our branch health clinics aboard Marine Corps
Base Camp Lejeune and started a pilot project at our Wounded
Warrior Battalion, where we have our most vulnerable marines
who are transitioning out of the service, and doing a warm
handoff right to our branch health clinic to see a VA team so
we don't lose them in the system, they can have some
continuity. And I think that that is going to pay great
dividends in the future.
Mr. O'Rourke. Thank you.
I am out of time. I will yield back to the chair.
Dr. Heck. Well, with the panel's indulgence, we will do
something that we haven't done before, at least in my tenure as
chair, and that is move to a third round of questions.
Colonel Heimall, I am really intrigued about the command
structure at Wally World [Walter Reed] right now. So you have a
director with no command authority, as I understand it, over
the personnel within the facility. So who actually does exert
command authority over those individuals? And how is that a
benefit or a hindrance to the overall operation of the
facility?
Colonel Heimall. Sir, I think, first of all, it is
important to understand, and to put it into Army terms, the
director exercises mission control for the healthcare delivery
mission at Walter Reed-Bethesda.
We have a very large Army detachment and a very large Navy
detachment. The special court-martial convening authority that
I would have normally had as an Army commander, that Colonel
Place has, resides with an Army troop commander who sits on
Bethesda. I see him several times a day normally, and we talk
closely, particularly on senior NCO [noncommissioned officer]
and officer issues. And General Becker, the Military District
of Washington commander, holds the general court-martial
convening authority.
Same thing for the Navy, though now with Rear Admiral Lane
as the director, Navy Bureau of Medicine and Surgery has
delegated UCMJ [Uniformed Code of Military Justice] authority
for the Navy detachment at Walter Reed and Fort Belvoir to
Admiral Lane. And so he is able to exercise that for the Navy
detachment.
Our small Air Force detachment, the authorities are over at
Malcolm Grow.
That really is no different than what my experience was as
an Army MTF commander, where I had a medical chain that really
had no general court-martial convening authority over my
soldiers at Fort Bliss. That went through the Fort Bliss
commander.
And so you are constantly building a relationship with your
senior commander on your installation and with your higher
headquarters to coordinate--you know, is every privileging
action on a physician an officer misconduct issue? It is not.
And so it doesn't need to be in the UCMJ chain. And how do you
build that understanding? It is through building the
relationship with your senior commander and with your medical
chain of command.
Dr. Heck. Okay. Thank you. That is very helpful.
You know, one of the other issues that we have discussed--
again, you know, the whole purpose behind this and this series
of hearings is in preparation for the MHS study and what does
MHS look like in the future. And that is why we thought it was
critically important to talk to the MTF commanders that are
really the foundation upon which MHS is built.
If you can, just talk a little bit about your staffing
models and how you figure out how many bodies you need in your
facility in uniform of given specialties. I would imagine it is
based on your go-to-war mission and what you are going to need
to send forward should the balloon go up.
And how do you balance that with then meeting the needs of
beneficiaries, you know, when you look at a specific model of
having so many in-uniform providers? And your feelings on the
substitutions of, well, you know, an OB/GYN [obstetrician/
gynecologist] can be .5 general surgeon if we move forward, and
is that the right way to staff for military contingencies.
I am going to start with Colonel Littlefield, if I could.
Colonel Littlefield. Certainly. Yes, sir.
Again, I come back to the word ``balance.'' It is something
we try to look at for the Air Force when we POM [program
objective memorandum] out or look ahead, years ahead. We try to
determine what that is going to be and have that ability to
provide the care to our members.
But it does start with what our wartime mission is. You
know, at the end of the day, there is no separation. We are
constantly keeping people ready; doesn't matter if it is
wartime or not. But if our people are deploying, we have to
have those people ready to go at a moment's notice and still
take care of the people back home, as well.
So I would just say projected out as much as we can,
discussions with our headquarters, and talking through the
benefits that we need to provide our community.
Dr. Heck. So would you say that, you know, you have a
certain number of uniformed healthcare providers based on your
wartime mission, and then do you beef that up based on your
beneficiary population is? Or do you just look to then get in
civilian providers to take care of the delta?
Captain Freedman.
Captain Freedman. Mr. Chairman, much like Colonel
Littlefield, our OPLANs [operational plans] determine a bit of
our manning there, with the combatant commanders feeding that
information. And it is put through what we call MedMACRE, which
is Medical Manpower All Corps Requirements Estimator. And in
that, we build a seashore rotation base, a platform for our
service men and women to rotate overseas, those forward
contingencies. And then we have the beneficiary mission and the
training mission all built into that too.
To get to your question on can we flex to meet the needs in
the local community, absolutely. We have a great mix of Active
Duty, as we have talked about from that estimate, but also GS
[general schedule] and contract staff members, all playing an
integral role. We have our GSes, our continuity to make sure
that when we PCS and transition there is someone to provide
that continuity of leadership and training for the staff. The
contract force can be brought in easily to meet mission
requirements from our commanders on the base or from working
with our managed care support contractor in trying to recapture
care.
So we have that base from the OPLANs, and then we have some
flexibility on the ground as a commander.
Dr. Heck. Either of the other--anything different from
either of you in that regard?
Colonel Place. It is remarkably similar. Once we get
through Total Army Analysis based on the COCOM [combatant
command] requirements, we go through a human capital
distribution program that then allocates out the uniformed
members. And then, after that, we preferentially go to GS. And
then, when we need to, based on, you know, time, how long you
need to have it, how quickly, and so forth. So we do the
analysis based on that to follow it up.
Colonel Heimall. Sir, I think the challenge we have at
Walter Reed, as I have learned over the last 5 months, is we
are dealing with three different staffing models. And we
somehow--everybody thinks theirs is perfect. I think there are
some really great things about each of the services' staffing
validation models.
The challenge is--and DHA has been very, very supportive in
helping us work through this--is how do we find the right one
to support what we are doing and demonstrate to the services
that their military staff assigned to us are really getting the
competencies and skills sustainment that they need when they go
back out to a smaller service platform or when they deploy with
their service.
Dr. Heck. Great. Thank you.
Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
And perhaps I will give Captain Freedman and Colonel
Littlefield, if you have something you would like to add to the
discussion of: What should change? What would you like to see?
Captain Freedman. Thank you, Ranking Member Davis. When you
had asked that question, I had hoped to get to answer it.
Because when we talk about change, I am truly excited to be
living that change right now, as we look at changing from
providing health care to health and bringing patients involved
in making decisions. When we are looking at outcomes, we are
not looking at productivity models but really getting our
populations healthier, which, in the long run, is going to
provide a cost-benefit and it is going to be a more able
fighting force.
It is truly an exciting time in medicine but particularly
in military medicine and MHS as we lead the charge on some of
these initiatives.
Mrs. Davis. Thank you.
Colonel.
Colonel Littlefield. Ma'am, I would concur. I would say the
focus on prevention, as opposed to taking care of it after the
fact, an injury or medical condition; educating the patients on
the importance of that, and not just the Active Duty members
but the families, the retirees, and just placing the importance
on how much more you can save doing that. And the access to
care can become an important factor in that, as well, too, when
you may not have to rush in to get an appointment if you are
taking care.
So I would just say the education on prevention.
Mrs. Davis. Great. Thank you. I appreciate that. And we are
seeing a lot of those changes.
Just very quickly, one of the concerns that was expressed
here at one point was, shouldn't we have fewer OB/GYNs and more
trauma surgeons? You all mentioned--I think most of you
mentioned in your remarks that, you know, obviously, that
preponderance of physicians are really helping to deliver
babies, which is a good thing. But what do you say to people
when they say, shouldn't they be doing that in the community?
Colonel Place. Well, I would frame it a little bit
differently, ma'am, if I could. I think we have to make sure
that we have a broad perspective. You know, we have to respond
to all things. So Ebola, a great example. We have professionals
whose full-time job is to look at those kinds of tropical and
emerging diseases and so forth. We have folks that specialize
in disaster management. So there are a lot of other things
that, frankly, the Nation is going to ask us to do, and we have
to be prepared to do that.
So I always become concerned when we talk about trauma
management, and that is the coin of the realm for what we talk
about, when most of the care that gets provided in theater is
not. I am a family physician, so most of what gets done is what
I do. And every now and then, we go do some trauma too.
Being a combat support hospital commander in Helmand
province with our British colleagues at Camp Bastion and so
forth, I understand trauma and I understand how important it is
to do that well. But there are a lot of other things that we
have to be very good at.
So I would just urge caution if we say that the thing that
is important is trauma, because that is going to leave us a
shortfall in a lot of other things.
Colonel Heimall. And, ma'am, I think that is one of the
things that really makes military medicine unique compared to a
civilian healthcare system. Increasingly, as Ms. Tsongas
pointed out, larger numbers of women serving in our force. One
of the things that we are seeing is an increase in the number
of new cancer diagnoses among our forces every year. A portion
of those are gynecological cancers. It gives us an opportunity
to be able to manage that from a readiness perspective with
those providers and our force.
As Colonel Place said, he is a family physician.
Oftentimes, the first physician that a wounded soldier or
sailor or service member sees on the battlefield is going to be
a pediatrician or a family physician or a cardiologist who is
in a battalion aid station.
We ask those providers to go through advanced trauma life
support and tactical combat casualty care, and then we ask them
to actually execute that on the battlefield. Our civilian
counterparts do not do that with their pediatricians and their
cardiologists and their internists.
Mrs. Davis. Right. Yeah.
Captain Freedman. And I would like to point out that taking
care of families impacts readiness. It is not just a benefit.
This truly impacts the readiness of our Nation. I bring our
commanding generals from Marine Corps Base Camp Lejeune to our
centering room for pregnancy so he can see what happens to the
family members, because that is truly a concern of his because
he knows that impacts readiness. So I think that that is
important.
And the other piece that we do incredibly well in military
medicine is as providers to give disposition to the line
commanders. That doesn't happen in the civilian communities.
You can get a diagnosis, but a disposition--does this marine or
sailor or soldier, airman, do they need to be on light duty?
Can they carry a weapon? Can they do their mission? You can't
learn that overnight. That has to be brought up in the system.
So I think we are very proud to be able to do that.
Mrs. Davis. Thank you.
Thank you all.
Thank you, Mr. Chairman.
Dr. Heck. Thanks.
All right. I have one last question.
Captain Freedman, you talked about some of your innovative
access programs, whether it is using a smartphone or your
advice line. Is that a best practice through BUMED [Bureau of
Medicine and Surgery], or is that something you are just doing
at your facility?
Captain Freedman. Thank you, Chairman.
It is actually brought by Navy Medicine to innovate--and
that is what is great about our system--through our regional
commands to share best practices with each other. So we are not
the only MTF to have a smartphone application. We have an
incredible number of downloads, over 6,000 right now, and
patients are actually using them.
So we learn from each other, but it is not--even though we
developed it at Camp Lejeune, it is something that we share
throughout the services.
Dr. Heck. So it populates amongst the tri-service
community, not just within Navy Medicine.
Captain Freedman. Well, the innovation, I mean, it is an
individual application for our facility. But the concept is
something that we share throughout Navy Medicine. And I think
it is going to really, I mean, I am sure, as you are aware,
will change the way that we deliver medicine in 5 or 10 years
from now.
Dr. Heck. Yeah.
Colonel Place, you got something you want to add there?
Colonel Place. Yes, sir. I would add I know of at least two
Army facilities doing the same thing, that have created similar
apps. And we have talked; as commanders, we get together and
have opportunities to discuss.
So, yes, I think we do a pretty good job overall within the
services of innovating, to try and keep up with what the
expectations are from our beneficiaries. I think that is
important that we do that and they become best practices and
then we disseminate them out. So that whole knowledge
management piece is important, I think, within the services,
and I think we are doing much better at that.
Dr. Heck. Great.
Well, again, I want to thank all of you, the four of you,
for taking the time and hanging here in this very hot room for
an hour and a half and through three rounds of questions.
I found the information very insightful and helpful as we
try to tackle the MHS reform study, when and if we get it, but
certainly in looking forward of how we make the military
healthcare system meet its vision of having a dual readiness
mission of making sure we have ready healthcare professionals
to deploy and we keep our force ready to deploy.
So, again, thank you all very much.
And, Mrs. Davis, thanks for staying so long. I know it has
been a long one.
And we will be adjourned.
[Whereupon, at 3:37 p.m., the subcommittee was adjourned.]
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A P P E N D I X
February 3, 2016
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
February 3, 2016
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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
February 3, 2016
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RESPONSE TO QUESTION SUBMITTED BY DR. HECK
Colonel Place. Prior to 1995, no Level 2 trauma centers supported
Tacoma and Pierce County. All major trauma victims were transported to
Seattle, Washington or Portland, Oregon. In 1995, Madigan Army Medical
Center (MAMC), was approved and received full Washington state
designation as the only Level 2 trauma center serving the Tacoma area.
From 1997-2000, MAMC worked with civilian health systems to establish
civilian Level 2 trauma centers in Tacoma. The Tacoma Trauma Trust was
formed in 2000 and established two civilian Level 2 trauma centers to
serve Tacoma and Pierce County. Trauma duties are split between two
civilian hospitals, St. Joseph Medical Center and Tacoma General
Hospital, alternating coverage every other day. MAMC accepts trauma
patients every day. [See page 9.]
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RESPONSE TO QUESTION SUBMITTED BY MR. MacARTHUR
Captain Freedman. Thank you for your question and the opportunity
to provide additional information. One of the key components of
readiness is to ensure that we hone, train and sustain the clinical
skills of our providers. An important element of that strategy is
ensuring we have the right mix of patients with the appropriate level
of medical complexity to maintain the currency of skills for our entire
clinical staff. To help achieve this at Naval Hospital Camp Lejeune, we
focused on the enrollment of our eligible retired and retiree family
member beneficiaries.
Our multi-phased recapture efforts began with a concentrated and
sustained informational exchange campaign outlining our strategy. Our
team employed multiple information pathways to include our command's
Facebook page, Marine Corps Community Services and Base website
releases, Family Readiness Office exchanges and community media outlet
notifications to inform our retiree population of our plan and solicit
their partnership. Our hospital is an active and pivotal part of our
community and my leadership team and I participated in multiple events
to encourage retiree participation and enrollment. These events occur
throughout the year and included retiree town halls, the annual retiree
appreciation fair, Regiment of Retired Marines Breakfast, Disabled
American Veterans Gatherings, USO/VFW events, Chamber of Commerce,
Military Affairs Committees meetings, and regional TRICARE benefit
briefings.
On the administrative front, we directed policy changes to open
enrollment to the retiree population within a 30 minute drive time to
Camp Lejeune. We focused on service members and families transitioning
from active duty and automatically enrolled all who selected TRICARE
Prime and resided within the Prime Service area, or PSA. Additionally,
we invited retirees currently receiving care in the network to change
their enrollment to NH Camp Lejeune, sending a retiree invitational
letter to 7,702 eligible beneficiaries in the PSA.
As a direct result of these efforts, we have had a 100 percent
increase in the number of enrolled retiree and retiree family members,
growing from 3,861 in January 2014 to an all-time high of 7,891
enrollees as of January 2016. Through this reengagement, we have been
able to meet our commitment to ensuring the readiness of our medical
staff, attracting and retaining the best clinicians while expanding our
clinical capability and service to the operational forces assigned to
Marine Corps Base Camp Lejeune and the local community. Perhaps most
importantly, we have re-affirmed our commitment to serving the most
deserving men and women in the world, those who have worn the cloth of
our nation and the families who support them. [See page 25.]
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