    [House Hearing, 114 Congress]
    [From the U.S. Government Publishing Office]

                             [H.A.S.C. No. 114-101]

                           ENSURING MEDICAL READINESS

                                 IN THE FUTURE

                                   __________

                                    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 26, 2016

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 _________

                    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
                     Dan Sennott, Professional Staff Member
                    Craig Greene, Professional Staff Member
                               Colin Bosse, Clerk

                                C O N T E N T S

                                  ----------
                                                                       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

    Caravalho, MG Joseph, USA, Joint Staff Surgeon General, U.S.
      Department of Defense..........................................     3
    D'Alleyrand, LTC Jean-Claude G., M.D., USA, Chief, Orthopaedic
      Traumatology Service, Walter Reed National Military Medical
      Center.........................................................    23
    Hogg, Maj Gen Dorothy, USAF, Deputy Surgeon General, United
      States Air Force...............................................     4
    Lawrence, Col Linda, M.D., USAF, Special Assistant to the Air
      Force Surgeon General for Trusted Care Transformation, Office
      of the Air Force Surgeon General, United States Air Force......    20
    Mabry, LTC Robert L., M.D., USA, Robert Wood Johnson Health
      Policy Fellow, U.S. House Committee on Energy and Commerce.....    22
    Moulton, RADM Terry J., USN, Deputy Surgeon General, United
      States Navy....................................................     7
    Tenhet, BG Robert, USA, Deputy Surgeon General, United States
      Army...........................................................     6

                                    APPENDIX

    Prepared Statements:

        Caravalho, MG Joseph.........................................    39
        D'Alleyrand, LTC Jean-Claude G...............................    99
        Hogg, Maj Gen Dorothy........................................    46
        Lawrence, Col Linda..........................................    78
        Mabry, LTC Robert L..........................................    83
        Moulton, RADM Terry J........................................    68
        Tenhet, BG Robert............................................    59

    Documents Submitted for the Record:

        [There were no Documents submitted.]

    Witness Responses to Questions Asked During the Hearing:

        Mr. O'Rourke.................................................   109
        Mr. Zinke....................................................   109

    Questions Submitted by Members Post Hearing:

        Mr. O'Rourke.................................................   113

                    ENSURING MEDICAL READINESS IN THE FUTURE

                                  ----------

                      House of Representatives,
                           Committee on Armed Services,
                            Subcommittee on Military Personnel,
                             Washington, DC, Friday, February 26, 2016.
        The subcommittee met, pursuant to call, at 9:28 a.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 this subcommittee
    meeting of the Military Personnel Subcommittee to order.
        I want to welcome everyone to the hearing of the Military
    Personnel Subcommittee to receive views on how best to ensure
    our future military medical readiness. This hearing is part of
    the committee's ongoing project to comprehensively review the
    current state of the Military Health System and military health
    care and, based on this information, identify areas that need
    improvement.
        Our purpose today is to discuss the top priority of the
    Military Health System: to ensure the medical readiness of our
    military forces, while also ensuring a ready medical force
    prepared to deploy in support of combat operations.
        Over the past 14 years of conflict, the services have
    worked tirelessly to improve medical readiness, ensuring both
    service members and medical providers are able to deploy and
    accomplish their missions. The medical readiness rates for each
    of the services have seen double-digit growth, as commanders
    and healthcare providers work together to identify and
    eliminate barriers to deployability.
        Combat medicine has also seen extraordinary advances,
    resulting in service member survival rates that were once
    thought unachievable. In many areas, the standards of care have
    been redefined as advances in areas ranging from transfusion
    medicine to casualty transport care reshape combat medicine.
    These crucial advances have not only benefited the military but
    civilian medicine as well.
        Many of these advances were made possible by the tireless
    efforts of military practitioners. Even in peacetime, military
    healthcare providers have the complex job of maintaining the
    medical readiness of service members at home stations while
    also manning, equipping, and deploying medical units with
    medical personnel who are trained in both military skills and
    specialized medical skills needed for wartime medicine.
        The hard-fought advances in combat care over the past 14
    years must be preserved. The medical specialties needed during
    war are not limited to trauma; however, during periods of
    limited deployment, trauma skills can quickly degrade, which is
    why we must do everything possible to maintain proficiency in
    both trauma and emergency medicine. It is crucial that military
    trauma teams have the proper patient volume and case complexity
    during times of limited deployment so that they can maintain
    the skills needed in combat.
        We will hear today from two panels, the first panel
    consisting of the Joint Staff Surgeon and service Deputy
    Surgeons General who can provide valuable insights regarding
    service-wide initiatives, and the second panel comprised of
    practitioners who can provide perspectives on the current
    challenges facing military emergency medicine and trauma
    practitioners.
        I look forward to hearing from our panels about the current
    efforts underway by the services to ensure we maintain high
    service member readiness and provider readiness during periods
    of limited deployment. In addition, I am interested to hear how
    the services ensure medical providers maintain their
    specialties, particularly in areas where patient volume is
    limited. Finally, I look forward to hearing the challenges
    facing practitioners as they look for innovative ways to
    maintain proficiency during periods of limited deployment.
        Before I introduce our panel, let me offer the ranking
    member, Mrs. Davis, an opportunity to make her opening remarks.

        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 from both of our panels this morning.
        This hearing should afford us the opportunity to hear a
    variety of perspectives on medical readiness. And, as you all
    know very, very well, nothing that we have to tell you, medical
    readiness is the foundation for which the military services'
    medical systems are built, not just the readiness of service
    members who are trained and proficient but also the readiness
    of the providers who ensure those service members are always
    fit to perform their mission.
        So much of the discussion on military readiness has been
    focused on trauma specialties in combat and how to maintain the
    skills the medical community has gained over the last 15 years
    of persistent conflict. I am interested to follow up on the
    discussion in your written statements about the development of
    the essential medical capabilities, as well as how each of the
    services maintains visibility over provider readiness to ensure
    that we have the proper number of trained providers when
    needed, and how you manage the trauma specialties, trying to
    track that. And I think, for all of us who are not immersed in
    this in the way that you are every single day, understanding
    how that really occurs has got to be important as well.
        I also want to acknowledge and thank the chairman for
    mentioning the contribution to civilian medicine that our armed
    services have made and the medical providers have made to our
    country. Staggering and incalculable, and I appreciate that
    greatly.
        Thank you, Mr. Chairman, and I look forward to the hearing.
        Dr. Heck. Thank you, Mrs. Davis.
        We are joined again today by two outstanding panels. We
    will give each witness the opportunity to present his or her
    testimony and each member an opportunity to question the
    witnesses.
        I would respectfully remind the witnesses to summarize to
    the greatest extent possible the highpoints of your written
    testimony in 5 minutes. The lighting system will be green. At 1
    minute remaining, it will turn yellow. When it turns red, I ask
    you to quickly try to summarize and finish up your testimony so
    we can move on through.
        Let me welcome our first panel: Major General Joseph
    Caravalho, Joint Staff Surgeon, Office of the Chairman of the
    Joint Chiefs of Staff; Major General Dorothy Hogg, Deputy
    Surgeon General, United States Air Force; Brigadier General
    Robert Tenhet, Deputy Surgeon General, United States Army; and
    Rear Admiral Terry Moulton, Deputy Surgeon General, the United
    States Navy.
        I ask unanimous consent that non-subcommittee members be
    allowed to participate in today's hearing after all
    subcommittee members have had an opportunity to ask questions.
    Without objection, non-subcommittee members will be recognized
    at the appropriate time for 5 minutes.
        With that, Major General Caravalho, you are recognized for
    5 minutes.

      STATEMENT OF MG JOSEPH CARAVALHO, USA, JOINT STAFF SURGEON
                  GENERAL, U.S. DEPARTMENT OF DEFENSE

        General Caravalho. Thank you, Chairman Heck, Ranking Member
    Davis, and distinguished members of the subcommittee. I am
    pleased to be seated alongside my colleagues, and I am
    especially grateful for the opportunity to discuss medical
    readiness with you today.
        My written testimony has been submitted for the record.
    Today, I would like to highlight three points in my oral
    testimony.
        However, as this is my first opportunity to meet with this
    committee in my capacity as the Joint Staff Surgeon, I would
    like to first take a moment to tell you about my role.
    Essentially, I have the responsibility to provide the Chairman
    of the Joint Chiefs of Staff and other senior leaders with the
    best military medical advice in support of the joint force.
        In my role as the facilitator for global medical
    synchronization, I work with other Joint Staff directorates to
    service Surgeons General and the Assistant Secretary of Defense
    for Health Affairs to meet the Chairman's intent in delivering
    health services to the combatant commanders and the joint
    force.
        Now, first of all, I would like to say I am extremely proud
    of the accomplishments to date of the joint medical force
    across the full spectrum of military operations. And with the
    Chairman's vision of future security environments, my first
    point is military medicine must be better aligned to
    continually demonstrate its readiness posture to the
    Department's senior leaders.
        It is my observation the joint force expects military
    medicine to be more than interoperable and, at times, more than
    joint. I believe whenever and wherever feasible, while
    remaining cognizant of service responsibilities, to best
    support the joint force, the services' medical forces must be
    interchangeably aligned.
        The Chairman's recently published Joint Concept for Health
    Services moves us in that direction. Now, this document
    describes in broad terms the Chairman's vision for what the
    future joint force will need from military medicine to support
    globally integrated operations.
        To this end, the services have begun work on establishing
    core medical specialty requirements that will aid in creating a
    more interchangeable joint medical force. Readiness metrics
    will then reflect each medical specialty's ability to function
    across the full spectrum of military operations.
        Next, I have also observed an increasing number of requests
    for medical support to smaller, more widely dispersed ground
    forces, and I expect this trend to continue. With this, my
    second point is the medical community must adapt to new
    paradigms of health service support. To meet this challenge, we
    have already begun work towards a formalized and disciplined
    review to develop new organizations, training, policies, and
    doctrine.
        My third point is I view military medical centers,
    hospitals, and clinics as our home stations' front lines of
    care. They provide ready warfighters and medical forces alike,
    while delivering quality health care to our valued
    beneficiaries. Then, both during and following deployments,
    they offer continued high-quality care for those in need.
        Now, these platforms should not be compared directly to
    civilian healthcare facilities, as we are focused primarily on
    readiness.
        In conclusion, military medicine has but one mission, and
    that is to support the joint force with globally integrated
    health services. We will not lose focus on the world-class
    health care our service members and families deserve, but it
    will be performed in support of our primary mission of medical
    readiness.
        From home station to operational deployments to evacuation
    and post-deployment settings, I feel strongly the military
    medical team across all the services will remain relevant,
    adaptive, and highly valued members of the joint force.
        Thank you for the opportunity to address the committee and
    for your enduring support of our service members and their
    families.
        [The prepared statement of General Caravalho can be found
    in the Appendix on page 39.]

        STATEMENT OF MAJ GEN DOROTHY HOGG, USAF, DEPUTY SURGEON
                    GENERAL, UNITED STATES AIR FORCE

        General Hogg. Chairman Heck, Ranking Member Davis, and
    distinguished members of the committee, thank you for the
    opportunity to come before you today to discuss the future of
    Air Force medical readiness.
        Fielding ready medics is the key to providing world-class
    health care at home and in the deployed environment. Let me
    illustrate this point.
        Last week, Craig Joint Theater Hospital in Afghanistan
    admitted a NATO [North Atlantic Treaty Organization] patient
    suffering from adult respiratory distress syndrome. The patient
    ultimately needed extracorporeal membrane oxygenation, or ECMO,
    and aeromedical evacuation to Landstuhl Regional Medical Center
    in Germany.
        While awaiting evacuation, the patient's oxygen levels
    decreased rapidly, leading to a life-threatening irregular
    heart rate, resulting in advanced cardiac life support and
    kidney dialysis. Craig's critical care medical team jumped into
    action to stabilize the patient and prep him for immediate
    evacuation.
        The complexities of this emergency illustrate the medical
    readiness skills required of our medics in managing not only
    trauma patients but nontrauma patients as well. This level of
    readiness is achieved through caring for complex patients with
    similar disease etiologies in our Military Health System.
        Every Air Force military treatment facility is a medical
    readiness platform aligned with an operational wing that
    directly enhances the medical readiness of warfighters and
    their families. The care we provide our beneficiaries enables
    us to sustain the readiness of our medical force. And our
    readiness is directly related to the volume, diversity, and
    acuity of our patient population.
        The Air Force Medical Service has a broad portfolio of
    readiness training programs to prepare individual medical
    specialists and deployable medical teams for reliable
    performance across the full range of military operations. The
    readiness portfolio spans care provided within our MTFs
    [military treatment facilities] to specialized advanced trauma
    training delivered in our civilian Level I trauma partnership
    platforms.
        Our Readiness Skills Verification Program establishes
    baseline skills required in a deployed environment. These
    skills are identified by senior clinical consultants and
    enlisted functional area managers based on combatant
    commanders' requirements and are updated with lessons learned
    and emerging medical evidence.
        In tandem, the Sustained Medical and Readiness Trained, or
    SMART, program expands training opportunities for skills
    requiring a higher volume and complexity of hands-on care than
    normally seen in our smaller military treatment facilities,
    utilizing local training affiliations or regional currency
    sites, such as the University Medical Center in Las Vegas,
    Nevada.
        For well over a decade, we have also had cadres of
    physicians, nurses, and technicians embedded in our Centers for
    Sustainment of Trauma and Readiness Skills, known as C-STARS,
    located in Baltimore, Cincinnati, and St. Louis. Hundreds of
    our medics have received elite trauma and critical care
    training and remain prepared to deploy anytime, anywhere.
        Similarly, Air Force graduate medical education programs
    develop the knowledge, skills, and attitudes of highly
    qualified medical personnel while supporting the Air Force
    Medical Service missions. These training programs deliver
    health care to our military members and other beneficiaries,
    ensures the competency and currency of medical personnel, and
    contributes to the readiness of medical airmen.
        The Air Force Medical Service is committed to preserving
    the medical skills obtained in the last 15 years of conflict
    and will continue to meet the evolving requirements of
    combatant commanders. With your support, we will continue to
    provide trusted and reliable health services to our airmen and
    their families for years to come.
        Thank you, and I look forward to your questions.
        [The prepared statement of General Hogg can be found in the
    Appendix on page 46.]

      STATEMENT OF BG ROBERT TENHET, USA, DEPUTY SURGEON GENERAL,
                           UNITED STATES ARMY

        General Tenhet. Chairman Heck, Ranking Member Davis, and
    distinguished members of the subcommittee, thank you for this
    opportunity to provide the Army perspective on ensuring medical
    readiness now and into the future.
        Today's uncertain global environment continues to place
    high demands on the Army. Over the past year, the Army deployed
    over 190,000 soldiers to more than 140 countries around the
    world in support of various operations. Readiness is the Army's
    number one priority.
        And, as Ranking Member Davis mentioned earlier, our trained
    and ready medical force contributed to the highest
    survivability rate in the history of warfare despite the
    increasing severity of battle injuries. These advances in
    combat casualty care are primarily due to the integrated system
    of health that currently extends from the battlefield through
    Landstuhl Regional Medical Center in Germany to our in-patient
    hospitals in the United States.
        Today, we are faced with the question of how to sustain the
    competency of our medical force, which has performed so well in
    the past 14-plus years. During the second panel, you will hear
    from two combat-tested Army physicians, Lieutenant Colonel Bob
    Mabry, an emergency medical physician and certified pre-
    hospital physician specialist, and Lieutenant Colonel Jean-
    Claude D'Alleyrand, an Army trauma orthopedic surgeon, who will
    discuss challenges in pre-hospital care as well as maintaining
    surgical skills.
        However, we must not focus exclusively on the sustainment
    of combat trauma, surgery, and burn capabilities. Our Army and
    soldiers must be prepared for a multitude of contingency
    missions: to engage in conventional conflict against large
    armies and smaller, as mentioned by our Joint Surgeon; defend
    the homeland; and respond to a wide range of crises, ranging
    from peacekeeping to disaster relief and humanitarian
    assistance.
        The Army must maintain a broad range of medical
    capabilities to support this full range of military
    requirements. The 2014 deployment of 2,500 personnel to support
    Operation United Assistance in Liberia demonstrated the value
    of non-trauma-related medical specialities. Some argue these
    examples are not part of our mission set for ready and relevant
    medical support, but, invariably, when the task is unique and
    difficult, the Nation leans on its military.
        To ensure the readiness of the entire medical team for this
    broad range of missions, we must maintain and sustain our
    medical centers, hospitals, and clinics as our readiness and
    training platforms. This system ensures our medical force is
    trained, ready, and relevant to provide primary and specialty
    care in the myriad settings and conditions faced around the
    world.
        We must continue to develop innovative partnerships with
    the VA [Department of Veterans Affairs], civilian hospitals,
    and other organizations to ensure our entire medical team
    continues to be exposed to a varied and complex mix of
    patients. This is essential to train, challenge, and to hone
    the skills of our entire medical team.
        In addition, we must continue to train the next generation
    of the Army Medicine team through our graduate medical
    education programs. These programs are vital to our ability to
    recruit and retain highly skilled medical providers. Most
    importantly, these programs are the primary means of
    transferring knowledge from this generation of military
    providers to the next.
        While our system has proven to be very successful over the
    last 14 years, we must continue to improve and evolve it to
    meet the challenging needs of our Nation's Army. Since the
    beginning of our Nation's history, when we send our Nation's
    sons and daughters into harm's way, they need to know that the
    Army Medicine is there, relevant, and ready.
        I am committed to ensuring we maintain and improve the
    readiness of our medical force. I look forward to working with
    Congress in this endeavor. And I want to thank my partners in
    the DOD [Department of Defense], my colleagues here on the
    panel, and Congress for your continued support.
        [The prepared statement of General Tenhet can be found in
    the Appendix on page 59.]

        STATEMENT OF RADM TERRY J. MOULTON, USN, DEPUTY SURGEON
                      GENERAL, UNITED STATES NAVY

        Admiral Moulton. Good morning, Chairman Heck, Ranking
    Member Davis, distinguished members of the committee. Thank you
    for providing me the opportunity to share some perspectives on
    Navy Medicine and our most important strategic priority,
    medical readiness. We are grateful to the committee for your
    leadership and strong support of military medicine.
        Force health protection is the bedrock of Navy Medicine. It
    is what we do and why we exist. And this mission spans the full
    spectrum of health care, from optimizing the health and fitness
    of the force, to maintaining robust disease surveillance and
    prevention programs, to saving lives on the battlefield.
        And on any given day, Navy Medicine is underway and
    operating forward with the fleet and the Marine forces around
    the globe. We operate in all warfare domains, in all
    environments, and must also deliver important specialized
    capabilities to the warfighters. Our personnel, whether an
    independent duty corpsman, a flight surgeon, an undersea
    medical officer serving aboard a submarine, a ship, or
    squadron, or a fleet Marine force corpsman in the field with a
    Marine unit, must be trained and equipped to execute their
    specific mission.
        Our readiness posture also requires us to be capable of
    meeting critical surge requirements in support of contingencies
    and combat operations. And Navy Medicine's expedition medical
    capabilities are important as we provide that care through all
    the echelons of care, from the battlefield to the bedside of
    our military treatment facilities.
        This is clearly evident as Navy Medicine continues to
    sustain unparalleled levels of mission success, competency, and
    professionalism while providing world-class trauma care and
    expeditionary force health protection to U.S. and coalition
    forces in southern Afghanistan.
        It also enables us to support humanitarian assistance and
    disaster response missions since our hospital ships have the
    capability to provide relief in the wake of catastrophic events
    like tsunamis and earthquakes. And our global health engagement
    strategy requires us to be ready to support these diverse
    missions around the globe.
        I cannot overstate the importance of our military treatment
    facilities in ensuring readiness of our personnel. The ability
    to deliver the full range of medical capabilities to the
    operational commander is highly dependent on the training and
    clinical currency of our personnel. And our MTFs are critical
    to providing these skills and competencies and must remain
    foundational to meeting our current and future operational
    requirements.
        Navy Medicine also continues to leverage our strategic
    partnerships with leading civilian trauma centers so our
    personnel can hone and sustain their skills, including the Navy
    Trauma Center at LA [Los Angeles] and USC [University of
    Southern California] Medical Center. And this program has
    trained over 2,800 of our deploying medical personnel since
    2002 and continues to enhance their combat trauma skills and
    medical readiness.
        And it is also important to recognize that our GME
    programs, graduate medical education programs, at our medical
    centers and our family medicine teaching hospitals support
    readiness by providing trained physicians to meet our
    operational requirements. And these programs rely on our MTFs
    having access to robust beneficiary populations and support our
    case number and complexity.
        The services, along with the Joint Staff and DOD, are
    working to identify, define, categorize, and prioritize
    essential medical capabilities, or EMCs. These refer to those
    health services that are required to deliver comprehensive
    health care in support of globally integrated operations and
    will provide the framework for maintaining the medical ready
    force.
        In the last 15 years of war, I have seen unprecedented
    advances in military medicine, and this progress was the result
    of a highly trained and well-equipped force dedicated to
    rapidly deploying the most effective lifesaving skills and
    techniques. And all of us in military medicine are committed to
    ensuring the lessons learned are sustained and effectively
    implemented throughout the MHS [Military Health System], and we
    are committed to continuous improvement. And these efforts
    require rigorous ongoing assessment of our capabilities,
    identification of gaps, and implementation of sound solutions.
    And all of us recognize that there is hard work ahead for that,
    to maintain medical readiness moving forward.
        Again, thank you for your support, and I look forward to
    your questions.
        [The prepared statement of Admiral Moulton can be found in
    the Appendix on page 68.]
        Dr. Heck. Thank you all for your testimony.
        We will begin the 5-minute round of questioning by members.
        A recent study of military medical staff concluded that the
    military seems to understaff operationally required specialties
    and overstaffs specialties more towards providing beneficiary
    care.
        So I would ask, how do the services balance maintaining
    that mix of having the docs needed or the entire healthcare
    spectrum needed to take care of military beneficiaries or to
    maintain their combat skills? And I would guess that part of
    the EMCs is going to help define that.
        For instance, you know, you look at certain facilities and
    there seems to be an abundance of OB-GYN [obstetrics and
    gynecology] and pediatrics, understanding that in humanitarian
    care we have to be prepared to provide those things, but not
    necessarily the level or the number of specialists or
    specialties required to provide combat casualty care.
        So that would be my first question.
        And to follow on to that, when we try to maintain the level
    of training of, let's say, our teams that are going to provide
    combat casualty care, I think, General, you mentioned your
    SMART program, and I appreciate the shout-out to University
    Medical Center, my former place of employment.
        But how do we ensure that the entire team--the
    anesthesiologist, the medic, the nurse, everybody--is trained,
    as opposed to just rotating out the trauma surgeon to a Level I
    trauma center?
        So whoever wants to tackle it first, we can just go down
    the line.
        General Hogg. Yes, sir, I will take that.
        So we need to maintain the readiness not only of our Active
    Duty members but of our families also. And the OB-GYN and the
    pediatric care that we provide help us to maintain that family
    readiness so that when that Active Duty member is deployed they
    have confidence that their family will be taken care of. And,
    also, those specialties will provide some military medical
    readiness due to complications that might occur during those
    episodes of care.
        The ability to get the whole team trained can be
    challenging at times. Most of the specialty care that we get
    within the Air Force Medical Service, we rely on our civilian
    partners to help achieve that. And it is at their mercy whether
    they want us to come into their facility. There is nothing
    compelling them, per se, to partner with us.
        We do have some challenges with our technicians, our
    technical specialties, getting them into the civilian
    facilities, because they are not equivalent. The civilian
    community doesn't really understand their equivalencies. Once
    we get them in the door, they are all on board and usually ask
    us, do you have more?
        And so we try by getting in the physician and the nurse,
    and then, once we get them into our partnerships, we tag along
    a technician. And once they see the capabilities of our
    technicians, usually that helps.
        Dr. Heck. Anybody else want to add?
        General Tenhet. I will add to General Hogg's comments here.
        In a deployed setting, trauma care takes up about 15
    percent of the numbers we see in theater, so 85 percent of
    those are disease/non-battle injury. In any given camp or FOB
    [forward operating base], you may have upwards of 30 percent
    females. So just with the OB-GYN, I mean, gynecologists in
    theater is not a misnomer.
        So, of the evacuations used in the wonderful Strat Air
    [Strategic Airlift] that the Air Force has, 80 percent of our
    evacs [evacuations] are disease/non-battle injury as well. So
    to sustain just within the trauma system itself, we have to
    look across the entire spectrum of medicine.
        And as you talked about the--or asked the question on the
    OR [operating room] piece, we estimate it takes up to 80 staff
    members to support 1 OR. So it becomes a convoluted system to
    try and train to standard using the team approach and
    collective training.
        So our forward surgical teams you are probably familiar
    with, we do take them into team training, collective training
    down at Ryder in Miami. And we are looking to expand that
    across the U.S. and maybe even globally as we go into the
    interwar years.
        Admiral Moulton. Sir, I would just comment to your first
    question, you know, about maintaining the balance, how do we
    ensure that we are meeting our operational requirements and
    then the peacetime care as well, for us, there are priorities
    for distribution of our resources.
        First of all, we are going to support the operational
    requirements. That is 100 percent staffing. And then we would
    look to our overseas activities, which are forward-deployed.
    And then, lastly, is our MTFs. And then they are augmented by
    civilians and contractors to maintain that skill and to build
    that credibility before deploying again.
        And then the second question, back to the entire team,
    rather than just the trauma surgeons or surgeons in general,
    you know, we are moving back to a platform readiness. And for
    the last 15 years, we have been doing a lot of individual
    augmentations, so now, moving back to platform readiness, we
    can train the whole unit. You will know where you are assigned,
    and you will know what the training requirements are for that
    platform, and then you will train as a team before deployment.
        Dr. Heck. Okay. Thank you all. My time has expired.
        Mrs. Davis.
        Mrs. Davis. Thank you, Mr. Chairman.
        And I wanted to go back just to the EMCs, the essential
    medical capabilities, for a second. Obviously, you have been
    working on it very hard, I think, but when do you expect to
    complete them? And how long will it take to implement across
    the individual force?
        General Hogg. Yes, ma'am. So the Air Force Medical Service
    supports the development of the EMCs, and we have been actively
    engaged in defining what those are.
        The timeframe, we will have the beginnings of some
    essential medical capabilities, I believe, in October of this
    year. And then the implementation, right now I really don't--we
    haven't got the timeline for that.
        General Caravalho. Ma'am, if I may say that the EMCs are
    primarily going to describe what is already being done by the
    services now, except that they are using the civilian
    healthcare model of are you board-certified, are you
    credentialed, licensed, and privileged. The EMCs is going to
    put it--I believe is going to be very helpful because it will
    put it into the DOD reporting system style so that now senior
    leaders can say are my medics ready, just like are my
    submariners ready and are my aviators ready.
        Mrs. Davis. Uh-huh.
        General Caravalho. I will speak--I think it will speak to--
    it won't be too high-level, it won't be strategic, in that
    ``take care of patients,'' of which everything falls within.
    And it won't be too tactical, to say what do our
    ophthalmologists do and what do our cardiologists do. It is
    going to be along the lines of providing hospitalization,
    providing patient movement, something along those lines, under
    which, then the essential task list will be generated by the
    services and the primary skills, attributes that everyone will
    need.
        And I believe each provider will then be able to say,
    regardless of my specialty as an NCO [noncommissioned officer]
    or as an officer, what do I bring to this fight. So I may not
    be a general surgeon, but I will be asked to be a surgeon; what
    are the skills I will need to be a surgeon in any realm that I
    am asked to participate, whether major combat operations,
    humanitarian assistance, or what have you.
        I think that is how that is going to play out. I think we
    will start to be, as was mentioned, start to be able to codify
    that in a Department's reporting system later this year.
        Mrs. Davis. Uh-huh. Do you think, I mean, you have pretty
    much described this right now, I think, that--do you see a
    major impact on training requirements then? Is that really
    going to----
        General Caravalho. I think we are going to--we are not
    going to create a new system. I think we already, I think the
    services already know proficiency and currency using the peer
    review, the systems that civilian healthcare industry uses. We
    are just going to codify it and report it so that the senior
    leaders know that, no matter what I ask you to do, fight
    tonight, sustain operation, are you able to do--are you able to
    fight. I am hoping then that, whether they ask for Army or Navy
    or Air Force, no matter what the Chairman is looking for, it
    won't matter because we are using the same codified skill sets.
        Mrs. Davis. Uh-huh.
        General Caravalho. And if we are truly interchangeable and
    one service is short a surgeon, for instance, using EMCs, we
    can look to another service and say, okay, you have met the
    standard, can you come in and fill, as opposed to it must be
    all Army or all Navy or all Air Force every time there is a
    requirement.
        Mrs. Davis. Yeah.
        Could you all respond? I mean, does that make a real
    difference?
        General Tenhet. So when we get into the KSAs [knowledge,
    skills, and abilities]--so you build the EMCs, that is the
    overarching codification of this. And we are looking at 10,
    primarily, at this point in time. We haven't solidified that
    yet, but that is where I think we are going to go with this.
    It, oh, by the way, mirrors into the joint concept of health
    support, so that is process and progress in that model.
        But concomitant with the EMC is the knowledge, skills, and
    abilities that we are aligning across the services. And that
    gets into both the operational and down to the tactical level
    of the individual. So, within that construct, it is going to be
    a scorecard, just like the infantry uses in their unit status
    reporting; are they green, amber, or red. We are going to apply
    that to medicine.
        Mrs. Davis. Yeah. But is this going to be on an individual
    basis then? Will you know whether one specific physician is
    ready?
        General Tenhet. Absolutely. Absolutely.
        General Hogg. Yes, ma'am.
        Mrs. Davis. And is that true, that you don't know today?
        General Hogg. No, ma'am, we do know today. In the Air Force
    Medical Service, we have, I mentioned in my oral statement
    about the Readiness Skills Verification Program. Every medic in
    the Air Force Medical Service has a readiness skills
    verification checklist, if you will, that identifies the skills
    that are necessary for them to be competent in wartime
    scenarios or over the full range of military operations.
        That is looked at on a regular basis. Some of the training
    is knowledge-based, some of the training is didactic, and some
    of the training is hands-on. And they are required to complete
    those skills, depending on the timeline, in order to stay
    current.
        Mrs. Davis. Uh-huh. But in terms of, once this is
    operational, I understand it is not new to the system, but
    there is added value to it.
        General Caravalho. Yes, ma'am. If I may give an example of
    where we are short now, if you have a general surgeon who goes
    on to a fellowship and does plastic surgery and now she is
    practicing as a plastic surgeon for 10 years, when we deploy
    her, we will need her as a general surgeon, and she may never
    have been in someone's belly operating for 10 or 15 years. We
    track her as a competent, board-certified, credentialed,
    privileged plastic surgeon, and we lose sight of the general
    surgery part.
        EMCs will say, no matter where you are, when you deploy,
    have you met the skills and attributes we are looking for in a
    deployed setting.
        Mrs. Davis. Okay. Great.
        And for our specialty nurses, just a yes or no, is it going
    to be the same?
        General Hogg. Yes, ma'am, it is the same.
        Mrs. Davis. Okay. Thank you.
        Dr. Heck. Mr. O'Rourke.
        Mr. O'Rourke. Thank you.
        Not sure to whom I should address this question, but I am
    interested in the IDES, or the Integrated Disability Evaluation
    System, that is supposed to ensure that a wounded or disabled
    service member is either reintroduced back into Active Duty or
    the appropriate Reserve Component or is able to seamlessly
    transition out into VA medical care. And, following the
    flowchart the Department of Defense has published, it looks
    like that process should take about 295 days.
        So I guess my first question is: Are we, in fact, returning
    service members to Active Duty status in that time or helping
    them to separate in that time with a VA disability rating, or
    are we at some other mark either above or below 295?
        General Hogg. Yes, sir. In the Air Force system, IDES
    system, it is a collaborative process between DOD and VA, and
    parts of those process are owned by those two entities.
        In the part that the Air Force owns, the Air Force Medical
    Service owns, we are doing actually very well with getting
    members through, but the total process still is a little bit
    over the 295 days.
        Mr. O'Rourke. Do you know what it is for the Air Force?
        General Hogg. No, sir. I would have to get back to you with
    that.
        Mr. O'Rourke. Okay, for the record.
        And for anyone else, if anyone has a specific number, I
    would love to hear it now. If not, we would just request that
    as a followup question for the record.
        [The information referred to can be found in the Appendix
    on page 109.]
        Mr. O'Rourke. General Tenhet, did you want to add to that?
        General Tenhet. I was just going to mention we are at 291.
    However, you know, the Army's injuries, we have had some
    complex issues that keep that number around that window there.
        Working with the VA, we have improved that significantly in
    the last 4 to 5 years. And some of that has been from the
    pressure from Congress to work more collaboratively together.
    And also it is being able to share the documentation through
    Legacy Viewer, et cetera. Any and all medical interaction is
    now documented and shared across both the VA and DOD.
        Mr. O'Rourke. That gets to a followup question I would like
    to ask you, which is, I don't know how to gauge whether 295 is
    a lot of time or the appropriate amount of time, but there are
    certainly several stages, dozens of stages actually, in this
    process, some of which the service member has the opportunity
    to appeal a decision or make some other decision on his or her
    part, and then decisions that are made by the Department of
    Defense, decisions that are made by the VA.
        Do you see any obvious opportunities to further streamline
    this process, gain greater efficiencies, and ensure that the
    service member returns to duty or is able to transition out
    effectively and be in the care, again effectively, of the VA so
    that nothing is dropped?
        General Tenhet. There is always room for improvement, as a
    learning organization. The medicine peace of that window is
    actually a very small piece. It is mostly administrative. And I
    think all the services, medically, are meeting their mark. I
    think the coordination with the VA and working with our G-1
    [Deputy Chief of Staff of the Army] through the administrative
    piece of this, we can always continue to tighten that piece up.
        But it is back on the soldier. Fifty percent of those just
    2 years ago were being returned to service. We are down to
    about 40 percent, again, because of the remaining complex
    issues that we have.
        But the ability to work with the VA, the warm handoff, and
    also implementing the case management structure into this has
    really enhanced the program.
        Mr. O'Rourke. I have another question that may, because of
    limited time for you to answer, be appropriate to get for the
    record or to have an offline conversation. But in terms of that
    warm handoff, anecdotally, in talking to veterans in El Paso
    who served at Fort Bliss and were treated at William Beaumont
    Army Medical Center, they talk about excellent care at the
    military treatment facility, especially when it comes to mental
    health. They then say that regimen of care which was so
    expertly executed at William Beaumont, once I transitioned to
    the VA, it was very hard to see a psychiatrist or a
    psychologist or even a social worker to continue that care.
        So I understand the goal. It is not happening. I would
    love--and there is not time for you to respond right now, but I
    would love to get your thoughts, either in writing or offline,
    about how we can do a better job and what role specifically the
    Army or Department of Defense could play in extending that care
    if somebody is already in treatment.
        Mr. O'Rourke. With that, I will yield back to the Chair.
        Dr. Heck. Mr. Knight.
        Mr. Knight. Thank you, Mr. Chair.
        I just have some basic questions.
        You know, in California, we have opened another medical
    school out there because of the deficiency for surgeons and
    doctors that we have in California and across the country. Are
    we finding that in Army and Navy and Air Force Medicine, that
    we are not getting enough applicants, that we are not having
    enough surgeons and doctors?
        General Hogg. No, sir. We staff to our requirements, and so
    we typically have plenty of applicants to attend our military
    medical programs.
        Admiral Moulton. And for the Navy, I would say, as well,
    that our recruiting efforts have been very successful over the
    last several years. So we are not facing any shortages there.
        General Tenhet. Same for the Army, sir.
        I think our challenge is the retention piece of this.
    Especially as the wars start to wane, especially in the trauma
    medicine arena, the retention portion of this becomes more
    challenging as we go forward.
        Mr. Knight. Okay.
        And as we have been at war now for 15 years, and for some
    purposes for the last 25 years, we have seen readiness be the
    number one goal. And I think that should always be the number
    one goal in the military, is readiness.
        But as our young men and women have gone into theater two,
    three, four, five times, we have started to see an awful lot of
    things that maybe we dealt with in other wars, maybe in Vietnam
    and Korea and World War II, but they are very prevalent today.
    We have renamed these things. I think in World War II we named
    it ``shell shock,'' and today we have ``PTSD'' [post-traumatic
    stress disorder] and ``traumatic brain'' and things like that.
    They are all an effect of seeing something that normal people
    don't ever want to see, and that affects someone.
        How are we treating that differently today than maybe we
    did 15 or 20 years ago?
        General Hogg. Yes, sir. I think that the biggest way that
    we are treating that differently is recognizing that it does
    exist and that it does have an effect on our members coming
    back from being exposed to those kinds of circumstances.
        We certainly have increased our mental health care, and we
    continually look to practice evidence-based medicine in
    relationship to PTSD and TBI [traumatic brain injury]. And we
    continue to care for those individuals coming back.
        General Tenhet. I will just add to the comments. I think
    just admitting that we do have these problems, Congress
    supporting the efforts--$184 million in the last 15 years in
    research. We are working with the NCAA [National Collegiate
    Athletic Association], the NFL [National Football League], with
    their programs, making tremendous strides there. I think it is
    450 research programs ongoing right now just in our Medical
    Research and Materiel Command.
        Mr. Knight. Admiral.
        Admiral Moulton. I was just going to also talk about the
    partnerships that we have had, reaching out to UCLA [University
    of California at Los Angeles] and our NICoE [National Intrepid
    Center of Excellence] and really approaching it across the
    system vice in isolated areas. So I think we are making good
    strides in that.
        Mr. Knight. And just in my last minute here, recently I
    have sat down with some folks that are working on new and
    innovative ways of treating our folks on the battlefield. Some
    of them are these bandages where you can see if they are
    actually healing or if it is not healing and things of that
    nature and under-the-skin type of treatments that we can check
    and we can monitor if it is working or if it is not working or
    if the skin is healing or not healing.
        Have we seen that because we have been at war in the last
    15 years more? Or is that just because we are getting more and
    more advanced in the medical field?
        General Hogg. I will take that one too.
        It is both. It is both. I think that as you are exposed to
    situations and you deliver care, you are always thinking about,
    could I do this better and, if so, how could I do that better?
    So our research programs are helping us to look at those
    specific care issues and figure out how could we do it better
    to improve the survivability of our warfighters downrange.
        So I think it is both. It is technology is advancing and we
    are able to capitalize on that. But the care that we are
    providing downrange and the kinds of things that we are seeing
    causes us to look inside and go, could we do that better?
        Mr. Knight. Thank you, General.
        And I yield back.
        Dr. Heck. Dr. Wenstrup.
        Dr. Wenstrup. Thank you, Mr. Chairman.
        I appreciate you all being here today.
        I want to talk a little bit about some of the process of
    implementing the things that we want to see as far as keeping
    the skill levels up and credentialing that, et cetera. And, as
    we know, so much of our military medicine is in the Reserve
    Component and so not quite as captive an audience to check all
    these boxes, if you will.
        And, for example, I spent time with CCATT [Critical Care
    Air Transport Team] in Cincinnati, and I thank the Air Force
    for letting an Army guy go in there and participate in that.
    But great training, pre-deployment training, and you really
    have to qualify to be able to go and serve on that mission. And
    I think, when I was there, everyone was Active Duty. They could
    be reservists, as well, to come into that scenario.
        But, by and large, too--so I served a year in Iraq at a CSH
    [combat support hospital]. And in the OR, I was the only one
    there for a year, and you had others rotating in 90 days. For
    some, it was been there, done that; you know, not the first
    time; they got it. For a young surgeon coming in, it was like,
    holy cow, I have never seen anything like this, I have never
    done anything like this.
        And even in the Reserve Component, as you mentioned,
    General, we have general surgeons that may be doing plastics,
    but you know what? At that time, that didn't matter, you are
    going to do this.
        And so how do we get the Reserve Component, in particular,
    to be able to check all these boxes, make sure that they are
    ready? And do we have enough surgeons to fill that void?
        Anyone.
        General Hogg. In the Air Force Medical Service, the
    training that we provide is opened up to the total force. So
    the Reserves and the Guard can attend C-STARS, they can attend
    SMART. They have the same requirements that we have, as far as
    our Readiness Skills Verification Program, to maintain
    competencies and currency.
        The professional medics in the Reserve, the physicians, the
    nurses, a little less concerning as far as competency, because
    oftentimes they are practicing in their specialties. Where we
    have a challenge is with our enlisted medics, because
    oftentimes they are not practicing within their specialty. And
    so they have a very robust program to, during their annual
    trainings and whatnots, to try to get them up to speed.
        Dr. Wenstrup. Thank you.
        General Caravalho. Sir, the intent, I believe, for the EMCs
    is going to be across all components. We shouldn't have an
    Active Duty standard and a Reserve Component standard. But I
    acknowledge that it is going to be difficult on your battle
    assembly to get after some of these things.
        So we may face an individual who doesn't have the right
    clinical mix, acuity, caseload to meet an EMC-type standard. I
    am hoping that across the board we are going to say, if you
    can't get it clinically, what are the reasonable facsimiles
    that you can then show your proficiency and currency? Online
    training, modeling; partnering, strategic partnering, with
    civilian or VA entities.
        I think if we do this correctly, when you mobilize the
    reservists, you must institute time. And we have done this with
    this war. We have learned that you have to provide some time to
    kind of get their mind into a--you are going to see not just a
    gunshot wound, not just a knife wound, but you are going to see
    blast injury, head injury and a gunshot wound and a knife wound
    at the same time--and a burn.
        So that is number one. So the Miami's [Ryder Trauma
    Center], the Cincinnati trainings of the world before you
    deploy is going to be critical.
        The second thing is there has to be a critical mass of
    expertise resident when the individuals show up. In other
    words, we have been successful, I believe, with one burn center
    in San Antonio rather than a burn center at every facility to
    ensure everyone has burn center skills. And you rotate staff
    through there, that that one person, whether it is a nurse, a
    tech, or doc, can say, this is the burn standard, everybody get
    on board.
        And I think we are going to have to use those types of
    creative skills to ensure that folks who may not be ready will
    get ready. Because we know, on the back end, they want to be
    ready. So when they are willing, it doesn't take long for them
    to get on board.
        Dr. Wenstrup. So maybe that can be their AT [annual
    training]?
        General Caravalho. Yes, sir. Yes, sir.
        Dr. Wenstrup. Thank you. I yield back.
        Dr. Heck. Mr. Zinke.
        Mr. Zinke. Thank you, Mr. Chairman. I appreciate you
    allowing me to talk before the committee.
        My background is SEALs [Sea, Air and Land teams]. And I
    have seen the evolution of casualty care, which has been
    impressive. I still remain a little concerned about the
    acquisition part. I don't think we are as fast as the private
    sector is at getting new techniques to the front. But my
    question really is about the training.
        In looking back at my career, with explosive breaching and
    TBI, and looking at what has happened in the NFL and all of a
    sudden an awareness of concussions over a period of time, I
    remember as a SEAL going into facilities, and we would do 400
    explosive breaches in a day and then do it continuously.
        What are we doing to examine our training regimen based on
    what we know today to make sure that we aren't creating, you
    know, situations, you know, like long-term concussion damage,
    TBI, in our training regimen? Are we looking at it actively? Do
    we need to put more resources in it? What can we do to make
    sure that it is being done?
        Because oftentimes, you know, what I call the meat-eaters,
    the frontline guys, don't pay a lot of attention to the support
    folks, and I want to make sure that they do. And what do we
    need to do to make sure that happens?
        Admiral.
        Admiral Moulton. Sir, I would have to take that. I am not
    familiar with that enough to talk intelligently about it.
        [The information referred to can be found in the Appendix
    on page 109.]
        General Tenhet. You have to look at the force structure
    piece of this, as well. So, as we are looking at medicine and
    ensuring we sustain skills as we go forward, the interwar
    years, the innovation that comes from some of that, applying
    this, we are not going to have the capability--this is just Bob
    Tenhet speaking about the future, where I see it going--we are
    not going to have that capability at our smaller facilities to
    have the high-complex, high-acuity-type patients going into
    those facilities.
        And we have already taken steps just at Fort Sill, Knox,
    and Jackson in removing our surgeons and using the surrounding
    capabilities there in the community areas and actually moving
    those surgeons to higher-acuity platforms, our health readiness
    platforms. We are going to have to see more of that as we go
    forward to ensure that we have the training capability. And I
    will tell you, it is even a challenge at some of the places we
    are moving them to look at high-complexity, high-acuity cases
    as well.
        So I think the sharing agreements, working with the
    civilian populace and, I mentioned earlier, even looking at
    international programs, we may have to go there. Because the
    Miami's, there are only so many of those that exist out there.
    So you are looking at individual skills, and you are also
    looking at the collective skills training.
        Mr. Zinke. Yeah. I guess my point is that, you know, there
    are a lot of preventative things that we should be doing up
    front rather than waiting until it is an acute problem. And
    especially with explosive breach, I assume it is getting very
    similar to going into a boxing match. So I just want to make
    sure we get ahead of it so we don't have the problems long
    term.
        General.
        General Hogg. Yes, sir. With the recent collaboration that
    we have with the sports industry and the academy, I feel that
    we will definitely start to see some of those changes coming
    out of those studies that will inform us on how to better
    prepare and to prevent these kinds of injuries.
        General Caravalho. Sir, in my experience with you
    carnivores, I agree that generally they don't like to listen to
    medical, and our approach has been ``it is easy to be hard but
    hard to be smart.''
        What I am excited about readiness nowadays is that we are
    following some of the soft truths that they are talking about,
    that you can't recreate someone overnight, so how do you keep
    someone in the fight for the duration of his or her career and
    then offer a full life after that career.
        So we are getting smarter in our training. The warfighters
    are bringing us in, on board, to help them understand how to do
    it right. And we are focusing, as well, on how do we prevent
    illness and how do we promote wellness so that you are
    survivable, agile, and resilient during your time in the
    military.
        Mr. Zinke. Well, certainly, if we can do anything to
    promote some interest and move in that direction, you know, let
    us know.
        General Caravalho. Yes, sir.
        Mr. Zinke. And thank you.
        Thank you, Mr. Chairman.
        Dr. Heck. Ms. Speier.
        Ms. Speier. Thank you, Mr. Chairman.
        And thank you all for being here.
        I would like to follow up on the questions that Congressman
    Zinke just offered up. There is a wealth of information about
    chronic traumatic encephalopathy [CTE]. It not the NFL that is
    researching it. The NFL is trying to sweep it under the rug.
    Boston University has now, I think, examined the brains of, I
    don't know, maybe 100 persons who were in the--some in the
    military but most in sports.
        There is a Dr. Omalu, who is the coroner who first kind of
    identified CTE, that is doing research now with a physician at
    USC on PET [positron emission tomography] scans of persons who
    are alive. And they have just done a number of PET scans on
    veterans, and each PET scan they did showed CTE. One of the
    problems is it is not just the concussions; it is the
    subconcussive hits that individuals receive.
        And I really think it is incumbent on us to start to do a
    much better job of identifying it and promoting research in
    this area as it relates to those who serve in the military. And
    I am kind of surprised and a little bit stunned that you
    haven't already undertaken this.
        I was told by someone very recently that SEALs now are
    actually wearing a monitor to determine how many--I don't know
    if they are concussions or just hits that they receive. Could
    someone speak to that?
        General Caravalho. Ma'am, in one of my last jobs in the
    medical research community, we were working with DARPA [Defense
    Advanced Research Projects Agency], and there were blast gauges
    and different types of devices that one could place across
    their body and on their helmet that would look at the--it was
    an accelerometer to get a sense if there was a rapid
    deceleration. And that would then codify how many events you
    had.
        Knowing that our troopers in general don't want to say,
    ``Coach, take me out,'' so they will not complain of these
    hits, that is number one.
        Number two is IED [improvised explosive device]-related TBI
    probably represents less than 20 percent of all TBI that at
    least the Army has seen. So most of it is just in normal
    training, whether it is combatives or parachute jumping or just
    normal Army training.
        I think you are right that longitudinally we need to
    understand these concussive and subconcussive events and its
    effect over time. And the military is also looking at doing
    pathologic studies of CT. I cannot speak to PET scanning or
    pre-mortem studies as you described. But we have a keen
    interest in that in the Department, and we certainly want to
    partner with any academic center in getting after this. We
    don't care who finds out what the answer is; we want to get
    after the answer.
        Ms. Speier. All right. Thank you.
        I yield back.
        Dr. Heck. Well, I want to thank you all for your testimony
    here today. Again, the purpose for this hearing is that, as we
    undertake the reformation of the military healthcare system, we
    want to make sure that we keep readiness first and foremost in
    our minds and that we don't impede, one, the readiness of our
    military medical providers, but certainly that we don't hinder
    the medical readiness of our troops. So, again, we thank you
    very much.
        Mrs. Davis. May I ask a clarification----
        Dr. Heck. Certainly, Mrs. Davis.
        Mrs. Davis. Thank you.
        Thank you all, again, for being here.
        I wanted to clarify a little bit, because we were talking
    about moving physicians into civilian facilities and back and
    forth, and I understand how it important that is. We also know
    that a number of our military providers also moonlight for
    training.
        But if we are doing that--and, as I understand it, you are
    basically managing that within individual services. Is that
    correct? So don't we need a more centralized way to manage that
    and to be able to identify the different skill sets that you
    are using where you have a lot of movement of those providers,
    of those physicians?
        General Hogg. Yes, ma'am. I think as we define those
    essential military capabilities, we will be able to partner
    with our other services where we are co-located to utilize
    those civilian facilities.
        The providers that we send there, not all of them are there
    full-time all the time. Some are there as their primary duty in
    that civilian facility, but many of them, again, go back and
    forth. So they provide outpatient care in the MTF, the military
    treatment facility, but then provide the specialty care,
    because it is not available in the MTF, in the civilian
    facility.
        But I do believe that as we define what those essential
    medical capabilities are, we will find opportunities where we
    could collaborate in that area, as well.
        Mrs. Davis. Uh-huh.
        Admiral Moulton. Ma'am, I would also add, we are doing that
    in what we call multiservice markets, where we are working
    together in a multihospital system or multiclinic system where
    there are larger populations so we can bring in those kind of
    cases for us. And then are we adequately staffing, or what is
    that number of providers that ought to be in that area so that
    they get the amount of workload for their training.
        And then we look at more partnerships with the VA or more
    partnerships with the private sector. So we are doing some of
    that.
        Mrs. Davis. Okay. Well, that is good. I am glad. Sometimes
    it seems as if, maybe culture, what have you--that there are
    obstacles to doing that. And if that is the ideal--and, again,
    looking to all of you, is that ideal, is that much better, that
    there is that information-sharing so that we know that someone
    is at the proficiency level required? And if it is in the Army
    but you don't know it in the Navy, it is not going to do all of
    us any good, right?
        Okay. Great. I am glad that is at least improving. Thank
    you very much.
        Thank you, Chairman.
        Dr. Heck. Again, I thank the first panel for your
    participation today.
        And if we can now, we will just swap out panels and
    continue to move forward.
        I would now like to welcome our second distinguished panel.
    We heard from the, I think, 30,000-foot view. Now we are going
    to bring it down to a little bit more tactical and operational.
        With us this morning is Colonel Linda Lawrence, Special
    Assistant to the Air Force Surgeon General for Trusted Care
    Transformation, Office of the Air Force Surgeon General, but
    also past president of the American College of Emergency
    Physicians; Lieutenant Colonel Promotable Robert Mabry, who is
    here as a Robert Wood Johnson Health Policy Fellow with the
    U.S. House Committee on Energy and Commerce but has a long and
    distinguished past, beginning as an SF [Special Forces] medic;
    and Lieutenant Colonel Jean-Claude D'Alleyrand, Chief of
    Orthopaedic Traumatology Service at the Walter Reed National
    Military Medical Center.
        I appreciate all of you taking the time to be with us this
    morning.
        Colonel Lawrence, you are recognized for 5 minutes for your
    opening statement.

    STATEMENT OF COL LINDA LAWRENCE, M.D., USAF, SPECIAL ASSISTANT
           TO THE AIR FORCE SURGEON GENERAL FOR TRUSTED CARE
    TRANSFORMATION, OFFICE OF THE AIR FORCE SURGEON GENERAL, UNITED
                            STATES AIR FORCE

        Colonel Lawrence. Thank you.
        Chairman Heck, Ranking Member Davis, and distinguished
    members of the committee, thank you for the opportunity to come
    before you today to discuss the future of Air Force Medical
    Service readiness.
        I am a residency-trained emergency medicine physician with
    over 23 years of Active Duty service in a variety of positions,
    such as academics, clinical leadership, 5 years as the Air
    Force Surgeon General Emergency Medicine Consultant, and in
    multiple command assignments, including command positions in
    the deployed environment.
        As an emergency physician, you learn early it takes more
    than your own individual skills to be successful. I like to
    look at medical readiness from a tiered approach. The basics
    are individual skills, which we assess through our Readiness
    Skills Verification Program. For an emergency physician, these
    involve many procedural skills common for resuscitation of
    patients, both medical and surgical, which ideally includes a
    daily practice environment that provides access to sick and
    critically ill patients.
        The next tier would be how we come together as teams, for
    which in emergency physician we have multiple deployable unit
    type codes that are found throughout the echelons of care. Just
    as any sports team of all-star athletes cannot be a winning
    team unless they practice together, the same analogy applies
    for our medical teams. On our deployable teams, we need to have
    skills around a common set of standards or guidelines which
    drive processes, where every member of the team knows their
    role as well as the role of others.
        We begin to build that capability or teamwork skills
    through processes in our day-to-day work in our MTFs. Many
    think we need to see the same type of patients--for example,
    trauma patients--to build those skills. That is not true. We
    build them every time we come together as a team to perform a
    procedure, respond to a complication or resuscitation. Even
    actions of coordination of care in handoff become critical
    skills.
        The best care can quickly be compromised by a lack of
    shared processes, poor communication and teamwork. Every day in
    our MTFs, we are constantly improving our processes, handoffs,
    and practicing the art of good communication and teamwork.
    Every patient engagement sustains the readiness of the medical
    force and an environment that promotes continuous learning and
    improvement.
        Our commitment to trusted care is based on a set of
    principles which promote high reliability and safety. These
    principles not only improve the care we deliver to our patients
    but also improve the processes and skills we bring to the
    deployed environment.
        Beyond our daily roles in our MTFs, we need the opportunity
    to challenge and assess our individual and team skills, which
    is provided through platforms like C-STARS and simulation.
    Through these training modalities, we can replicate some of the
    unique demands of the operational environment, reinforce the
    use of combat care clinical practice guidelines, and assess our
    performance as individuals and teams. This type of training is
    invaluable, and, while it takes us away from supporting the 24/
    7 mission at our military treatment facilities we work in, it
    is the price of readiness.
        Finally, readiness is more than combat support. It includes
    global health engagement and the day-to-day work to maintain a
    medically ready force and ready medics. Every day, we support
    medical readiness in the care we deliver to our beneficiaries.
        I am grateful for your support and the opportunity to speak
    with you today and look forward to your questions.
        [The prepared statement of Colonel Lawrence can be found in
    the Appendix on page 78.]
        Dr. Heck. Thank you.
        Lieutenant Colonel Mabry.

       STATEMENT OF LTC ROBERT L. MABRY, M.D., USA, ROBERT WOOD
     JOHNSON HEALTH POLICY FELLOW, U.S. HOUSE COMMITTEE ON ENERGY
                              AND COMMERCE

        Colonel Mabry. Chairman Heck, Ranking Member Davis,
    distinguished members of the subcommittee, thank you for the
    opportunity to discuss battlefield medical readiness with you
    today.
        After nearly 15 years of war, the Military Health System
    has made tremendous advances. Today, if you are wounded in
    battle and arrive alive to a combat hospital, survival is
    virtually assured.
        Combat casualty care, however, does not begin at the
    hospital. It begins in the field at the point of injury and
    continues through the evacuation chain. Our research shows that
    up to one in four battlefield deaths are potentially
    survivable. However, the vast majority of these bleed to death
    before they even make it to a doctor. Care delivered on the
    battlefield outside of the hospital is the first and key link
    in the chain of survival and is the next frontier for making
    any significant advances in combat casualty care.
        I believe we face five challenges to improving battlefield
    survival.
        First and most importantly is ownership. Army Medicine
    trains and equips the medical force, but line commanders
    execute healthcare delivery on the battlefield. We must
    determine who is responsible for improving battlefield care
    delivery. The axiom, ``When everybody is responsible, no one is
    responsible,'' applies.
        Second, data and metrics. We can't improve what we don't
    measure. We continue to know very little about what happens to
    casualties before they arrive to the hospital.
        Third, expertise. We have very few clinical experts focused
    on care outside the hospital. Out of about 4,500 Army
    physicians, there are only 4 board-certified specialists in
    this field.
        Fourth, research and development. Our R&D efforts are
    focused on developing lifesaving drugs and devices, yet very
    little research is done on the delivery system or, in other
    words, how do you get the right care to the right patient at
    the right time.
        Finally, culture. Our organizational culture is centered on
    caring for military beneficiaries in our fixed facilities. This
    is our biggest mission, yet it is our wartime mission that
    makes us unique and justifies our cost to the Nation.
        I would like to highlight these challenges by briefly
    telling the story of the simple tourniquet. The most effective
    thing a soldier can do to save another soldier's life on the
    battlefield is to stop bleeding.
        The strap-and-buckle tourniquet was first issued during the
    Civil War, then again in World War I, World War II, Korea, and
    Vietnam. In 1993, I deployed to Mogadishu, Somalia, as a
    Special Forces medic in one of the most well-equipped, well-
    trained units in the world with a strap-and-buckle tourniquet.
    We went to war in Iraq and Afghanistan with essentially the
    same tourniquet that was issued during the Civil War.
        There is only one problem with the strap-and-buckle
    tourniquet: It doesn't work.
        In 1945, Dr. Luther Wolff, an incredibly experienced Army
    surgeon who cared for thousands of patients fighting across
    Europe, wrote an article in the Army Medical Department Journal
    describing how the strap-and-buckle tourniquet was ineffective
    and should be removed from the inventory. That was in 1945.
        Yet it remained in the inventory. Death rates from
    extremity hemorrhage in Korea and Vietnam ranged from 7 to 9
    percent. That means that 7,000 sons, fathers, husbands,
    brothers lost their lives because they did not have an
    effective tourniquet. In the initial phase of Iraq and
    Afghanistan, our death rates from extremity hemorrhage were the
    same as the Korean war.
        In 2003, a Special Forces medic invented the combat
    applications tourniquet. This new tourniquet worked well and
    was widely adopted by U.S. forces, driving down deaths from
    extremity injury to virtually nothing.
        Meanwhile, the strap-and-buckle tourniquet, first issued
    during the Civil War, noted not to work during World War II,
    was finally removed from the DOD inventory in 2008.
        How did this happen? How did the most advanced military in
    the world miss this? More so, how do we prevent something like
    this from happening again? Ownership, data, expertise,
    research, culture.
        Thank you again for the opportunity to speak today. I look
    forward to your questions.
        [The prepared statement of Colonel Mabry can be found in
    the Appendix on page 83.]
        Dr. Heck. Thank you.
        Lieutenant Colonel D'Alleyrand.

    STATEMENT OF LTC JEAN-CLAUDE G. D'ALLEYRAND, M.D., USA, CHIEF,
    ORTHOPAEDIC TRAUMATOLOGY SERVICE, WALTER REED NATIONAL MILITARY
                             MEDICAL CENTER

        Colonel D'Alleyrand. Chairman Heck, Ranking Member Davis,
    and distinguished members of the subcommittee, thank you for
    the opportunity to speak today.
        During past conflicts, there have been delays in our
    ability to provide optimal care for our wounded, particularly
    when there have been many years since the previous conflict.
    These interwar years are typically associated with the decline
    in the funding and infrastructure of our trauma and
    rehabilitative systems as well as a lack of training for our
    trauma surgeons. Senior surgeons with experience in combat
    injuries may no longer be in the military by the time the next
    conflict arises, and those that remain have most likely been
    struggling to maintain their skills in the peacetime
    environment.
        In order to adequately care for wounded warriors, trauma
    surgeons need two different skill sets. They need to be able to
    treat conventional trauma, such as the injuries seen in the
    civilian sector, and they also need to be able to treat combat-
    related trauma.
        Conventional trauma proficiency can be maintained with
    adequate exposure to civilian trauma by allowing surgeons and
    military hospitals to treat civilian patients and by
    facilitating the continuing medical education of trauma
    specialists. Combat-related trauma skills, however, can't be
    sustained during peacetime because injuries from explosions or
    machine guns are, thankfully, almost nonexistent in our
    society.
        Therefore, our focus should not be on the sustainment of
    these skills but, rather, on retention, specifically the
    retention of those providers who have the firsthand experience
    treating combat casualties, including not only the surgeons but
    also the wound care nurses, therapists, prosthetists, and the
    other specialists who form the chain between the point of
    injury and the final return to function.
        It has been only 3 years since the casualty flow slowed to
    a trickle, and, already, many, if not most, of the providers
    that I worked with during the peak of the war are gone. At this
    rate, there will be very few of us remaining when the next
    conflict comes around.
        I ask now that each of you think about what you would do if
    your spouse or child were gravely injured in a traffic
    accident. Without exception, each of you would do your research
    and you would take them to the best surgeons that you could
    find. Our combat-wounded can't choose; they go where we send
    them. So it is our responsibility to send them to the best
    trauma specialist that we can.
        But without aggressively maintaining their skills, who
    knows how many patients our specialists can optimally treat?
    Maybe 80 percent? Maybe? But 80 percent is a B-minus. And is a
    B-minus really the best that we can do for the young men and
    women that we send into harm's way to preserve our way of life?
    No. Our combat-wounded deserve A-plus trauma specialists, and
    we are morally obligated to provide them.
        To do so, we need to maximize our trauma specialists'
    experience and education and to retain those who have already
    been through the steep learning curve that we all face when we
    first learn to care for combat-wounded.
        Ladies and gentlemen, on behalf of my trauma colleagues and
    the wounded warriors who we serve, I thank you for your time
    and continued support.
        [The prepared statement of Colonel D'Alleyrand can be found
    in the Appendix on page 99.]
        Dr. Heck. I thank you all for your testimony, and I think
    it is great as a follow-on to the first panel.
        You know, we all understand that it is the small amount of
    care that we provide that is truly trauma care within the
    military, and, as was mentioned, 85 percent is disease and non-
    battle injury, which we would expect that most physicians or
    healthcare providers would be able to take care of through
    their daily practice and be competent in.
        That is why I tend to focus more on that other 15 percent,
    where we potentially see the degradation of skills during the
    interwar years. And my greatest concern, as has been expressed
    by this panel, is how do we make sure that the lessons learned
    over the last 15 years of war don't get lost or we don't lose
    those providers who have gained that knowledge as we make sure
    we are ready for the hopefully-never-to-come next war.
        And part of that answer has been, well, we rotate folks out
    to different programs, whether it is C-STARS or down at Miami-
    Dade or a university medical center. But I still have the
    concern that that is not adequately preparing the team in order
    to respond and be ready to perform.
        So, as those who, you know, have worked where the rubber
    really meets the road, how do you address this issue? How would
    you propose we ensure that the entire team, from the trauma
    surgeon to the anesthesiologist to the trauma nurse to the x-
    ray tech to the phlebotomist, all know how to operate as a team
    in the stressful situation of the trauma activation, whether it
    is at a FST [forward surgical team] or a combat support
    hospital, soon to be a field hospital? How would you address
    that problem that I am fearful we will see over the next
    decade?
        Colonel Lawrence. I think it comes back to do we maintain
    robust medical ecosystems in our large military treatment
    facilities. And with that, what I am trying to say is we must
    maintain hospitals that have a diverse patient population that
    is sick, that is complex.
        And I hear you, Chairman Heck, that I agree, we need to see
    trauma, but, you know, if I put a chest tube in for a trauma
    patient or I put a chest tube in for a congestive heart failure
    patient, my team gets the same experience, and that procedure
    is a procedure.
        And so, in order to maintain some of the lessons learned
    and have the best, we need to maintain GME [graduate medical
    education] hospitals. And sometimes there has been challenges.
    Well, that costs too. If we ever consider removing GME, I
    believe that will be the death knell to our robust hospitals
    maintaining those lessons learned, bringing up the next
    generation of researchers and training our own.
        I saw the opportunity when I was the Chief of Emergency
    Medicine down at Wilford Hall. The research we did was in
    collaboration with NIH [National Institutes of Health] and
    others, and we taught that to our residents, and we were able
    to teach them the lessons learned. But not only did the
    residents get it, all the staff would get it.
        And so I encourage that we look at those platforms and we
    looked at USUHS, our Uniformed Services University, and how do
    we strengthen with our academic partners in the outside as
    well.
        Dr. Heck. You know, Colonel Mabry, you alluded to the
    issues of care from the point of injury to the receiving
    facility. And so, while it may be easier to address some of the
    training needs within a fixed facility because a team is a team
    regardless of the procedure or how the procedure is being
    performed, how would you address the concerns? Because, you
    know, having the 68 Whiskey [combat medic] respond on post to
    some medical emergency isn't the same as responding to a
    battlefield casualty.
        Colonel Mabry. Sir, thank you for the question.
        So what you are getting at, Dr. Heck, is one of the
    quintessential challenges of military medicine, which is how do
    you train providers to deal with horrifically injured combat
    casualties when you don't see horrifically injured combat
    casualties on a day-to-day basis.
        So some of that is going to be simulation. Some of that is
    going to be taking care of sick patients with other conditions
    like Colonel Lawrence has described. But you have to have that
    exposure.
        And so one of the challenges with our medics is, under the
    current regimen, the first time they are going to see a
    seriously injured casualty is when they are on the battlefield.
    And it may be dark, they may be being shot at, and it may be
    their best friend.
        So I think we have to figure out ways to expose our medics
    to critically ill patients before that time. One of the bright
    spots is the Critical Care Flight Paramedic Program, which we
    have instituted. That requires medics to gain a civilian
    paramedic credential and hands-on critical care training in the
    hospital to be critical care paramedics like you would see in a
    traditional air ambulance system in the United States. By
    virtue of that training, they are required to do hands-on
    patient care and they are required to see sick patients in the
    hospital.
        So it is going to be some mix of simulation, some mix of,
    if you have a civilian credential, you, like some of the
    doctors do, can moonlight as an EMT [emergency medical
    technician]. But just seeing casualties every day and seeing
    patients every day and doing that thinking out in the field
    with another medic on the ambulance is very valuable even when
    you deal with sick trauma patients.
        Dr. Heck. And then, Colonel D'Alleyrand, as an orthopedist,
    do you believe that being able to take an orthopedic surgeon
    out of a fixed facility, let's say has not previously deployed,
    and then all of a sudden throwing them into an FST, how are we
    going to assure that that orthopedist is prepared to function
    as an FST member in a situation similar to the pre-hospital
    care provider that they never may have been put into
    previously?
        Colonel D'Alleyrand. Well, I think that is a very difficult
    question to answer. The majority of, let's put it this way:
    There are roughly 130 to 150 orthopods within the Army. Maybe
    six of us, seven of us are trauma specialists. So the person
    that you are going to deploy is a total joint surgeon, a sport
    surgeon, and there really is no effective way to transfer an
    entire body of knowledge, a career's worth of knowledge to that
    person.
        I think that if you retain senior personnel and if these
    people go through their residency programs with senior trauma
    surgeons who have been there and done that and have had those
    experiences, then you can bring them up along the way with
    these life lessons so it becomes part of what they know about
    orthopedists. Because the military orthopedist programs have
    somewhat of a deployment-related slant in some part of its DNA
    [deoxyribonucleic acid] regardless of how isolated you are from
    the war.
        So I think that, you know, that is a key cornerstone. And I
    think on a systems level, which Dr. Mabry can speak at length
    about, about having a Joint Trauma System that establishes good
    clinical practice guidelines and establishes dogma, that they
    can at least have an algorithm that may be not the perfect
    substitute for being a traumatologist at Walter Reed but at
    least can give them a path towards doing the right thing at the
    right time.
        Dr. Heck. Okay. Thank you.
        My time has more than expired. Mrs. Davis.
        Mrs. Davis. Thank you, Mr. Chairman.
        Again, thank you all very much for being here.
        I am going to ask you to do something that is kind of
    difficult. Could you respond to what you heard earlier in
    terms, particularly, of exactly what you just said, Colonel,
    the systems-level organization that is going to give us what is
    required? You know, kind of getting at that question, what is
    it going to take in order to try and be sure that the skill
    sets that are going all the way through the nurse specialties,
    all of the people that are involved in trauma, so that we
    really maximize what I understand. We actually have 80 trauma
    surgeons that are certified in this way across the services? I
    am not sure if that is correct.
        But you heard, and I tried to ask this question, I am not
    sure if I asked it so artfully, but should we be doing more in
    terms of that more central organization so that we actually do
    get the best use of the, you know, exceptionally well-qualified
    people that we have, knowing that they are not getting the
    exposure either in the future?
        Colonel D'Alleyrand. I think it is beneficial to look at it
    at three different levels, the tactical, at the strategic
    level.
        So myself, as a surgeon, there are certain skill sets that
    I need to have to handle the very broad range of injuries that
    come back from theater, be it from the upper limits of
    survivability in terms of multi-extremity amputee, blast wound,
    open pelvic injuries, to things that more resemble what you
    would take off the highway. And those sort of ebb and flow over
    the years.
        So there are things that can be done for me as an
    individual, be it working at a civilian trauma center, and
    making it easier for me to continue my own education and
    ongoing training, which, currently, I mostly subsidize myself.
    That only makes me as one member of the team proficient.
    Everyone around me, the x-ray techs, scrub techs, ICU
    [intensive care unit] nurses, et cetera, basically go from a
    civilian setting straight into a war setting with no training,
    if I am the only one who is trained.
        So I think making key hospitals that might be expected to
    see war casualties, making them trauma centers during peacetime
    or throughout even in and out of conflict, that makes the whole
    team more efficiently trained.
        But then, finally, on the system level, which, again, is
    Dr. Mabry's wheelhouse, I think that is going to be an
    overriding entity that can at least help establish the
    evidence-based guidelines to help guide our practice.
        Mrs. Davis. Uh-huh.
        Dr. Mabry.
        Colonel Mabry. So one of the biggest challenges we have,
    ma'am, is that, unlike the warfighter, when we are home, we are
    providing health care in our fixed facilities day-to-day. The
    warfighter is going to the range and training. And so we are
    doing our civilian beneficiary mission, for the most part,
    whereas the infantry soldier and the special forces soldier are
    out training, preparing for the next war.
        So we have to figure out how to kind of thread the needle
    where we can maintain our healthcare benefit but, at the same
    time, go to war ready and prepared for the next set of
    conflicts or next war without a learning period, a learning
    curve, which is traditionally what happens.
        Mrs. Davis. Uh-huh. But the systems piece, though, in terms
    of who organizes, who has the oversight to be sure that things
    are moving properly. You mention, I thought that was, you can't
    approve what you don't measure.
        Colonel Mabry. Yes, ma'am.
        Mrs. Davis. So to the extent that there is--whether it is
    the DHA [Defense Health Agency]--where does that system
    organization lie? Is it there today? Is it being utilized the
    way that it should? Is it covering, you know, all aspects of
    research and development, or at least aware of it?
        Colonel Mabry. Yeah, so there is a challenge where there is
    some lack of interconnectivity. So, in other words, during the
    start of this war, a lot of talented surgeons recognized we
    needed a trauma system. We went to war initially in 2001
    without a trauma system. And so it took about 4 years to build
    the trauma system. That became the Joint Trauma System, the
    Joint Theater Trauma System, where we had senior trauma
    surgeons deployed in conference and advising and coaching,
    developing clinical practice guidelines, which, really, you can
    trace the improvement to our battlefield casualty outcomes to
    two things; that is one of them.
        And so the Joint Trauma System is currently the repository
    for the system, but that is only in one command. It is only in
    CENTCOM's [Central Command's] AOR [area of responsibility]. And
    it is uncertain whether we will continue to have the Joint
    Trauma System as the conflict winds down.
        Mrs. Davis. Uh-huh.
        Yes, Colonel Lawrence.
        Colonel Lawrence. I would like to expand on what Dr.
    Mabry----
        Mrs. Davis. I am sorry, my time is up. Should we go ahead--
    --
        Dr. Heck. There are just a few of us here, so we can go
    further.
        Mrs. Davis. Okay.
        Colonel Lawrence. Dr. Mabry is correct, that is a very
    important part. And the Joint Theater Trauma System, it
    encompasses more than the surgeons. And how are we going to
    preserve that? There are discussions, I am told, at the senior
    level with our MHS senior leaders, and they are discussing
    that.
        I think, to get back, what you are hearing is there needs
    to be a value placed on readiness. And my concern and I have
    been in for almost 24 years of Active Duty is, as the conflicts
    decline, we are going back to measuring health care competitive
    with the civilian sector, and we are going to lose that
    quotient of readiness.
        And in the healthcare system today, we are shifting away,
    too, from looking at productivity to looking at value and
    value-based care. And I believe that is what we are getting at.
    It is, how do we preserve outcomes not just on the battlefield
    but in our MTFs as well? And if we look at the value equation,
    which is health and care over cost, where do you put readiness?
    I would argue readiness needs to be up on the top with health
    and care.
        And if we design the system that is going to allow that
    because all of us have talked and we heard the panel earlier--
    about the need for our people to spend time away. I mentioned
    that, that, you know, you will never get everything in our
    Military Health System, so we need a synergistic system that is
    going to allow us to spend some time at the C-STARS and SMART
    platforms. But where do you put that if you are going to
    measure our productivity on what we do in the MTFs?
        So, as we build that system that has sustained and endured
    as, hopefully, the need for conflict declines, we need to say,
    where is that value equation?
        Mrs. Davis. Yeah. Okay. Thank you.
        Dr. Heck. Dr. Wenstrup.
        Dr. Wenstrup. Thank you, Mr. Chairman.
        It is a pleasure to have you all here today.
        You know, a friend of mine is an Air Force trauma surgeon,
    a reservist. You may know Dr. Joe Hannigman. And we went to
    high school together. But he shares the thought, there was
    multiple deployments, and at first he used to say, ``I am going
    to try and get you everything here that you would get at
    home.'' Now he comes home and says, ``I am going to try to get
    you everything here at home that I would get one of our troops
    in theater,'' and that is how far we have come in the last 10
    to 15 years. And I don't think there has been any greater
    privilege for me, in my lifetime, as to be any part of that and
    to take care of our troops.
        One of the things that I read in my friend Dr.
    D'Alleyrand's testimony, what Hippocrates said, ``War is the
    only proper school for surgeons.'' And I think there is a lot
    to be said for that. It is how do we capture all this knowledge
    and maintain it and share it. And I think we all recognize the
    dilemma; it is where do we go from here.
        First, I would like to ask Colonel D'Alleyrand, I think you
    take the opportunity every chance you get when I have seen you
    at Walter Reed, with the residents in particular: this is what
    you do here, but this is not what you would do downrange.
    Because it is a different set of circumstances, right? You talk
    about fungal infections, you talk about open wounds, you don't
    put a rod in here, and this and that.
        So how much of an opportunity do you get to carry that over
    and try to make sure that it is sustained in a resident, a new
    doctor coming up?
        Colonel D'Alleyrand. We do have a it is called the Combat
    Extremity Surgery Course, and it is a joint course that we run
    with the Navy as well. And so that is taught a couple times a
    year, typically with upper-level residents or general orthopods
    who are looking at an upcoming deployment.
        It is difficult, though. It is a 2-day course, and we teach
    a lot of, sort of, doctrine and, sort of, hard-fought lessons,
    but, I mean, how good can you be at anything in 2 days if you
    have never really been exposed to it?
        So it is difficult to communicate that body of knowledge to
    anyone, even--you know, I trained at Shock Trauma in Baltimore.
    I thought I had seen, you know, the worst energy injuries that
    you could have, and it wasn't even remotely in the ballpark of
    what we are seeing at Walter Reed.
        So I don't think there is any way to truly prepare them,
    but I think having senior faculty who have had multiple
    deployments, who have had those hard-won life lessons that
    don't always work out well when you are operating in a tent in
    the middle of the night, having those guys around, especially
    during the interwar periods, to impart that knowledge is the
    best thing you can get to some sort of corporate memory.
        Dr. Wenstrup. And to that point that you have made, there
    are opportunities to take those that have left wearing the
    uniform to be part of the teaching process, those that have
    actually served in combat. I think maybe we need to take a look
    at that.
        I really would love all of you to weigh in, because we are
    talking about different ideas of military just providing trauma
    services, like at SAMMC [San Antonio Military Medical Center],
    and then also moonlighting. Is there a hybrid out there? I
    think we need some guidance in how can we help you here to
    fulfill that role.
        Colonel Mabry. Sir, I will take a stab at that.
        So I was at the Staff College doing a research paper, and I
    came across a book where they were addressing some of the same
    concerns following World War II. And they were talking about
    bonuses for physicians. And then there was a paragraph in there
    that talked about the way to keep physicians in the military is
    to give them meaningful work. And so, if you have the surgeons
    who are doing the kind of surgery they like to do on a high-
    volume basis, what they find meaningful, then that is going to
    help with retention.
        With regard to training in civilian centers, I guess I
    would say, if you crash your car and you have to have your
    spleen removed, do you want a surgeon that is familiar,
    proficient, or expert in removal of the spleen?
        And so I think our challenge is how to have on the--toward
    the expert spectrum, you know, when we go to the next conflict.
    Because, usually, again, there is a learning curve for the
    first couple of years, and our challenge this time is to go to
    war next time without a learning curve.
        Dr. Wenstrup. Colonel.
        Colonel Lawrence. And I would say that learning curve is
    going to constantly be there. Because, as we have seen the
    advances that we have had in these last 15 years, I think that
    is what we are all talking about. How do we preserve that
    mindset and how do we preserve the system that allows us to
    continue to advance?
        And so, again, I will go back to the extreme importance,
    you have heard, of GME and not just graduate medical education
    but our nurse training programs, our technician training
    programs. We need to keep that. And that is where we can pass
    some of these lessons learned.
        But we need money to continue research. And we need to look
    at where can we partner with academic institutions and
    professional organizations to take these lessons learned and
    continue to grow. How do we sustain the Joint Theater Trauma
    System? I mean, if we tuck that away in a closet and pull it
    out, it is not going to be any good, all right? But if we
    continue--there is a partnership right now with the American
    College of Surgeons and the MHS. And they are talking about
    looking at similar partnership right now with the American
    College of Emergency Physicians.
        So, you know, when we start to bring in the professional
    organizations, we don't only help our military, we are going to
    translate those lessons learned into society and vice versa. We
    are going to keep that learning cycle going, and we are going
    to continue those partnerships.
        So those partnerships, though, cost money. Research costs
    money. And time away from our clinical practices to engage
    costs time.
        But that is what I find when I talk to physicians,
    particularly emergency physicians. Anything they can do which
    shows value of them and that opportunity to go out there and
    continue to partner with their colleagues and learn and make
    the entire system better, that is going to keep them in the
    suits.
        Dr. Wenstrup. Thank you.
        I yield back.
        Dr. Heck. Dr. D'Alleyrand, when was the last time that you
    deployed?
        Colonel D'Alleyrand. I just got back 2 months ago from a
    deployment to East Africa.
        Dr. Heck. Okay. So, you know, as one of the handful of, you
    know, orthopedic traumatologists within the Military Health
    System, now that you are at Walter Reed, which does not receive
    civilian trauma, how do you envision the ability to maintain,
    just on a personal basis, your trauma-level skills that you
    have developed over the past several deployments?
        Colonel D'Alleyrand. It is a problem that I have been
    struggling with for a number of years now. So I do a number of
    things in order to maintain what I consider to be an acceptable
    level of proficiency. I spend two of my weekends a month
    moonlighting at local trauma centers. I pay my own way to go to
    trauma courses. I teach at trauma courses. I basically do
    everything that I can just to try to maintain a certain level.
    Is it enough? I wish it were more, frankly. It is what it is.
        And, you know, certainly, in the deployed setting, those
    are always difficult questions because it is always a different
    experience. I was at a couple different places in Afghanistan,
    and it is very different if you are operating in a rocket-proof
    Role 3 facility compared to operating in flip-flops in a tent
    that has, you know, helicopter prop wash knocking the tent
    around. And Africa was very different entirely.
        So I definitely have used my trauma skill set specifically
    for blast wounds, et cetera, on deployment, but deployment also
    lots of times is where you have intense degradation of your
    skill set as well, long periods of just disuse and waiting for
    something to happen, too.
        Dr. Heck. So, in your opinion, if Walter Reed was
    integrated into the civilian EMS [emergency medical system]
    system as a receiving facility for civilian trauma, similar to
    Madigan or Brooke, would that help you and others like you be
    able to maintain your skills to a higher level?
        Colonel D'Alleyrand. I think without question. If you look
    at any job, any skill that you can think of, a musician, a
    professional athlete, et cetera, you would never consider being
    excellent in that field by dabbling in that field. You know,
    the weekend athlete is, by definition, a weekend athlete.
        So, as I said earlier, and it is obviously common sense, if
    I were to work full time at a civilian trauma center and be
    given the opportunity to do sabbaticals and rotate at other
    facilities where there are regional experts in certain
    techniques, that would make me, you know, ideally suited for my
    profession, but I would still only be one piece in the big
    machine. And by opening the doors to key facilities, Walter
    Reed being one of them, as difficult an undertaking as that may
    be, that at least gets the entire hospital ready for some
    measure of trauma.
        It is not going to necessarily be ready for blast wound,
    open pelvis, fungus-infested--the stuff we were seeing when
    Helmand province was really going off in the winter of 2011,
    2010 to 2011. But a facility that is used to seeing high-energy
    constant flow of trauma is going to be the best-suited that we
    could have for that situation.
        Dr. Heck. I appreciate that.
        And I just want to go back to something that both Colonel
    Mabry and then Colonel Lawrence alluded to, which is, you know,
    the cost of readiness. And I agree that we cannot compare the
    military healthcare system to the civilian healthcare system,
    because you have a unique role and mission to fulfill that the
    civilian sector does not have.
        And, Colonel Mabry, you said it. You know, when you are
    back or the medics are back from deployment, they are doing
    their job in beneficiary care and not necessarily getting the
    ability to go train like the 11 Bravo [infantryman] does, where
    their only job is really to train for the next war.
        And I appreciate what you said, Colonel Lawrence, about our
    move toward value-based care and where do we put readiness into
    that equation. You know, earlier this week, we had a briefing
    from DHA on how they are trying to look at, you know,
    increasing efficiencies and capability in the military
    healthcare system by increasing hours, increasing throughput.
        So the balance that we have to come up with is, how does
    that impact the ability for the military healthcare provider to
    be able to go do those other things that they need to do to be
    able to execute their military mission?
        And so I have always said and will continue to say that
    military healthcare readiness comes with a cost, and we have to
    be ready to assume that cost if we want to be prepared to go to
    war both with a ready medical force and a medically ready
    combat force.
        So I appreciate you folks being here.
        Mrs. Davis.
        Mrs. Davis. Thank you, Mr. Chairman.
        And just really quickly, and going back to you, Colonel
    Mabry, on the ownership issue that you mentioned, is that in
    conflict in any way with jointness?
        Colonel Mabry. No, ma'am. It is just unique to the
    battlefield. So, you know----
        Mrs. Davis. And we do jointness on the battlefield. I guess
    I am wondering as we move to nothing on the battlefield.
        Colonel Mabry. The point being is, outside of the hospital,
    outside of the combat support hospital, it is the operational
    commander who owns that real estate. It is the operational
    commander who owns the medics, the battalion medical officers,
    the critical care flight paramedics, the flight nurses. They
    work for the combat commander. But yet we defer medical
    expertise to the medical departments. But they don't have
    ownership of those assets.
        And so there is a friction point there, in that we are
    responsible for developing the doctrine and the training but
    the line commander is responsible for the execution. So who
    owns battlefield medicine is kind of one of our quintessential
    challenges. And so who is then able to organize the data, the
    training, the research to feed back into the system to improve
    care?
        And, during this war, it has taken a lot of very strong
    personalities over a decade to get to those systems in place--
    --
        Mrs. Davis. But you want the institution to be there to do
    that.
        Colonel Mabry. So how does the institution do that is going
    to be a big challenge.
        Mrs. Davis. What do you think?
        Colonel Mabry. I think we need to have a senior person in
    charge of it. So, in the Army Medical Department, we have a
    brigadier general that is in charge of veterinary medicine, the
    Veterinary Corps. I think combat casualty care would equally
    benefit from senior leadership. Whether that is a line officer
    or a medical officer, I think that would have to be worked out.
        Mrs. Davis. Uh-huh.
        Is there any disagreement with that?
        Colonel Lawrence, do you think that is--what would you say?
        Colonel Lawrence. I would say one of the things that we
    need to realize is it is not either/or. And sometimes we look
    at in-garrison health care, what we deliver in our MTFs, and
    our training and currency that we need there, to what do we
    need in a deployed environment; and, oh, that is our medical
    readiness training, and that is over here. And we need to say,
    how is it all one part of the system?
        Mrs. Davis. Right.
        Colonel Lawrence. And I think, you know, there are
    different--I can't speak to the Army. I can speak to the Air
    Force. We respond to the line, you know. And when I was a
    hospital commander, I worked for a wing commander, a line
    commander, but they did understand the importance of our
    training.
        And so getting back to how do we take and have that system,
    which is I think what you are saying. We need to stop looking
    at readiness is a price over here we pay and health care is
    over here, but how are they merged together, and how do we look
    at that delivery benefit to have it so that there is a training
    piece in there that you do in your day-to-day but there is also
    a training piece that you are not going to get there, and how
    do you explain that to the mission commander.
        Mrs. Davis. Uh-huh.
        Colonel, did you just want to add anything to that?
        Colonel D'Alleyrand. I have nothing substantial to add.
        Mrs. Davis. Okay.
        Colonel D'Alleyrand. I think there is definitely precedent
    for----
        Mrs. Davis. Thank you. I feel like we have asked the same
    question many different ways, but we really feel a
    responsibility to help and get this right.
        Colonel Mabry. Ma'am, in the pre-hospital setting, I can
    point to one Army unit that has done this exceptionally well.
    That is the 75th Ranger Regiment. When General McChrystal was
    the Ranger regimental commander, he added battlefield medicine
    or tactical combat casualty care as one of his big four command
    priorities.
        And, since then, the Ranger regimental commander has owned
    that casualty response system, and they have detailed
    documentation on what happens to every Ranger casualty. They
    are very well-trained. Their line leaders, their squad leaders,
    platoon sergeants, first sergeants are trained in the tactical
    medical system. And they have been able to demonstrate a
    remarkable survival rate and exceptional care to all of their
    Ranger casualties because of the commander's ownership of the
    system.
        Mrs. Davis. All right. Great. Thank you very much. And I am
    sure that even when we look internationally to our partners,
    our allies, the kind of exchanges that go on, maybe that is
    another area to look at more in terms of getting that kind of
    experience.
        Thank you very much.
        Dr. Heck. Well, again, I want to thank you all, both the
    first and the second panel, for taking the time to spend with
    us this morning to provide us with your views on how we can
    help maintain military medical readiness. It is most
    instructive. And, certainly, the comments you have made will
    help inform this subcommittee's decisions as we move forward.
        Again, I appreciate everybody's participation.
        There being no further business, the subcommittee stands
    adjourned.
        [Whereupon, at 11:15 a.m., the subcommittee was adjourned.]

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                                A P P E N D I X

                               February 26, 2016

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                  PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                               February 26, 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 26, 2016

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                RESPONSES TO QUESTIONS SUBMITTED BY MR. O'ROURKE

        General Hogg. Together the Air Force and VA have met the 295-day
    goal for IDES Active Component members since October 2014 and since
    November 2015 for AF Reserve Component members. Active Component Airmen
    who completed the IDES in January 2016 averaged 248 days from referral
    for disability evaluation to receipt of a VA benefits decision or
    return to duty, which was within the 295-day standard. Reserve
    Component Airmen averaged 300 days, which was within the 305-day
    standard.   [See page 13.]
        Admiral Moulton. The Department of the Navy (DON) fully supports
    the goals behind the Integrated Disability Evaluation System (IDES) and
    remains fully engaged with the Department of Defense (DOD), the
    Department of Veterans Affairs (VA), and the other Military Departments
    to continue to improve and enhance this Service member-centric program
    to eliminate the post-separation ``benefit gap'' for wounded, ill, and
    injured Service members. For the Active Component (AC), the DON has
    approximately 4,383 Service members (roughly 56% Marines and 44% Navy)
    enrolled in IDES. This number represents less than 1% of the combined
    service end-strengths of the Navy and Marine Corps. For the Reserve
    Component (RC), the DON currently has approximately 114 active cases
    for the Navy and 120 for the Marine Corps enrolled in IDES.
        As of January 2016, AC Sailors spend on average 255 days and AC
    Marines spend on average 230 days in IDES, which includes the completed
    transition to the VA. As of January 2016, RC Sailors spend on average
    204 days and RC Marines spend on average 307 days in IDES. We continue
    to explore ways to reduce the time Service members spend in the AC 295-
    day goal and RC 305-day goal IDES processes without compromising the
    integrity or accuracy of the system.   [See page 13.]
        General Tenhet. The Army has met the 295 day IDES processing
    standards for the past 12 months. The average processing time for total
    Army (all compos and appealed cases) is 256 days as of 20 Mar 16.
    [See page 13.]
                                     ______

                  RESPONSE TO QUESTION SUBMITTED BY MR. ZINKE
        Admiral Moulton. Congressman Zinke, Navy Medicine has a concerted
    effort to address how we manage concussions, TBI, and blast energy
    effects on our service men and women. As you are all too aware,
    cumulative effects of blast exposures can play a critical role in the
    longevity of our readiness. We have previous and ongoing studies on
    blast research and noise hazards to prevent, track, and monitor the
    effect of impact forces. The Naval Medical Research Center has been
    working with Marine breachers such as Combat Engineers and Explosive
    Ordnance Disposal since 2008 to assess the impact of blast exposures
    during dynamic entry training. As a result of the initial observations,
    they are now assessing neurocognitive effects in the most experienced
    Marine breachers. The Naval Health Research Center, in collaboration
    with Walter Reed Army Institute of Research, has conducted a number of
    observational studies assessing overpressure exposures during training,
    using sensors mounted on combat helmets and body armor for the last
    three years. These studies have included communities such as Navy EOD,
    Army Special Forces, and civilian law enforcement tactical teams.
    Current efforts are examining blast exposure effects in human brain
    surrogates. Future studies will longitudinally examine overpressure
    exposures on medical outcomes within specific military occupations. The
    Naval Submarine Medical Research Laboratory has two ongoing studies to
    better understand noise hazards experienced during training evolutions
    as they relate to impulse exposure. They are researching why firing
    range exposures are causing quickly and dramatically causing hearing
    loss despite multiple combat tours without hearing loss. The second
    study addresses hearing protection device fit testing at accession
    where the initial training environment begins. Most recently, Navy
    Medicine established research collaborations with the University of
    Pittsburgh's world-renowned Sports Concussion program. Although there
    have been no implemented changes in protocol for negating the
    cumulative effects of blast exposures, Navy Medicine continues to
    collaborate with academic and civilian sector partners for research and
    defining best practices. We are grateful for your strong and unwavering
    support to our service members and our ability to deliver world-class
    care to the best warfighters in the world.   [See page 17.]

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                  QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                               February 26, 2016

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                      QUESTIONS SUBMITTED BY MR. O'ROURKE

        Mr. O'Rourke. In your opinion, what can be done to ensure that
    service members that are receiving mental healthcare from MTFs, under
    TRICARE, have the same access and quality of care when they transition
    to the VA healthcare system? Do you have any specific ideas on what can
    be done to improve the quality of care during and following this
    handoff?
        General Caravalho. I would like to defer this answer to the
    Services, as care at our MTFs is fully in their Title X
    responsibilities
        Unfortunately, once a Soldier has transitioned into the care of the
    VA or another healthcare system the Army loses the ability to effect
    the care that is received.
        Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual
    1332.18 (Volume 2), Disability Evaluation System (DES) Manual:
    Integrated Disability Evaluation System (IDES), depicts the standard
    timeline for IDES. According to the enclosure, the overall IDES process
    should take 295 calendar days for Active Component service members and
    305 calendar days for Reserve Component service members. The enclosure
    also shows that, during the Physical Evaluation Board Phase, the
    jurisdiction for the process transitions from the Department of Defense
    to the Department of Veteran's Affairs (VA) and that this transition
    should occur between the 115 and 190 day mark, depending on whether or
    not the service members rebuts the results of the board. Where does
    each service component stand in terms of the amount of days, on
    average, that it takes to make the transition to the VA? Please include
    both cases when the service member rebuts the findings of the Physical
    Evaluation Board and when the service member does not.
        General Hogg. The Air Force Active component takes 248 days for the
    IDES process, which is within the 295 day standard. The Air Force
    Reserve component takes 300 days for the IDES process, which is within
    the 305 day standard. For the two medical related stages of the IDES
    process, referral and MEB stages, both the Active and Reserve
    Components have met standards since October 2012. The Air Force Surgeon
    General's office does not track cases separately.
        Mr. O'Rourke. In your opinion, what can be done to ensure that
    service members that are receiving mental healthcare from MTFs, under
    TRICARE, have the same access and quality of care when they transition
    to the VA healthcare system? Do you have any specific ideas on what can
    be done to improve the quality of care during and following this
    handoff?
        General Hogg. The ``inTransition'' program has been instrumental in
    enhancing the continuity and support of service members throughout
    their transition from military mental healthcare to the VA. We continue
    to make improvements to the process specifically with timely access and
    communication. The hallmarks of clinical quality of care are timeliness
    of treatment and appropriate follow up intervals which is largely
    dependent on access to care. Tracking adherence to appropriate access
    standards for behavioral health care is essential. Additionally,
    enhancing communication and integration between the military healthcare
    and VA systems is vital to ensuring both continuity and quality care.
    Utilizing a shared or, mutually accessible electronic health record and
    continued open dialogue between DOD and VA facilitates care
    integration. Continuing education of DOD and VA medical personnel on
    programs, policies and procedures within the other agency will improve
    the transition process and allow staff on both sides to address patient
    concerns and provide accurate and timely information to transitioning
    service members.
        Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual
    1332.18 (Volume 2), Disability Evaluation System (DES) Manual:
    Integrated Disability Evaluation System (IDES), depicts the standard
    timeline for IDES. According to the enclosure, the overall IDES process
    should take 295 calendar days for Active Component service members and
    305 calendar days for Reserve Component service members. The enclosure
    also shows that, during the Physical Evaluation Board Phase, the
    jurisdiction for the process transitions from the Department of Defense
    to the Department of Veteran's Affairs (VA) and that this transition
    should occur between the 115 and 190 day mark, depending on whether or
    not the service members rebuts the results of the board. Where does
    each service component stand in terms of the amount of days, on
    average, that it takes to make the transition to the VA? Please include
    both cases when the service member rebuts the findings of the Physical
    Evaluation Board and when the service member does not.
        General Tenhet. The Army has met the 295 day IDES processing
    standards for the past 12 months. The average processing time for total
    Army (all compos and appealed cases) is 256 days as of 20 Mar 16. IDES
    consists of three distinct phases, each of which includes involvement
    from the Department of Veteran's Affairs (VA).
        Phase1 is the Medical Evaluation Board (MEB) which determines
    whether a Soldier meets medical retention standards. The Army has 100
    days to complete this phase, of which 55 days are allotted to the VA
    for claim development and to complete the disability examinations. The
    Soldier has an opportunity to request an impartial medical review and/
    or to appeal the MEB findings before the case is sent to the Physical
    Evaluation Board (PEB) for adjudication. Phase2 is the PEB which
    determines if the Soldier's failing conditions make him unfit for
    continued Service. The first stage of the PEB is the informal PEB
    (IPEB) which determines if the Service member is fit for duty. If the
    IPEB determines that a Service member is unfit, the case is transferred
    to the VA to be rated by the VA Disability Rating Activity Site (DRAS).
    The Service member's first opportunity to appeal the PEB findings
    occurs after the ratings are initiated.
        Phase3 is the Transition Phase which allows time for the Soldier to
    be returned to duty, if found fit, or to process out of the Army, if
    found unfit.
        The average IDES processing time for those cases with no MEB or PEB
    appeal is 250 days. The average processing time is 289 days when
    Soldiers appeal only the MEB findings, 381 days when only the PEB is
    appeal, and 422 days when the MEB and PEB are appealed.
        Mr. O'Rourke. In your opinion, what can be done to ensure that
    service members that are receiving mental healthcare from MTFs, under
    TRICARE, have the same access and quality of care when they transition
    to the VA healthcare system? Do you have any specific ideas on what can
    be done to improve the quality of care during and following this
    handoff?
        General Tenhet. It is critical to ensure that Soldiers with
    behavioral health conditions are engaged in care immediately after
    leaving active duty. Early engagements with the VA or another
    healthcare system reduce the chance that a Soldier's behavioral health
    condition will be adversely impacted during transition.
        Soldiers with behavioral health conditions leaving the Army are
    automatically enrolled in the Department of Defense ``In Transition''
    program, which links the Soldier and his/her Family with a care
    coordinator. The coordinator assists the Soldier by locating behavioral
    healthcare resources in the VA or another healthcare system.
        Unfortunately, once a Soldier has transitioned into the care of the
    VA or another healthcare system the Army loses the ability to effect
    the care that is received.
        Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual
    1332.18 (Volume 2), Disability Evaluation System (DES) Manual:
    Integrated Disability Evaluation System (IDES), depicts the standard
    timeline for IDES. According to the enclosure, the overall IDES process
    should take 295 calendar days for Active Component service members and
    305 calendar days for Reserve Component service members. The enclosure
    also shows that, during the Physical Evaluation Board Phase, the
    jurisdiction for the process transitions from the Department of Defense
    to the Department of Veteran's Affairs (VA) and that this transition
    should occur between the 115 and 190 day mark, depending on whether or
    not the service members rebuts the results of the board. Where does
    each service component stand in terms of the amount of days, on
    average, that it takes to make the transition to the VA? Please include
    both cases when the service member rebuts the findings of the Physical
    Evaluation Board and when the service member does not.
        Admiral Moulton. The Department of the Navy (DON) fully supports
    the goals behind the Integrated Disability Evaluation Department (IDES)
    and remains fully engaged with the Department of Defense (DOD), the
    Department of Veterans Affairs (VA), and the other Military
    Departments, to continue to improve and enhance this Service member-
    centric program to eliminate the post-separation ``benefit gap'' for
    wounded, ill, and injured Service members. For the Active Component
    (AC), the DON has approximately 4,383 Service members (roughly 56%
    Marines and 44% Navy) enrolled in IDES. This number represents less
    than 1% of the combined service end-strengths of the Navy and Marine
    Corps. For the Reserve Component (RC), the DON currently has
    approximately 114 active cases for the Navy and 120 for the Marine
    Corps enrolled in IDES.
        As of January 2016, AC Sailors spend on average 255 days and AC
    Marines spend on average 230 days in IDES, which includes the completed
    transition to the VA. As of January 2016, RC Sailors spend on average
    204 days and RC Marines spend on average 307 days in IDES. While we do
    not track cases separately when the Service member rebuts the findings
    of the Physical Evaluation Board and when the Service member does not;
    we do know approximately 10% of servicemembers request a formal
    Physical Evaluation Board which adds 58 days to the process. The 58
    days are included in the averages listed within this paragraph. While
    this is much faster than the AC 295-day goal or RC 305-day goal for RC
    Navy, it is still longer than we would like. We are working diligently
    on improving our RC Marines Corps numbers to align closer to the RC
    Navy results. We also continue to explore ways to reduce the time
    Service members spend in IDES without compromising the integrity or
    accuracy of the system.
        Mr. O'Rourke. In your opinion, what can be done to ensure that
    service members that are receiving mental healthcare from MTFs, under
    TRICARE, have the same access and quality of care when they transition
    to the VA healthcare system? Do you have any specific ideas on what can
    be done to improve the quality of care during and following this
    handoff?
        Admiral Moulton. Continued efforts to ensure interoperability and
    communication between DOD and VA healthcare systems, as well as
    TRICARE, are instrumental to ensuring same access and quality of care
    for service members when they transition to the VA healthcare system.
    Specific efforts which will continue to support the quality of care
    during and following this handoff include:
          Automatic enrollment in the DOD's InTransition program
    for all service members seen for a mental health concern during the 12
    months preceding their separation from military service. InTransition
    ensures connection with the gaining healthcare provider to introduce
    the service member and facilitate appointments; follow up with gaining
    providers to ensure continuum of care; and provide the patient with
    support and resource location should members encounter a crisis
    situation.
          DOD and VA electronic health records that are
    interoperable and facilitate communication between DOD and VA
    providers.
          Quick access (5 7 days) to the VA health system for
    military personnel leaving active duty.
          Assignment of a DOD/VA Lead Coordinator (LC) to any
    patient with mental health concerns, not just those with diagnosed
    mental health conditions. Currently, the LC serves as the primary point
    of contact for the service member and their family or caregiver during
    the transition between DOD and VA. The LC ensures that when a patient
    with complex care needs a transfer, that a ``warm hand-off'' to another
    LC and Care Management Team (CMT) on the receiving end of the transfer
    is accomplished.
          NDAA 2016, Section 715 requires that DOD and VA establish
    a joint uniform formulary that at a minimum includes medications
    related to control of pain, sleep disorders, and psychiatric
    conditions, including PTSD. While those efforts are underway to
    establish a Continuity of Care Drug List, the Report to Congress will
    be submitted no later than July 2016. Further, VA issued a directive in
    January 2015 that establishes policy to continue mental health
    medications initiated by DOD authorized providers for recently
    discharged service members.