[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]                                    



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                         U.S. GOVERNMENT PUBLISHING OFFICE 

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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.]
                                 ______
                                 
            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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