[Senate Hearing 114-653]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2017

                              ----------                              


                        WEDNESDAY, MARCH 9, 2016

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:33 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Thad Cochran (chairman) presiding.
    Present: Senators Cochran, Murkowski, Blunt, Daines, 
Durbin, Mikulski, and Schatz.

                         DEPARTMENT OF DEFENSE

                         Defense Health Program

STATEMENT OF LIEUTENANT GENERAL NADJA WEST, SURGEON 
            GENERAL, DEPARTMENT OF THE ARMY


               opening statement of senator thad cochran


    Senator Cochran. Good morning. The Subcommittee will come 
to order. Today we are reviewing the fiscal year 2017 budget 
request for the Defense Health Program with a distinguished 
panel of witnesses.
    Lieutenant General Nadja West, Surgeon General of the Army.
    Vice Admiral Forrest Faison, Surgeon General of the Navy.
    Lieutenant General Mark Ediger, Surgeon General of the Air 
Force.
    Mr. Christopher Miller, Program Executive Officer of the 
Defense Health Care Management Systems.
    Our military has made great strides in many areas ranging 
from disease research and treatment to expedited treatment and 
medical evacuations off the battlefield, all to provide better 
training and education techniques for advanced learning.
    We're particularly proud of the work performed in our State 
at Keesler Air Force Base. The 81st Medical Group flies out of 
there.
    In July 2015 the Department was awarded a $4.3 billion 
contract for its new electronic health records system. As 
procurement and deployment of the new records system continues 
in fiscal year 2017, we sincerely hope that the Department of 
Defense will not lose sight of the goal of being fully 
interoperable with the Department of Veterans Affairs.
    While budget constraints remain in place, healthcare costs 
continue to grow. The budget request proposes a consolidation 
of TRICARE and modest increases in pharmacy co-pays and in 
enrollment fees.
    I look forward to hearing your views on these proposals and 
how we can improve the access, quality, and safety of the 
healthcare we provide to servicemembers and their families both 
today and in the future.
    [The statement follows:]
               Prepared Statement of Senator Thad Cochran
    Today, the Subcommittee on Defense Appropriations is reviewing the 
fiscal year 2017 budget request for the Defense Health Program. We are 
pleased to welcome:
  --Lieutenant General Nadja West, Surgeon General of the Army;
  --Vice Admiral Forrest Faison, Surgeon General of the Navy;
  --Lieutenant General Mark Ediger, Surgeon General of the Air Force; 
        and
  --Mr. Christopher Miller, Program Executive Officer of the Defense 
        Healthcare Management Systems.
    Our military has made great strides in many areas ranging from 
disease research and treatment, to expedited treatment and medical 
evacuations off the battlefield, to better training and education 
techniques for advanced learning. We are particularly proud of the work 
performed in our State at Keesler Air Force Base by the 81st Medical 
Group, which flies out of there.
    In July 2015, the Department awarded a $4.3 billion contract for 
its new electronic health record system. As procurement and deployment 
of the new record system continues in fiscal year 2017, we sincerely 
hope that the Department of Defense will not lose sight of the goal of 
being fully interoperable with the Department of Veterans Affairs.
    While budget constraints remain in place, healthcare costs continue 
to grow. The budget request proposes a consolidation of TRICARE and 
modest increases in pharmacy co-pays and enrollment fees.
    I look forward to hearing your views on these proposals and how we 
can improve the access, the quality, and the safety of the healthcare 
we provide to servicemembers and their families, both today and in the 
future.

    Senator Cochran. We will put your full statements, which 
you have prepared, in the record.
    I'm now pleased to turn to the distinguished Vice Chairman 
of our Committee, Senator Durbin, for any remarks he would care 
to make.

                 STATEMENT OF SENATOR RICHARD J. DURBIN

    Senator Durbin. Thank you, Mr. Chairman.
    Let me first apologize for being a few minutes late. I'm in 
the Judiciary Committee with a hearing with the Attorney 
General about a block away. So I'm trying to balance both.
    This is an important hearing. I'm glad that these witnesses 
have come to testify today.
    DOD (Department of Defense) medical research has led to 
profound improvements in the care of our troops and in the 
health of America. Recent improvements in trauma medicine have 
increased survival rate for battlefield injuries to over 90 
percent, unthinkable in previous conflicts. It is the reality 
today.
    One reason why.
    Over the past several years we have dramatically increased, 
excuse me, medical research through the Department of Defense. 
There have been many breakthroughs in battlefield medicine, 
medical devices and infectious disease as a result.
    I also want to commend our military for their leadership 
role, global leadership role, in dealing with Ebola, the 
outbreak. We depended on our military to really, literally, 
save parts of Africa and our world from this outbreak.
    We also know that your pitching in, when it comes to the 
outbreak against the Zika virus today.
    Medical readiness is a key component of military readiness.
    I've spoken to many of you and I will raise again in this 
hearing the fact that the rate of tobacco use within our 
military is higher than in civilian life. And we know what the 
costs are in terms of the health of the men and women who serve 
our Nation. We need to be conscientious in reducing that 
number.
    I would close by saying there's one unsettling moment in 
the last few months when I was handed a reprogramming request 
for about two billion dollars that was misspent through our 
medical programs on compound pharmaceuticals. It was an outrage 
what happened. But I want to hear more to make sure that we are 
going to put an end to that kind of abuse in the future.
    I look forward to your testimony.
    Thank you.
    [The statement follows:]
            Prepared Statement of Senator Richard J. Durbin
    Mr. Chairman, I am pleased to join you in welcoming our witnesses 
to our hearing on the fiscal year 2017 budget request for the 
Department of Defense health programs.
    It is a unique opportunity to have three new Surgeons General 
testifying today. I look forward to hearing their thoughts on the state 
of military medicine in general, and particularly on the benefits of 
medical research and what more we can do to discourage tobacco use 
among service members.
    I also welcome Mr. Miller, with Defense Healthcare Management.
    DOD medical research has led to profound improvements in the care 
of our troops, and Americans as a whole. For example, recent 
improvements in trauma medicine have increased the survival rate for 
battlefield injuries to over 90 percent.
    That is one reason why, over the past 3 years, this Subcommittee--
working on a bipartisan basis--has increased funding for defense 
medical research by over 25 percent.
    Our troops clearly benefit from this research. We can count the 
breakthroughs in battlefield medicine, medical devices, infectious 
disease, the treatment of traumatic brain injury--the list goes on. 
Many of these breakthroughs apply to the civilian sector as well.
    DOD medical investments play a critical role in getting ahead of 
infectious diseases as well--protecting our homeland while also helping 
our allies. For instance, the U.S. military played a critical role in 
responding to the Ebola outbreak. DOD is also lending its unique 
research expertise to the fight against Zika.
    The subcommittee has recently completed posture hearings with each 
of the Services. One major theme for this year is the emphasis on 
military readiness, or making sure that our troops are trained, 
equipped and ready to answer the call to deploy.
    Medical readiness is a key component of military readiness. Every 
soldier, sailor, airman, and Marine must be physically ready to meet 
the challenges ahead.
    It is a scientific fact that tobacco use impedes physical fitness 
and makes recovery from injury harder. Given all that we know about the 
negative effects of tobacco, I will ask our witnesses what they are 
doing--and what else we can do--to reduce the use of tobacco in the 
armed forces.
    We have a host of other challenges to consider as well--possible 
military healthcare reform, keeping an eye on the cost of compound 
pharmaceuticals, making progress on developing the integrated 
Electronic Health Record, and our continuing fight against sexual 
harassment and reducing the incidence of suicide. All of these subjects 
speak to the breadth and depth of the myriad issues you must deal with 
every day.
    Across all of these domains, to be successful we must continue to 
innovate, and an example of healthcare innovation is found in my home 
State of Illinois. The Lovell Federal Health Care Facility is a joint 
venture between DOD and the VA which is piloting new and more effective 
ways to provide healthcare services to service members and veterans. 
While there are challenges in integrating these two cultures, we are 
learning a great deal that is applicable to our future ability to 
provide better care to these populations.
    We have a lot to discuss here today and I thank you for your 
testimony and again for your service to our Nation.

    Senator Cochran. Thank you, Senator.
    Let me first call on Lieutenant General Nadja West, the 
Surgeon General of the Army for his comments or statement at 
this time.

           SUMMARY STATEMENT OF LIEUTENANT GENERAL NADJA WEST

    General West. Good morning, Sir.
    Chairman Cochran, Vice Chairman Durbin and distinguished 
members of the Subcommittee, thank you for the opportunity to 
appear before you today to discuss Army medicine and highlight 
the important work the soldiers and civilians of this unique 
organization perform daily in support of our Army and our 
nation.
    Before I begin, though, on behalf of the dedicated 
professionals within Army medicine I would like to extend our 
appreciation to Congress for your continued support of what we 
do. And we hope that you're proud of our efforts.
    I would like to open by recognizing America's sons and 
daughters currently in harm's way. Ninety-eight hundred troops 
that are committed to operations in Afghanistan, 36 hundred in 
Iraq and over 176 thousand forward stationed or deployed in 140 
countries around the world. They remain foremost in my mind as 
our primary mission is to support the war fighter.
    Since 1775 we have remained one team with one purpose, 
conserving the fighting strength, to support the war fighter 
and all those entrusted to our care. Army medicine is comprised 
of a committed team of over 150 thousand professionals who 
provide a continuum of integrated health services, research and 
training and education that no other healthcare organization in 
the world can provide. Army medicine combined with our Navy and 
our Air Force colleagues comprise a joint medical force without 
peer.
    Today I would like to focus on where we are now and provide 
an overview of my priorities for Army medicine.
    So the Army is the foundation for the Joint Force. And Army 
medicine is the foundation for the Joint Health Services 
Enterprise. For the past 14 years we've supported joint 
campaigns in Iraq and Afghanistan, responded to natural 
disasters and have taken decisive action during other 
contingencies such as was just mentioned, the U.S. Government 
response to the Ebola outbreak in West Africa. And in doing so 
Army medicine remains and it continues to prove to be the 
Nation's premier expeditionary medical force meeting the 
challenges of a complex world and we remain globally engaged, 
regionally aligned and surge ready to face the ever changing 
challenges of tomorrow.
    So Army medicine's first priority, readiness and health, is 
a direct reflection of my Chief General Milley's number one 
priority, readiness.
    As he says, ``Readiness is number one and there is no other 
number one.'' So we see readiness as health, readiness and 
health, closely coupled as our Army derives its power from the 
collective strength of our soldiers rather than advanced 
platforms. So our soldiers are our most prized and effective 
weapon systems and a soldier's health is an essential component 
of his or her readiness.
    While we focus on our readiness mission, we must also 
ensure we provide all those entrusted to our care with access 
to high quality and safe healthcare.
    As we look for ways to continue to improve how we operate, 
we see improving access to care as a matter of concern for all 
of us. While we've improved access by 21 percent since 2014, 
we're still not fully meeting our beneficiary's expectations. 
And so accordingly I've directed actions to rapidly improve 
access to care.
    So I have a goal of creating 260 thousand appointments, 
more of those primary care visits which is above the 6.1 
million visits that we provided last year and 119 thousand more 
specialty care visits which is above the 7.9 million 
appointments and visits we provided during that same timeframe.
    We're also evolving our model of healthcare delivery to 
include basically health delivery which is a part of access, I 
think, more in the engagement with our beneficiaries which 
might lead to requesting less appointments and therefore 
improving access.
    My next priority, force development, is designed to better 
prepare Army medicine for the challenges of tomorrow. The price 
for the so-called conceit of the present, meaning not 
recognizing the need to be always prepared, is very high 
indeed. I need only reference Task Force Smith to evoke images 
of soldiers paying the price in blood for a lack of readiness 
for an unknown future.
    My commitment to our Nation, our Army and to Congress today 
is that the Army will never, will never, be caught unprepared 
for tomorrow's challenges.
    Taking care of our soldiers, their families and our DA-
civilians and our retired population is integral to all we do. 
Our people are our most precious resource and we will continue 
to care for them. Army medicine will continue to stand as a 
unique organization that has the versatility, the agility and 
the scale to adapt to the challenges that arise at home or 
abroad.
    Our Nation's mothers and fathers know that when their sons 
and daughters become ill or injured, we are ready, we are there 
and this is truly a sacred trust to our Nation. Our readiness 
to support our war fighters can never and will never be in 
doubt. Army medicine stands ready to support those who serve 
our Nation.
    And I thank Congress for your continued support in our 
Army, in our soldiers and to Army medicine and I look forward 
to your questions.
    Thank you.
    [The statement follows:]
          Prepared Statement of Lieutenant General Nadja West
    Chairman Cochran, Ranking Member Durbin, and distinguished members 
of the subcommittee, thank you for the opportunity to appear before you 
to discuss the future of Army Medicine and highlight the important work 
the Soldiers and DOD civilians of this world-class organization perform 
daily. On behalf of these dedicated professionals, I extend our 
appreciation to Congress for your faithful support to military 
medicine.
    Let me open by recognizing America's sons and daughters currently 
in harm's way--9,800 U.S. troops are committed to operations in 
Afghanistan, approximately 3,500 in Iraq, and over 176,000 forward-
stationed or deployed around the world.
    Army Medicine is comprised of a committed team of over 150,000 
Active Duty, Reserve Component, Civilian and Contract professionals who 
serve on five continents and across 18 time zones, providing cutting 
edge medical readiness and healthcare throughout the world.
    I am honored to have the privilege of serving as The Army Surgeon 
General and Commanding General of U.S. Army Medical Command. Since 
1775, Army Medicine has supported our Nation and our Nation's Army 
whenever and wherever needed. For the past 14 years we supported Joint 
campaigns in Iraq and Afghanistan, responded to natural disasters, and 
took decisive action during other contingencies such as the U.S. 
Government response to the Ebola outbreak in West Africa. Because 
demands on the Army will remain constant, Readiness is my #1 priority.
    As always, we fully intend to maintain our long-standing commitment 
not only to treating the wounds of war, but also the non-combat 
injuries and illnesses of our Soldiers, their families, and our 
retirees. My four priorities are: (1) Readiness and Health; (2) 
Healthcare Delivery; (3) Force Development; and (4) Taking care of 
Soldiers, their families, DA civilians, and retirees. These four 
priorities are strategically nested with those of the U.S. Army and the 
Joint Health Services enterprise (JHSent). No matter the challenge, 
these priorities will allow Army medicine to provide the support 
necessary for our Soldiers to fight and win in a complex world.
                            budget overview
    Our fiscal year 2017 budget request provides adequate funding to 
support the essential elements of our four priorities. Military 
medicine and the Army have seen almost no budget increases in the past 
4 years. To control expenditures we have achieved efficiency and 
productivity gains to control our costs. We have done that while 
improving access and ensuring quality. Our fiscal year 2017 request is 
lean but adequate.
    I would like to highlight the people aspects of our budget which 
supports a military, civilian and contracted workforce that is 
essential to our ability to deliver healthcare. Healthcare is still a 
touch business and requires skilled professionals to deliver services. 
In recent years Army Medicine has struggled to attract and retain the 
civilian workforce necessary to ensure mission success and achieve 
improvements in healthcare access and quality among other programs; 
having lost nearly 5,000 civilian employees as a result of 
sequestration. Because our workforce has been smaller than needed, for 
the last 2 years Congress reduced our labor budget below requested 
levels. However, our civilian workforce has finally stabilized at 
budgeted levels. Our fiscal year 2017 request reflects the amounts 
necessary to sustain our current workforce. Additional reductions by 
Congress will require us to reduce services and curtail programs that 
we rely on to maintain our readiness.
    While the Bipartisan Budget Agreement Act of 2015 provides short-
term predictability for fiscal year 2016 and fiscal year 2017, the 
fiscal uncertainty beyond fiscal year 2017 presents a significant 
challenge. If sequestration returns, Army Medicine will face further 
reductions to military and civilian personnel which will likely force 
us to reduce services and cause us to convert more hospitals to 
clinics. Operating under these conditions would exacerbate our 
challenges with access and not allow sufficient mitigation strategies 
to address potential safety concerns that may be provoked by low 
patient volume. In addition, this would negatively impact our ability 
to support the health readiness of our Soldiers, impact the readiness 
of our providers, and break trust with our Soldiers, Families, and 
Retirees, by forcing them to the TRICARE network.
                 readiness and health: our top priority
    The global security environment continues to degrade and place high 
demands on the United States Army. The Army's number one priority is 
Readiness.
    Army Medicine's primary mission is supporting the Warfighter. In 
supporting the Warfighter, we uphold the solemn commitment our Nation's 
Army has made to our Soldiers when sending them in harm's way. Army 
Medicine has a two-fold readiness mission. We must ensure Soldiers are 
medically ready to deploy, and we must generate and maintain a rapidly 
responsive and broad spectrum of medical capabilities--properly trained 
and equipped individuals and units--while supporting our Soldiers, 
Families, and Retirees at home.
Soldier Health Readiness
    The Army derives its power from the collective strength of its 
Soldiers rather than advanced platforms. Our Soldiers are our most 
prized and effective weapons system. A Soldier's health is an essential 
component of his or her readiness. Although, medical readiness of the 
force has increased from 73 percent to 83 percent since 2012, more than 
57,000 Soldiers across all Components were medically non-deployable as 
of January 31, 2016. In the Active Component alone, 29,800 were 
medically non-deployable, equivalent to approximately 6.5 Brigade 
Combat Teams worth of Soldiers. In 2015, Army Medicine published the 
inaugural `Health of the Force' report to provide leaders with a more 
holistic understanding of the health readiness of the force.*
    Seventy-six percent of the non-deployable Soldiers have a related 
musculoskeletal injury (MSKI). Many MSKI are preventable; 80 percent 
are the result of physical training overuse and sports related 
injuries. Obesity and low levels of fitness also degrade medical 
readiness. Despite current body composition standards, 13 percent of 
Soldiers have body mass index (BMI) * 30, which is considered 
clinically obese. These Soldiers are 86 percent less likely to be 
medically deployable. Obese service members in a brigade in Afghanistan 
were 40 percent more likely to experience an injury than those with a 
healthy weight. Sleep deprivation, fatigue and insomnia are comorbid 
with mental illnesses and injuries, reduce mission readiness and 
contribute to Service Member medically non-deployable profiles.
    In 2012, Army Medicine continued our evolution to aggressively 
transition from a healthcare system--a system that primarily focused on 
treating injuries and illness--to a System for Health to proactively 
focuses on improving health and wellness of all Service Members, 
Families, and Retirees. Health readiness and fitness are fundamental to 
Soldier performance and comprise the foundation of the Army's combat 
power and land dominance. Army Medicine has partnered with key 
stakeholders across the Army to develop the Performance Triad Strategy. 
This is a comprehensive strategy to invest in our Soldiers, DA-
Civilians, Retirees, and their Families with the goal to enhance 
personal health readiness, sustain resilience, and optimize 
performance. As part of our comprehensive strategy, programs like the 
Performance Triad (P3) augment other initiatives such as Army Wellness 
Centers, Move to Health, and Go Dental First Class. Our medical 
readiness transformation is aimed to improve health readiness while 
providing better tools and resources for Command Teams.
Performance Triad Training Programs & Products
    The Performance Triad (P3) training programs and products are the 
cornerstone of the System for Health and link directly to the Army's 
Ready and Resilient Campaign and the Army Human Dimension Strategy. The 
P3 strategy provides tools for unit and installation leaders to improve 
the physical, cognitive, and emotional fitness and health of their 
Soldiers through techniques that optimize restful sleep, regular 
physical activity, and good nutrition. Based on pilot study results 
beginning in fiscal year 2014, the Performance Triad is a solution and 
key enabler to improve individual and unit readiness. It synchronizes 
the best advances in sports science and technology to improve 
knowledge, attitudes and behaviors in relation to sleep, activity, and 
nutrition.
    The fiscal year 2014 pilot was conducted in three active duty 
battalions from August 2013 to May 2014. It confirmed Soldiers are not 
meeting the basic Performance Triad targets essential for health, 
performance, and readiness. Only 4-5 percent of Soldiers met all sleep 
targets, 29-42 percent met all activity targets, and only 2.4-3.6 
percent met all of the nutrition targets across the three units.
    The fiscal year 2014 pilot yielded valuable insights which shaped 
the fiscal year 2015-2016 pilot to improve the reach, adoption, 
implementation, and maintenance of the program Army wide. The fiscal 
year 2015-2016 pilot expanded the program to approximately 11,000 
active duty Soldiers across five FORSCOM brigades, the Army Medical 
Department Center and School (AMEDDC&S), one Army Reserve brigade, and 
one Army National Guard brigade. The cost of the current study is 
$6,700,000 million which we believe is an investment in Total Army 
Family and health readiness. The fiscal year 2015-2016 pilot will 
conclude Summer of 2016 and the formal analysis will be completed Fall 
of 2016, and will inform Army wide implementation.
    Preliminary fiscal year 2015-2016 pilot results indicate that 
Soldiers expect the Army to treat them as tactical athletes. Army-wide 
implementation can impact at a minimum, preventable disease, illness, 
and injury. Also, we anticipate a rising trend in self-monitoring of 
personal health readiness and an increase in peer support. While these 
are promising mid-point findings, the formal analyses this fall will 
garner more accurate results. Successful implementation of Performance 
Triad across the Total Army will improve the health readiness of the 
force. Optimization of each individual's performance becomes more 
critical as the Army end strength decreases and budgets decline. By 
applying the lessons learned from the fiscal year 2014 pilot and 
through the ongoing fiscal year 2015-2016 pilot, we are changing the 
culture of the Army by embedding the Performance Triad into the Army's 
DNA.
Move-to-Health Program
    The ``Move to Health'' Program educates healthcare teams to focus 
on improving health outcomes, by integrating the Performance Triad, 
mindfulness, and other health and wellness initiatives for our 
beneficiaries. It provides clinic personnel with additional tools to 
engage Solders and their Families to empower them to be active partners 
in their health and healthcare outside of clinic or hospital settings. 
The curriculum is adapted from the Veteran's Health Administration 
(VHA) ``Whole Health'' program.
    The ``Move to Health'' pilot was launched at eight of our 
facilities and trained 376 physicians, nurses, and other health 
professionals. The Army Public Health Center (Provisional) provided 
oversight. Although the final evaluation results are pending, the 
initial results are promising. Based on improved team performance noted 
locally, Madigan Army Medical Center has already decided to train 100 
percent of its teams on ``Move to Health''. The initial results 
demonstrated significant improvements in self-efficacy, attitudes 
towards patient-centered care, and an increased willingness to engage 
in holistic health and behavior approaches to address pain management, 
cardiovascular disease, and gastrointestinal disease.
Army Wellness Centers
    Army Wellness Centers (AWC) provide community based health 
promotion services to promote and sustain healthy lifestyles and to 
enhance the readiness of the force. AWCs represent an actionable 
platform to deliver evidence based practices designed to promote 
positive lifestyle change. All staff members of our Army Wellness 
Centers are trained in wellness coaching. Equipment utilized in an AWC 
is composed of advanced technology to measure the four components of 
physical fitness--cardiorespiratory, body composition, muscular 
fitness, and flexibility. Stress, nutritional habits, and other health 
behaviors are also assessed. These services are supported by a budget 
of nearly $70 million.
    In 2015, 27 locations met the standards and were classified as 
AWCs. In fiscal year 2016, we will add four new sites with full 
implementation of 37 AWCs occurring by the end of 2018. Active Duty 
Soldiers made up the majority of AWC participants served (63 percent), 
followed by Family members (20 percent), Department of the Army 
civilians (9 percent), Retirees (3 percent), Unreported (3 percent), 
and Reservists (2 percent). The overall consumer satisfaction rating 
was 97 percent, and each individual Army Wellness Center either met or 
exceeded the goal of 95 percent satisfaction.
    Forty-eight to 58 percent of participants who set a goal with the 
Army Wellness Center health educator to lose weight saw a significant 
decrease in BMI. Clients who returned for follow-up within 1 year 
generally improved their risk factors for disease. Improvements were 
observed in body fat, body mass index (BMI), diet and nutritional 
habits, perceived stress, cardiorespiratory fitness, and blood 
pressure.
Dental Readiness
    Go First Class (GFC) is a comprehensive Army-wide initiative that 
simultaneously addresses dental readiness, wellness, and prevention 
while returning valuable training time to Soldiers and their units. 
During their annual dental exam, Soldiers now routinely receive a 
dental cleaning, and if needed dental fillings. Soldier benefits 
include spending less time traveling to and from dental appointments, 
reducing the number of hours spent in the clinic, and eliminating the 
requirement for follow-on appointments.
    Since January 2011, Go First Class and other initiatives have 
contributed to a 25 percent decrease in acute care appointments, a 50 
percent reduction in Dental Readiness Classification 3 (non-
deployable), and a 60 percent reduction in all treatment needs. GFC has 
directly improved Soldiers' Dental Readiness (deployable) and Dental 
Wellness (no dental needs), reaching all-time historic highs of 96 
percent and 60 percent, respectively.
Medical Readiness Transformation
    As the Army downsizes from its peak of 566,000 Active Duty 
personnel to 450,000 by the end of fiscal year 2017, the Army must 
reduce the number of medically non-deployable Soldiers to retain combat 
power. Therefore, Army Medicine is leading a medical readiness 
transformation to improve Command Teams' visibility of medical 
readiness information at all levels. This will simplify the process by 
which they make deployability determinations and lead to timely 
identification, corrective action, and accountable oversight of unit 
and individual medical readiness.
    We are redesigning the process of profiling, which documents 
Soldier's temporary and permanent medical and behavioral health 
conditions as well as any functional limitations, in order to improve 
transparency and consistency in communicating medical readiness 
information to Commanders. Soldiers will no longer have overlapping 
temporary profiles, and will instead have a single active profile for 
all conditions. The Army is simplifying the Medical Readiness 
Classification (MRC) codes used to identify Soldiers as being 
``deployable'' or ``non-deployable.'' We have developed a new 
``Commander's Portal'' to allow Command teams to more easily view 
Medical Readiness data and make deployability determinations without 
requiring log on to multiple systems.
    The newly developed Medical Readiness Assessment Tool (MRAT) allows 
commanders and clinicians to proactively address medical readiness by 
identifying Soldiers with recurring medical profiles that are headed 
down a trajectory that could result in a permanent deployment limiting 
profile. It does this through a predictive model that identifies a 
Soldier's risk for becoming medically non-deployable during the next 12 
months. Awareness of these high risk Soldiers enables clinicians to 
intervene to determine root causes for medical issues and develop 
courses of action to maximize readiness of the Soldier and ensure he or 
she receives the care needed.
    We are aggressively training the force to fully implement the 
Medical Readiness Transformation by June 1, 2016.
Responsive Medical Capabilities
    The Army must maintain a rapidly responsive and broad spectrum of 
medical capabilities that can conduct rapid deployment in support of 
Combatant Commanders' requirements. Our medical capabilities must be 
prepared to support the full range of military operations with mission 
ready personnel able to rapidly transition from garrison to delivering 
the appropriate health service support in an area of operation.
    During the past 14 years of combat operations, our trained and 
ready medical providers contributed to a survivability rate of 92 
percent, the highest in the history of warfare, despite the increasing 
severity of battle injuries. These advances in combat casualty care 
resulted from our integrated healthcare system that spans the continuum 
of care from prevention, to treatment of illness or injury, to recovery 
and rehabilitation in garrison.
    However, focusing exclusively on sustainment of combat trauma, 
surgery and burn capabilities would be a failure born of 
shortsightedness and could potentially lead to catastrophic 
consequences for the future. Our experience shows that the Army must 
maintain a broad range of medical capabilities to support the full 
range of military requirements. From 2001 to 2015, only 16 percent of 
those evacuated from Iraq and 21 percent of those evacuated from 
Afghanistan were injured in battle. The remaining Service members, 84 
percent in Iraq and 79 percent in Afghanistan, were evacuated for 
disease or non-battle injuries. Similarly, greater than 95 percent of 
those that received care and remained in theater were treated for 
disease and non-battle injuries rather than combat injuries.
    The 2014 deployment of over 2,500 personnel to support Operation 
United Assistance in Liberia demonstrated the value of non-trauma 
related medical specialties. Infectious disease is often a major threat 
to our Soldiers rather than armed combatants. The geographically 
endemic medical risks to our forces in support of the rebalance to Asia 
and operations in Africa point to the continued need to remain ready to 
utilize the entire spectrum of Army medicine in the execution of all 
manner of military contingency operations.
    In fiscal year 2015, the MEDCOM deployed 1,998 Soldiers to support 
a variety of missions supporting Combatant Command requirements. Of 
these, 238 personnel deployed to support 38 theater security 
cooperation missions; 129 Soldiers and civilians conducted 55 subject 
matter expert exchanges; and 139 employees were integral team members 
on 59 Defense Threat Reduction Agency (DTRA) missions. As of January 6, 
2016, 354 MEDCOM Soldiers were deployed and another 159 were in a 
prepared to deploy status in support of globally integrated operations.
    Army Medicine capabilities employed in Global Health-related 
engagements contributed in numerous areas in support of Combatant 
Commands to include battling Ebola (Africa), rabies wildlife prevention 
program (Kosovo), regional tropical disease research, bio surveillance 
and threat reduction (Thailand, Republic of Georgia and Kenya), 
proliferation of best practices in prosthetics and rehabilitation (UK, 
Pakistan, Republic of Georgia), advancement of professional military 
nursing (France, Vietnam, and Japan) and support to exceptional medical 
care cases through the DOD Secretarial Designee Program (Norway, 
Afghanistan, Australia, Ecuador, Italy, Romania, and the Republic of 
Georgia).
    We see our medical centers, hospitals and clinics as our health 
readiness platforms. They ensure we maintain trained and ready medical 
personnel. Our large medical centers serve as specialized training 
centers for our medical teams to provide care and clinical research for 
complex battle injury and illness. Our medical centers are complemented 
by a variety of military treatment facility types, from ambulatory 
clinics to community hospitals that prepare our medical force to 
provide primary and routine specialty care in a myriad of settings and 
conditions around the world. These facilities must be capable of 
enrolling a broad range of patients with a wide variety of illnesses 
and injuries.
    Army Graduate Medical Education (GME) programs are critical to 
develop trained and ready medical personnel. Army GME is the largest 
GME platform in the DOD and supplies more than 90 percent of all 
Medical Corps (MC) physicians for the Army. Our GME programs have 
nearly 1,500 trainees in 149 programs. The vast majority (93 percent) 
of Army GME training is conducted at 10 military treatment facilities. 
The remaining 7 percent is conducted in approximately 64 civilian 
academic institutions, primarily for fellowships. Civilian GME programs 
do not have the capacity to absorb our interns, residents, and fellows. 
Our GME programs continue to lead the Nation in training. The first 
time board certification pass rate of 95 percent across Army GME 
exceeds the 87 percent national rate. Agile GME program management 
assures ongoing alignment of training slots with deployment and 
readiness requirements.
    The Army continues to increase its partnerships with the VA through 
sharing agreements that provide care to VA beneficiaries in various 
healthcare facilities that have excess capacity. Treating VA 
beneficiaries supports Army GME programs and provider readiness. This 
is due to the fact that VA patients typically have needs that are much 
more complex and extensive than normally seen in Soldiers and family 
members. Further, this enables VA beneficiaries to receive high 
quality, cost effective, and timely care in locations where the VA may 
have limited capability or resources. In fiscal year 2014, Army 
Medicine provided $50.3 million in healthcare services to VA 
beneficiaries at 19 locations across the country.
    I would also like to highlight our partnership with the U.S. Army 
Special Operations Command, Joint Special Operations Medical Training 
Center (JSOMTC), to identify where we can collaborate to identify best 
practices and disseminate those to the entirety of the Total Force. 
JSOMTC provides a unique opportunity to capture lessons learned from 
the battlefield as special operations medical personnel provide 
support. The best practices they identify are instrumental in educating 
our medical personnel in the conventional force. To that end, we will 
continue efforts to bring the conventional and unconventional forces 
closer together and learn from each other. We anticipate this will 
motivate leaders at all levels to take a more active role in medical 
training and incorporate casualty-play into all other training.
Education and Training
    Army Medicine continues to enjoy tremendous success in attracting 
and educating the best medical minds. The multi-discipline Health 
Professions Scholarship Program (HPSP) produces over 450 graduates 
annually--80 percent of active duty physicians, dentists, optometrists, 
veterinarians, and clinical psychologists. Currently, we have 1596 HPSP 
students in medical, dental, veterinary, optometry, nurse anesthetist, 
clinical psychology and psychiatric nurse schools. Additionally, the 
Uniformed Services University of the Health Sciences (USUHS) is a 
critical institution dedicated to developing and training clinicians in 
leadership, clinical, and combat casualty care as well as operational 
medicine. USUHS is a critical source of accessions for the Medical 
Corps and provides valuable post-graduate education for nurses, 
dentists, administrators and other public health professionals.
    Our education programs are consistently recognized nationally. U.S. 
News and World Report's most recent survey of graduate schools ranked 
the U.S. Army Baylor Doctoral Program in Physical Therapy 5th in the 
country; the Inter-service Physician Assistant Program 11th; and the 
Army-Baylor University Graduate Program in Health Administration 
program 7th nationally. Furthermore, the U.S. Army Graduate Program in 
Anesthesia Nursing (USAGPAN) and the USUHS Daniel K. Inouye Graduate 
School of Nursing Doctor of Nursing Practice (DNP) Nurse Anesthesia 
program are regarded among the best in the Nation with graduates 
surpassing national averages on National Certification Exam first-time 
pass rates and overall scores.
    The Army has partnered with the Uniformed Service University of the 
Health Sciences to develop and implement the Enlisted to Medical Degree 
Preparatory Program (EMDP2). This 24-month program enables enlisted 
Service members to complete the preparatory course work for entry into 
medical school while maintaining active duty status. Four of the five 
Soldiers in the 2014 cohort have already been offered positions in the 
military medical school. This program will recruit and grow talent from 
within the ranks, optimize force development and enhance medic 
retention.
                          healthcare delivery
    Army Medicine's fundamental tasks are promoting, improving, 
conserving, and restoring the behavioral and physical well-being of 
those entrusted to our care. From the battlefield to the garrison 
environment, we will support the Operational requirements of Combatant 
Commanders while also ensuring the delivery of the healthcare benefit 
to our beneficiaries. We must provide our beneficiaries with access to 
high quality care. We will continue to focus on expanding Telehealth, 
sustaining Warrior Care and Behavioral Health, and supporting women in 
the Army.
Access to Care Initiatives
    Improving access to care remains a priority for Army Medicine. 
Specifically, our beneficiaries expect better primary care access. 
While we have improved access by 21 percent since 2014, we are still 
not fully meeting our beneficiaries' expectations. Therefore, I have 
directed actions to radically improve access to primary care in our 
MTFs. I have established a goal of creating 260,000 (4 percent) more 
primary care visits above the 6,100,00 million visits we provided in 
fiscal year 2015 and 119,000 (1.5 percent) more specialty care visits 
above the 7,900,000 we visits provided in fiscal year 2015.
    We are standardizing processes across the Services to drive 
improvement with access. Last year, Army Medicine instituted a ``First 
Call Resolution'' policy to ensure all enrolled beneficiaries receive a 
direct care system appointment or network authorization on their first 
call. In addition, Army Medicine implemented a simplified appointing 
policy to reduce the types of primary care appointments from 12 to 5 
with a focus on 24-hour acute appointments and future/follow-up 
appointments.
    Army Medicine continues to expand our off-installation healthcare 
program by placing Community Based Medical Homes (CBMH) in communities 
surrounding our military installations closer to where our 
beneficiaries live and work. Today over 10 percent of our enrolled 
beneficiaries receive their primary care in a CBMH, many of which have 
extended hours and offer behavioral health and prescription refill 
services. We currently have 20 CBMHs supporting 13 installations. In 
fiscal year 2016, we will open three more CBMHs at three installations 
and in fiscal year 2017, we will open two more CBMHs and our first open 
access acute care clinic in San Antonio.
    To further improve access to routine and specialty care, I am 
directing our MTFs to allow beneficiaries to book an appointment up to 
6 months in advance. This will allow beneficiaries to book follow-up 
appointments before departing at the conclusion of their MTF visit, 
eliminating the need for them to call back to make an appointment after 
they have left our facilities. We will increase the number of available 
appointments by increasing the time our physicians are available to see 
patients and reducing the number of unfilled appointments. 
Additionally, we are also conducting a comprehensive assessment across 
our installations to determine where we must expand clinic hours or 
establish Urgent Care Clinics to take care of our people.
    Army Medicine is also aggressively expanding the use of virtual 
tools, such as the Nurse Advice Line (NAL), TRICARE online, and Secure 
Messaging. In 2015, 55,000 beneficiaries were given self-care 
instructions through the NAL avoiding an unnecessary trip to the 
Emergency Department or Urgent Care Center. On January 15, 2016, 
Tricare Online (TOL) Pharmacy Refill went live. During the first week 
in February alone, 5,400 prescriptions were refilled via TOL allowing 
providers to focus more time on clinical care.
Army Medical Homes
    The Army Medical Home (AMH) is a multidisciplinary approach to 
deliver comprehensive primary care. Care is delivered through an 
integrated healthcare team who proactively engages patients as partners 
in health. The Army Medical Home model encompasses all primary care 
delivery sites in the direct care system, including our MTF-based 
Medical Homes, Community Based Medical Homes (CBMH) and the Soldier 
Centered Medical Homes (SCMHs).
    Primary Care is delivered through an integrated team of healthcare 
professionals that proactively engages patients as partners in health, 
with a stronger focus on prevention. Each patient will partner with a 
team of healthcare providers--physicians, nurses, behavioral health 
professionals, pharmacists, and others--to develop a comprehensive, 
personal healthcare plan. Currently, 134 AMHs across the United States, 
Europe, and the Pacific are caring for 1.3 million beneficiaries 
supported by a budget of $74.5 million. All of the AMHs have been 
recognized by the National Committee for Quality Assurance (NCQA) 
representing the gold standard of patient-centered medical care.
    The integration of Internal Behavioral Health Consultants (IBHC) 
and Behavioral Health Care Facilitators (BHCF) into Army Medical Homes 
has increased the availability of behavioral health services to all 
beneficiaries and reduced the stigma of behavioral health treatment. In 
addition, these Behavioral Health providers are an integral component 
of the treatment and prevention of behavioral health and behavioral 
medicine disorders in the beneficiary population. IBHCs address common 
behavioral health issues including depression and anxiety as well as 
assist with the treatment and prevention of many chronic medical 
conditions that can improve with lifestyle changes (diabetes, chronic 
pain, insomnia, obesity, nicotine use, etc.). Currently, 99 IBHCs and 
58 BHCFs are integrated within the Army Medical Homes.
Telehealth (TH)
    Army Medicine will continue to leverage technology to enhance 
access, readiness, quality, and safety for our beneficiaries. Army 
Telehealth (TH) currently provides clinical services across 18 time 
zones in over 30 countries and territories. Army Medicine executes 
approximately $14 million per year on clinical uses of TH such as Tele-
Behavioral Health (TBH). In fiscal year 2015, Army clinicians provided 
over 40K provider-patient encounters and provider-provider 
consultations in garrison and operational environments in over 30 
specialties via TH. Army TH accounts for over 90 percent of all 
clinical TH encounters in the DOD.
    Army Medicine invests in three TBH provider hubs with the majority 
of current spending for provider and staff salaries. These hubs are 
strategically located across the world to ensure 24/7 routine and 
emergency coverage. The April 2014 Fort Hood shooting is an example of 
emergency surge support. After the shooting, clinical support from 
Washington D.C., Honolulu, HI, and San Antonio, TX, was surged quickly 
to offer services to our Soldiers at Ft. Hood, TX. Other key programs 
include teleconsultations systems connecting deployed providers with 
specialty expertise in garrison; a mobile application system supporting 
warriors in transition; tele-mentoring programs in Pain Management; and 
a world class research portfolio innovating deployed TH systems.
    Because of its tremendous benefits, Army Medicine is expanding TH 
to create Connected, Consistent Patient Experience (CCPE)--a 360 care 
continuum around patients using advanced TH modalities. The core 
elements of the CCPE include: (1) implement TH visits to patients' 
locations (such as their homes); (2) optimize provider-provider 
teleconsultations systems; (3) pilot remote health monitoring; (4) 
enhance the current TH Operating Company Model for standardized global 
operations; and (5) mature Army TH in operational environments.
    As a glimpse of the future, Army Medicine is building a seamless, 
global teleconsultations platform. From battlefield to bedside, 
providers will be able to access specialty expertise from their 
colleagues--wherever in the world they are working. This enables 
patients to receive the best specialty expertise Army Medicine has to 
offer no matter where they are stationed.
Behavioral Health (BH)
    Behavioral healthcare is one of the most important factors in the 
readiness of the Force. I anticipate continued growth in the demand for 
behavioral healthcare, including TBH, even as overseas contingency 
operations decrease. This is mainly due to the cumulative strain of 
over 14 years of war on Soldiers and families, the unique stressors of 
military service, and the Army's continued emphasis on Soldiers seeking 
help. In fiscal year 2016, the Army will resource an estimated $300 
million to support BH programs.
    The Army is helping to decrease the stigma that others may feel in 
seeking behavioral healthcare. Programs such as Embedded Behavioral 
Health (EBH), Primary Care Behavioral Health and School Behavioral 
Health focus on reaching Soldiers and their families outside the MTF to 
improve access and reduce stigma.
    Embedded Behavioral Health teams now support 141 operational units, 
including all Brigade Combat Teams. EBH provides multidisciplinary 
behavioral healthcare to Soldiers in close proximity to their units. 
EBH has correlated with an increase in Soldiers' use of outpatient 
behavioral healthcare and a reduction in the need for acute inpatient 
psychiatric care. This indicates that Soldiers are receiving care 
earlier in the course of their BH condition, before crises occur. We 
will extend the EBH model of care to support all operational units 
across the Force no later than October 2016. Special Forces units on 
Army installations have the priority of support.
    The Army regularly screens Soldiers for BH conditions, including 
PTSD, at several points in the Force Generation cycle. The Army's 
screening program exceeds Department of Defense requirements and 
includes assessments annually and before and after every deployment. 
Also, screenings for BH conditions are performed at every primary care 
visit and BH professional have been placed in medical homes to expedite 
consultation and treatment. To expand behavioral healthcare to Children 
and other Family Members, MEDCOM has established clinics within 51 
schools and will expand to approximately 50 more to enhance access to 
and continuity of care.
    We are proud of the implementation of the Behavioral Health Data 
Portal (BHDP) at every MTF. BHDP is a web-application that gathers 
standardized, automated clinical data from Soldiers receiving care in 
BH clinics. The program analyzes and presents data to BH providers to 
support their clinical decisions and treatment planning. It tracks 
patient outcomes, satisfaction, and risk factors via web application to 
improve program assessment and treatment efficacy. This innovative 
program has been identified by the Department of Defense as a best 
practice and is being implemented by the Navy and Air Force.
    In March 2015, the Secretary of the Army (SA) directed the 
Assistant Secretary of the Army for Manpower and Reserve Affairs to 
conduct a comprehensive review of the Army Substance Abuse Program 
(ASAP). In October 2015, the Secretary approved ASA(M&RA)'s 
recommendation to realign clinical care under MEDCOM and integrate it 
with the Behavioral Health System of Care. The MEDCOM is developing a 
Substance Use Disorder Clinical Care capability that ensures holistic 
and integrated medical care for our Soldiers in accordance with 
published DOD policy, national standards, and best practices. The new 
$40 million program will provide additional opportunities for Soldiers 
to receive care for substance use disorders from over 300 specially 
trained counselors.
Improving Quality and Safety
    Since 1775, Army Medicine has reliably served our Nation, our Army 
and all those entrusted to our care. Army Medicine's commitment to 
patient safety has been, and remains, unwavering. In 2012, we began to 
incorporate elements of the ``High Reliability Organization'' (HRO) 
concept to continue to improve our practices in achieving the highest 
levels of patient safety. In 2015, we established the Deputy Chief of 
Staff for Quality and Safety to align all quality, patient safety, and 
organizational environmental and equipment safety elements within the 
same directorate. This alignment provides a synergistic environment to 
take advantage of analysis of problem areas and best practices across 
the full spectrum of quality and safety from within the command and in 
consultation with external experts and leaders.
    Army Medicine is collaborating with The Joint Commission Center for 
Healthcare Transformation to pilot an assessment program that gauges 
the HRO maturity of Army MTFs. The Joint Commission team completed 
three assessments in 2015 and one in January 2016. The evaluations 
revealed several leading practices that include the routine conduct of 
Command team safety walk-rounds and the incorporation of HRO concepts 
into staff orientation. Opportunities for improvement identified were 
clearly linking Commander's priorities to quality and safety and 
advancing training in the use of Lean and Six Sigma for process 
improvement and reduction of variance across the facility. These 
assessments are valuable to our facilities. Therefore we plan on 
conducting four more MTF assessments per year over the next 5 years. As 
the assessments are completed and analyzed, the lessons learned will be 
shared across the entire MEDCOM and with our Sister Services.
    Army Medicine is increasing its participation in the American 
College of Surgeons' National Surgical Quality Improvement Program 
(NSQIP) to reduce surgical complications, improve outcomes, and improve 
patient satisfaction. Currently, nine Army MTFs participate in NSQIP. 
By the end of 2016, all 22 Army MTFs with surgical services will 
participate in NSQIP. In 2015, Dwight D. Eisenhower Army Medical Center 
at Fort Gordon, GA was recognized by the American College of Surgeons 
as one of the Nation's Top 50 Hospitals for Surgical Quality out of the 
528 hospitals in the U.S. that participate in NSQIP.
    To drive further improvement, MEDCOM will design, develop and 
implement a Quality and Safety Center to more effectively use patient 
safety data, improve sharing of lessons learned across the MEDCOM, and 
increase transparency and availability of quality and safety 
information available to our leaders, staff, and beneficiaries. This 
center will be established in coordination with the Army Combat 
Readiness Center (CRC) and will leverage many of the successful 
practices incorporated by the CRC.
Wounded Warrior Care
    Caring for wounded, ill, and injured Soldiers is a sacred 
obligation and will remain an enduring mission. Since 2007, nearly 
70,000 wounded, ill, or injured Soldiers and their families received 
care from dedicated Warrior Care and Transition Program (WCTP) 
healthcare professionals with more than 30,000 (44 percent) returned 
to the force. This is a fully-funded program and the budget for fiscal 
year 2016 is approximately $810 million.
    The Warrior Transition Units (WTUs) provide mission command, 
medical management assistance, and transition assistance to Soldiers as 
they navigate the Army's medical treatment system. Within the WTUs, 
Soldiers receive personalized support from a Triad of Care that 
includes a nurse case manager, a squad leader, and the primary care 
manager. The Triad of Care is augmented by an interdisciplinary team of 
healthcare and transition specialists, to include social workers, 
physical therapists, occupational therapists, Army Wounded Warrior 
(AW2) Advocates, and many other professionals.
    Community Care Units (CCUs) are within most WTUs and extend WTU 
capabilities into the community. Soldiers assigned to a CCU heal at 
their home with the support of their families and communities, with the 
support of the Triad of Care.
    Since February 2014, Soldiers receiving care and oversight through 
the WCTP has decreased from approximately 7,000 to 2,659. Based on the 
declining population in WTUs, on August 27, 2015 the Army announced its 
plan to reduce the number of WTUs from 25 to 14 by August 2016.
    The WTU locations scheduled for inactivation are Fort Gordon, GA; 
Fort Knox, KY; JB Langley-Eustis, VA; Fort Leonard Wood, MO; Fort Sill, 
OK; Fort Polk, LA; Fort Wainwright, AK; JB Elmendorf-Richardson, AK; 
Fort Meade, MD; and Naval Medical Center, San Diego, CA. As of 8 
February 2016, there were a total of 171 Soldiers assigned to these 
WTUs.
    The remaining 14 WTUs are aligned to major power projection 
platforms or those co-located with major Army medical activities and 
centers providing support to wounded, ill and injured Soldiers who 
require at least 6 months of rehabilitative care and complex medical 
management.
    Throughout the consolidation effort, the WCTP will maintain a 
scalable and reversible posture to ensure uninterrupted care to our 
wounded, ill and injured population. The CCU mission of allowing 
Soldiers who do not require day-to-day care to recover closer to home 
and receive their care from the TRICARE network will not be affected by 
these consolidation efforts. The opportunity to recover closer to home 
will continue to be an option our Soldiers can exercise.
    Civilian employees impacted by the consolidation will be reassigned 
based on skill match, the needs of the Army, and available employment 
opportunities. Every attempt will be made to allow Reserve Component 
cadre to serve out their tours. Transferring Soldiers and their 
families will be managed closely during this operation.
    The Army will host the 2016 DOD Warrior Games in June 2016 at the 
U.S. Military Academy at West Point. The Warrior Games is the pinnacle 
event in the Army's adaptive reconditioning program for Soldiers 
recovering at the Army's Warrior Transition Units (WTUs). The Warrior 
Games feature 8 sporting events with approximately 200 athletes 
representing teams from each Service, SOCOM, and the British Armed 
Forces. As part of the Warrior Games, Soldiers can participate in a 
wide range of physical activities that support their physical and 
emotional well-being and contribute to a successful recovery, whether 
they are transitioning back to active duty or to civilian life.
Supporting Women in the Army
    In January 2013, then Secretary of the Defense (SECDEF) Leon 
Panetta rescinded the 1994 Direct Ground Combat Definition and 
Assignment Rule. Following 3 years of careful and comprehensive study, 
the Army recommended all military occupational specialties (MOS) be 
open to women. The Army believes the best-qualified Soldier, regardless 
of gender, should be allowed to serve in any position. In December 
2015, SECDEF Ashton Carter directed the full integration of women in 
the Armed Forces.
    Since 2011, the Army has opened 9 military occupational specialties 
and approximately 95,000 positions in Combat Arms units down to company 
and platoon level. To achieve full gender integration, the Army will 
implement published, measurable, gender-neutral standards, then 
initiate gender-neutral training, followed by deliberate and methodical 
assignment of female leaders (officers, then enlisted) to Infantry and 
Armor units.
    Army Medicine is supporting several tasks required for full gender 
integration. From October 2013 to June 2015, MEDCOM led the Soldier 
2020 Injury Rates/Attrition Rates Working Group that conducted a 
thorough review of current literature, identified gaps in research and 
surveillance requirements to provide strategic-level recommendations to 
for policies and injury surveillance concerning mitigation of 
musculoskeletal injuries, gender-specific attrition, performance, 
behavioral health disorders and women's health issues.
    Soldiers' injury rates have been consistently higher in female than 
male Soldiers in the basic training setting (2:1) for 30 years. The 
injury rates become closer in the Operational and Deployed Army (1.2-
1.4:1). This is likely due to improved levels of physical fitness and 
regular physical training sessions once Soldiers are assigned to units. 
Some studies compared male and female trainees of similar fitness 
levels and showed injury rates were nearly the same in a Basic Combat 
Training (BCT) environment. This suggests there is a subset of females 
that can perform at high fitness levels and who are less likely to be 
injured. Currently there is no medical data or research on long-term 
injury and disability rates for combat arms MOSs/AOCs for men or women. 
Consequently there is no foundation for predicting long-term injury 
rates and disability in Soldiers.
    Nutrition is key factor in performance. Blood iron levels declines 
in female service members during rigorous training, particularly in BCT 
and Advanced Individual Training (AIT). MEDCOM and TRADOC implemented a 
multivitamin with iron program for female Army trainees in January of 
fiscal year 2016 aimed at increasing performance and decreasing 
attrition rates. Other nutritional supplementation (primarily Calcium 
and Vitamin D) is being considered to address the incidence of stress 
fractures in Individual Entry Training (IET) Soldiers.
    The U.S. Army Research Institute of Environmental Medicine 
(USARIEM) worked closely with the Training and Doctrine Command 
(TRADOC) to develop the Occupational Physical Assessment Test (OPAT); a 
new criterion-based physical testing procedure for entry into seven 
physically demanding Combat Arms MOSs.
    The Women's Health Service Line (WHSL) manages the unique needs of 
women by building sound fundamentals in perinatal and newborn services, 
as well as gender-based programs. The WHSL was instrumental in the 
development of the MEDCOM Breastfeeding and Lactation Support Policy to 
ensure the MTFs incorporate the ``Ten Steps to Successful 
Breastfeeding'' concepts and ensure standardized breastfeeding 
education for all personnel who care for the mother and infant. This 
policy also supports the Army Directive 2015-43, Revised Breastfeeding 
and Lactation Support Policy, to ensure a designated place to express 
milk when employees/Soldiers return to work.
Sexual Assault/Sexual Harassment Prevention
    The Army and Army Medicine continue to confront the complex 
challenges of sexual assault. As an integral participant in the Army's 
Sexual Harassment/Assault Response and Prevention (SHARP) program, Army 
Medicine continues to be at the forefront of the management, regulatory 
guidance, and oversight of care for all sexual assault victims. Our 
goal is to be a nationally recognized leader in providing patient-
centered responses to all victims of sexual violence.
    Regardless of evidence of physical injury, all patients presenting 
to a MTF with an allegation of sexual assault receive comprehensive and 
compassionate treatment. All examinations are completed in accordance 
with Department of Justice (DOJ) ``National Protocol for the Sexual 
Assault Medical Forensic Examinations Adult/Adolescents'' current 
recommendations and training guidelines. They are offered a sexual 
assault medical forensic examination (SAMFE) conducted by a trained and 
competent SAMFE professional at the MTF or at a local facility through 
a memorandum of agreement. USAMEDCOM also provides at least one Sexual 
Assault Nurse Examiner (SANE) at every Military Treatment Facility 
(MTF) with a 24/7 emergency room (ER).
    Follow on care is coordinated and managed through the Sexual 
Assault Medical Management Team (SAMMT) at each MTF and the Sexual 
Assault Response Coordinators (SARCs), and Victim Advocates (VAs). The 
AMEDD SAMMT is designed to provide immediate and long-term patient 
care, from assessment of risk for pregnancy, options for emergency 
contraception, risk of sexually transmitted diseases/infections to 
include HIV prophylaxis, and necessary follow-up care and services. All 
patients, whether victims or suspects, are offered a referral to 
Behavioral Health at their first encounter and are encouraged to 
receive follow on psychological care. Long-term care plans are tailored 
to the meet the individual patient's medical and behavioral healthcare 
needs.
    Victims will not be re-victimized through loss of privacy and 
dignity. Whether the victim elects restricted or unrestricted 
reporting, confidentiality of medical information will be maintained in 
accordance with Health Insurance Portability and Accountability Act 
(HIPAA) guidelines. Scope and standards of medical care are the same, 
regardless of restricted or unrestricted reporting.
    The Office of the Surgeon General (OTSG) developed the first Sexual 
Assault Medical Forensic Examiner for Adult/Adolescent curriculum now 
universally taught by the AMEDDC&S. The SAMFE curriculum and training 
will be taught as a tri-service program effective fiscal year 2017 and 
meets or exceeds the Department of Justice (DOJ) national protocols and 
training standards. This inter-service effort for training will 
standardize the delivery of care provided to sexual assault patients 
and suspects.
    Womack Army Medical Center at Fort Bragg, NC could serve as a case-
study in bringing the medical facility and community closer together in 
responding to SHARP incidents. Womack has established a monthly 
training session that includes a forensics community of interest 
comprised of the MTF, installation, community, law enforcement, and 
prosecutors. This session allows personnel to review cases, identify 
best practices, and work together to address SHARP requirements. Womack 
is also currently planning to conduct a 2-day recertification session 
for SAFME personnel as well as a yearly summit for the local forensics 
community. The efforts at Womack are indicative of an engaged, 
proactive community of experts.
                           force development
    The Joint Concept for Health Services (JCHS) describes how the 
future Joint Force will provide Globally Integrated Health Services in 
support of Globally Integrated Operations. It describes a future 
operating environment that is more unpredictable, complex, and 
potentially more dangerous than today. The JCHS envisions a shift from 
the relatively static operations in Iraq and Afghanistan to sustained 
engagement and force projection/crisis response operations.
    In future operations, Army Medicine capabilities must be able to 
rapidly aggregate and disaggregate in support of forces that are 
dispersed over long distances. Army Medicine capabilities must be 
sufficiently modular, interoperable, agile, tailorable, and networked 
to enable the Joint Force Commander to quickly and efficiently combine 
and synchronize capabilities. Additionally, we must be prepared to 
operate in austere, expeditionary environments without the benefit of a 
robust theater medical infrastructure. We must continue to develop 
agile and adaptive leaders who are able to effectively operate in 
complex environments.
    The Army Medical Department Center and School (AMEDDC&S)/Health 
Readiness Center of Excellence (HRCoE) is leading our efforts to 
develop agile and adaptive leaders while evaluating our training, 
doctrine, and capabilities to ensure we are postured to support the 
Army in future operations.
    Published in August 2015, The Early Entry Medical Capabilities 
(EEMC) Concept of Operations (CONOP) is the product of analysis 
conducted by the AMEDDC&S to identify medical capabilities required to 
support future Joint and Army entry operations. The CONOP identifies 
six major capability areas: Battlefield Trauma Management, Trauma 
System, Medical Evacuation and En-Route Critical Care, Medical Training 
and Preparedness, Medical Information Management, and Mobility, 
Protection and Sustainment. AMEDDC&S is conducting ongoing studies in 
these areas to improve medical capabilities in support of early entry 
operations in the future.
    To provide more realistic combat casualty care training at the 
squad level, AMEDDC&S developed the Exportable Tactical Combat Casualty 
Care training. This training provides units with 3 days of progressive 
training beginning with classroom instruction, progressing to practice 
using virtual environments, and culminating in application using 
advanced combat casualty mannequins that breathe, bleed and are 
visually modeled realistically portray severe trauma. Also, to enhance 
training we are looking at bringing the Ranger First Responder model of 
medical care to the greater Army.
    In 2012, the AMEDDC&S began the Critical Care Flight Paramedic 
(CCFP) Training Program to provide flight medics with additional 
paramedic, critical care training, and civilian certifications. Since 
2012, 350 critical care paramedics from all components have graduated 
from this program. In 2015, the AMEDDC&S opened the CCFP Transport 
Medical Training Laboratory to enhance training for critical care 
paramedics. This immersive training environment utilizes multiple 
state-of-the-art Human Patient Simulators, a static airframe medical 
suite, and a configurable room that supports simulated combat casualty 
care from the point of injury through medical evacuation, forward 
surgical hospital, and the combat support hospital.
    AMEDDC&S is developing the science of Prolonged Field Care (PFC) to 
support a future operating environment where historic evacuation 
planning timelines may not be achievable. It is evaluating data from 
the Department of Defense Trauma Registry (DODTR), Joint Trauma System 
(JTS), and Armed Forces Medical Examiner (AFME) and conducting a review 
of all Clinical Practice Guidelines to determine what should or could 
be accomplished in the field. It is also developing the criteria for 
the enhanced medic of the future including Prolonged Field Care (PFC) 
principles, telemedicine capabilities and remote primary care to be 
incorporated into future training programs of instruction.
    AMEDDC&S developed the Forward Resuscitative and Surgical Team 
(FRST) based on lessons learned from Iraq and Afghanistan. The design 
was approved in 2015 with the medical equipment set approved in 2016. 
The FRST provides two surgical elements and two resuscitative elements 
that enable it to conduct split based operations. It is rapidly 
deployable and equipped to provide continuous operations in conjunction 
with the supporting medical company for up to 72 hours. It allows for 
urgent initial resuscitation and surgery for otherwise non-
transportable patients.
    Demonstrating institutional agility, the AMEDDC&S is currently 
organizing, training, equipping and deploying a regionally aligned 
medical team capable of providing immediate forward resuscitative field 
care, prolonged field care and enroute critical care in support of 
enduring AFRICOM operations. This initiative enhances the AMEDD 
training strategy development with San Antonio Military Medical Center 
(SAMMC), Walter Reid Army Institute of Research (WRAIR)/Global Emerging 
Infections Surveillance (GEIS), U.S. Army School of Aviation Medicine 
and MEDCOM education and training capabilities integrated into the pre-
deployment CONOPs and mission analysis.
Medical Research
    The U.S. Army Medical Research and Materiel Command (USAMRMC) is 
the Army's medical materiel developer, with responsibility for medical 
research, development, and acquisition (RDA), as well as medical 
logistics management. The USAMRMC manages the full life-cycle of 
medical technologies and materiel, from discovery through development, 
procurement, maintenance and disposal to support the readiness and 
optimal health of our armed forces; to provide our healthcare providers 
with technologies to protect Soldiers from disease and injury and to 
provide optimal care for casualties, particularly on the battlefield. 
USAMRMC conducts or manages groundbreaking research in combat casualty 
care (CCC); Traumatic Brain Injury (TBI); Psychological Health; and 
infectious diseases to protect against global disease threats as well 
as post-injury research in rehabilitative and regenerative medicine to 
improve the care and quality of life of severely injured Service 
Members. It is important that funding and planning decisions made today 
must preserve the Army's core medical research competencies through 
continued medical research investments. These investments sustain 
critical capabilities that ensure strategic flexibility to avoid 
technological surprise as we respond to future operational threats.
    The USAMRMC has spearheaded many major advances in trauma research 
and development. A recent success is a first-of-its-kind endovascular 
(inside the blood vessel) device (ER-REBOATM) for hemorrhage control 
and resuscitation that recently obtain a Food and Drug Administration 
clearance. The ER-REBOATM catheter recently had its first known use by 
a military surgeon working at a civilian trauma center, where a gun-
shot victim was resuscitated after nearly bleeding to death. In an 
effort to conserve and maximize the return on trauma research 
investments, the USAMRMC has awarded the first-of-its-kind National 
Trauma Research Database contract to develop a common repository of 
data stemming from DOD-funded trauma research. Advances stemming from 
this research program and lessons learned from operational trauma care 
in Iraq and Afghanistan are transforming care of civilians injured as a 
result of violence, accidents and natural disasters.
    The U.S. Army Medical Research and Materiel Command's TBI research 
portfolio includes projects not only related to TBI, but also to brain 
health. With Congress' investment, the DOD funded the development of an 
FDA approved TBI assessment technology, the ``Ahead 200.'' This device 
uses a disposable headset and commercial smartphone technology as an 
adjunct to standard clinical practice to aid in the evaluation of 
patients who present as having a mild traumatic brain injury within 24 
hours of injury, but may have a severe or life-threatening TBI and are 
being considered for a head Computed Tomography (CT).
    Historically, infectious diseases are responsible for more U.S. 
casualties than enemy fire. Continued progress to address these 
emerging threats requires sustained commitment to funding; developing 
personnel with expertise in infectious diseases; and maintaining 
stateside and overseas laboratory infrastructure and overseas field 
sites for clinical studies and response to emerging disease threats. 
Our research efforts in this area are leading to progress in the 
development of vaccines, treatment and preventive drugs, human 
diagnostics, and vector control tools. Two malaria treatment drugs are 
expected to be licensed in 2018; two malaria vaccine candidates are 
expected to be transitioned to advanced development (AD) in fiscal year 
2018 (safety and effectiveness clinical trials); and one malaria 
prophylaxis drug is expected to transition to AD in fiscal year 2019. 
Finally, we are conducting early clinical trials to evaluate the safety 
and immunogenicity of vaccines targeting Hemorrhagic Fever with Renal 
Syndrome and organisms causing bacterial diarrhea.
    The coordinated and swift response to the Ebola virus outbreak 
demonstrated the value of continued investment in infectious disease 
research and development capabilities, to include critical subject 
matter expertise and overseas laboratory infrastructure. The Ebola 
Virus Disease (EVD) research and development (R&D) efforts, executed at 
the USAMRMC and funded by the Chemical and Biological Defense Program 
(CBDP) and industry partners, contributed to the development of 
investigational EVD therapeutics, vaccines and developed the first 
Emergency Use Authorization (EUA) Ebola Virus Diagnostic Assay. The 
portfolio of potential treatments for Ebola under development includes 
biologics, engineered antivirals, and products to boost the host's own 
immune system.
    The latest Public Health concern that has Global Health 
implications is the Zika virus. This mosquito-borne Flavivirus is 
currently progressing through the Americas; local transmission has been 
reported in over 30 countries and territories in the region. There is 
no vaccine or effective therapeutic yet for disease prevention or 
treatment. There is a need for better diagnostic assays to quickly and 
clearly differentiate between similar viruses and to detect past Zika 
infection. The USAMRMC has resident Subject Matter Experts (SME) with 
years of R&D experience in the study of the Flavivirus family of 
infectious diseases and the Aedes mosquito. Our SMEs are currently 
participating as Army and DOD representatives in several interagency 
and international meetings and committees as they communicate and 
coordinate efforts to address the current concerns with the Zika virus 
outbreak.
    Further, the USAMRMC is continuing bio-surveillance and virus 
characterization activities through the overseas and domestic 
laboratories. USAMRMC laboratories have Zika virus isolates and are in 
the process of obtaining more geographically distinct isolates to 
support current biosurveillance and potentially expanded R&D 
activities. The Centers for Disease Control (CDC) lead the efforts to 
submit an Emergency Use Authorization (EUA) to the Food and Drug 
Administration (FDA). On February 26, 2016, the FDA approved an 
Emergency Use Authorization (EUA) for CDC Zika Immunoglobulin M (IgM) 
Antibody Capture Enzyme-Linked Immunosorbent Assay (``Zika MAC-
ELISA''). USAMRMC is now working in support of the National Laboratory 
Response Network.
Streamlining Structure
    Army Medicine continues to evaluate its headquarters structure to 
ensure it is properly sized and aligned to support the Army. In Fall 
2013, the AMEDD Futures Task Force was established to review the MEDCOM 
headquarters structure and provide recommendations on how to best 
balance and align it. The Task Force recommended a flattened and more 
integrated structure that is geographically aligned to support the 
Army. The Secretary of the Army approved this reorganization on April 
27, 2015 and MEDCOM initiated its transformation on July 8, 2015.
    By the end of the 2 year implementation in fiscal year 2017, the 
MEDCOM will transform from 20 to 14 subordinate Command HQs. This 30 
percent reduction of headquarters will reduce our administrative 
overhead structure to less than 4.2 percent of MEDCOM's total 
requirements and authorizations. We have completed transformation of 
fifteen functional regional command HQs to four multi-disciplinary 
Regional Health Commands (RHCs) by merging regional headquarters for 
public health and dental. RHCs are a single point of accountability for 
health readiness to regionally aligned forces around the globe. Within 
the Continental United States, RHC-Atlantic and RHC-Central are aligned 
with XVIII Airborne Corps and III Corps installations respectively. 
Overseas, RHC-Pacific aligned with U.S. Army Pacific to support the 
Army's strategic Rebalance to the Pacific. RHC-Europe is aligned with 
U.S. Army Europe and U.S. Army Africa. Finally, we transitioned the 
headquarters for the Public Health Command, Warrior Transition Command, 
and Dental Command to elevate and integrate them as functional key 
staff at the MEDCOM headquarters.
    Simultaneously, a work group was established to review the 
executive leadership within our MTFs. The results of this study led to 
an executive leadership model borrowed from the U.S. Navy, the AMEDD 
Health Executive Leadership Organization Structure (HELOS), which was 
approved for implementation on 12 Jun 15. The model standardizes the 
leadership structure for medical centers, large hospitals, small 
hospitals, and clinics. It provides increased leadership opportunities 
at the deputy level and enhances oversight of quality, safety, the 
patient experience, staff development, and productivity within all 
MTFs. The new leadership positions will provide additional 
opportunities to groom future hospital and medical center commanders. 
The endstate will be more experienced leaders who are more accountable.
                      caring of our beneficiaries
    TRICARE is an excellent benefit tailored to support our 
beneficiaries and their unique needs and situations while also 
supporting readiness by providing reinforcing capacity for our medical 
treatment facilities. Most agree that change is necessary to ensure the 
long-term sustainability of the program and to improve performance. 
However, reform must preserve the All-Volunteer Force and honor the 
sacrifices of our Soldiers and their Families. I support the TRICARE 
reforms proposed in the fiscal year 2017 President's Budget.
    Reforms should inspire beneficiaries to return to our direct care 
system and military run medical facilities. I believe the best place 
for them to receive care is in our military treatment facilities where 
we understand their needs, can manage and document their care, ensure 
quality, and can ensure their readiness.
    Reforms should incentivize health and healthy lifestyles. This is 
key to long-term cost control.
    We must ensure our beneficiaries have access to high quality, safe 
healthcare in our MTFs and in the TRICARE network. To this end, we must 
increase transparency and exchange of data between both healthcare 
systems.
    Reforms must not increase the financial burden on Active Duty 
Soldiers or Active Duty Family Members and minimize impact to our 
retired population. Any increased financial burden on retirees must be 
modest and not inhibit them seeking necessary medical care in our 
facilities.
                               conclusion
    Army Medicine is the Nation's premier and most versatile medical 
organization meeting the ever-changing challenges of today. No other 
healthcare organization in the world has the scale and scope of Army 
Medicine. No other healthcare organization in the world has the 
diversity, depth, and breadth of Army Medicine. No other healthcare 
organization in the world has the ability to support the continuum of 
care from the battlefield to garrison and in any environment 
imaginable. No other healthcare organization in the world provides the 
unique and integrated capabilities that Army Medicine delivers on a 
daily basis, around the world, in support of our Nation and our Army. 
As the military healthcare reform discussion continues we must remain 
focused on maintaining readiness while continuing to improve the health 
of all those entrusted to our care.
    While our system has proven very successful over the last 14 years 
of supporting the Warfighter, we need to continue to improve and evolve 
it to meet the changing needs of our Nation's Army. No other health 
organization is required to provide, nor is capable of providing, the 
full spectrum of care from point of injury or illness on a battlefield 
through rehabilitative care while continuing to maintain high quality 
care in garrison environments for its beneficiaries.
    I am committed to improving readiness, enhancing the healthcare 
delivered to our beneficiaries, evolving to support the Army in future 
conflicts, and to taking care of our Soldiers, civilians, and their 
Families.
    We remain fully committed to work with Congress, DOD, and all those 
entrusted to our care to improve our system.
    I want to thank my partners in the DOD, the VA, my colleagues here 
on the panel and the Congress for your continued support.

    Senator Cochran. We will now hear from Vice Admiral Faison, 
Surgeon General of the Navy.
STATEMENT OF VICE ADMIRAL C. FORREST FAISON III, 
            SURGEON GENERAL, DEPARTMENT OF THE NAVY
    Admiral Faison. Thank you, Sir.
    Chairman Cochran, Vice Chairman Durbin, distinguished 
members of the Committee, it's my honor to represent the men 
and women of Navy medicine, 63 thousand dedicated 
professionals, who every day, honor the trust placed in our 
hands in caring for those who have sacrificed to defend our 
freedom.
    I can report to you today that your Navy medicine team is 
operating forward and supporting the Navy/Marine Corps mandate 
to be where it matters, when it matters and ready to respond to 
any crisis. We are grateful for your strong and unwavering 
support of our servicemembers and their families.
    I would like to highlight a few important points.
    Military readiness is our mission. Navy medicine protects, 
promotes, and restores the health of sailors and marines around 
the world, at home or deployed, and in all warfare domains.
    In an increasingly complex world, as our Navy and Marine 
Corps stands watch and stands ready to defend our national 
interests around the globe, Navy medicine stands there as well 
to protect and to care for them. As an agile, rapidly 
deployable, medical force, this is what sets us apart from 
civilian healthcare.
    No civilian health plan in the world routinely leaves their 
families and homes and go in harm's way willingly to care for 
those in need.
    No health plan in the world daily puts their lives on the 
line in battle to defend and care for their patients.
    No healthcare plan in the world experiences the staffing 
deployments and turnover we routinely experience and still 
delivers world class healthcare.
    The proof is on the battlefield: the highest combat 
survival in recorded history!
    Wounded warriors are alive today who, in any previous 
conflict would have died of their injuries. Every wounded 
warrior is a testament to the effectiveness of the military 
health system because every one of them, from point of injury 
on the battlefield to advanced treatment in our medical 
centers, were cared for, completely, by men and women who got 
their training, experience, and preparation in our military 
treatment facilities. Those facilities are the foundation of 
battlefield survival and in my opinion as a former commander of 
the deployed combat expeditionary medical facility, a robust 
military health system is critical to future battlefield 
survival.
    Unparalleled combat survival in the longest conflict in our 
Nation's history is proof that a robust military health system 
that is also our training and research platforms for our 
battlefield providers from corpsman to physician is essential 
to combat survival.
    These three facts are not in dispute.
    We have the highest combat survival in recorded history. 
Many wounded warriors are alive today who would otherwise, had 
died of their wounds in any previous conflict. Every wounded 
warrior received their care from injury on the battlefield to 
recovery in our medical centers, completely and exclusively by 
men and women who receive their training, clinical experience 
and preparation in one of our military treatment facilities.
    I should add that investments in medical education and 
training along with medical research and development are 
critical to meeting both current and future mission 
requirements. Our training programs are among the best in the 
world while our global R and D is helping to keep our personnel 
safe today while countering the threats of tomorrow. This is 
the system that works and has proven itself time and again in 
the thousands of men and women alive today and the overall 
health of our military force and their families.
    It is also a system that is not perfect. The services are 
working hard to improve access, care continuity, convenience, 
and satisfaction that we provide in peacetime.
    We have made important strides in each of these areas while 
concurrently increasing enrollment, network recapture, staffing 
realignments, and other efforts to ensure we provide the 
clinical experience our staff needs to preserve skills, 
competencies, and ultimate battlefield survival in the next 
conflict.
    More needs to be done and none of us underestimates the 
magnitude of the effort required to improve our peacetime 
healthcare services. We are committed to continuing the 
necessary reforms to improve the patients experience, and most 
importantly, their health. But, we must do so without putting 
at risk the very system which has yielded such unprecedented 
survival.
    We will need your help in this effort and for your tireless 
support, I thank you for helping us to ensure that those 
sailors and marines, who stand the watch in the future, will 
have the same or better battlefield survival than today's 
wounded warriors have had.
    In our hands is a sacred trust to do all in our power to 
return home safely to their families, America's sons and 
daughters who have sacrificed to defend our freedom.
    I thank you for helping us to honor that trust.
    [The statement follows:]
        Prepared Statement of Vice Admiral C. Forrest Faison III
    Chairman Cochran, Vice Chairman Durbin, distinguished Members of 
the Subcommittee, it is my honor to represent the men and women of Navy 
Medicine--a team of 63,000 dedicated professionals, delivering world-
class care, anytime, anywhere. We are grateful for your steadfast 
support and I can report to you that Navy Medicine is mission-ready and 
unified in our commitment to serve those entrusted to our care.
                          strategic alignment
    Readiness, the core mission of the Navy Medicine, is inextricably 
linked with those we serve, the United States Navy and United States 
Marine Corps. We are fully engaged with supporting our maritime 
strategy as articulated by the Secretary of the Navy, Chief of Naval 
Operations and Commandant of the Marine Corps. Our leaders expect us to 
keep their Sailors and Marines healthy, ready to deploy, to deploy with 
them, as well as to protect their health, and when necessary, restore 
their health. Most importantly, we support the Navy-Marine Corps 
mandate to be where it matters, when it matters and ready to respond in 
time of crisis.
    Since becoming the Navy Surgeon General in December 2015, I have 
reaffirmed that our most important strategic imperative remains 
readiness: Keeping Sailors, Marines and their families healthy and 
ensuring that the Navy Medicine team is a ready medical force. The 
obligation to keep our Nation's service members and their families 
healthy is both a privilege and sacred trust earned over years by 
providing care at sea, on the battlefield and around the world in our 
medical centers, hospitals and clinics. Today's Sailors and Marines are 
the most highly trained, specialized, and educated in our history. 
Because of this, every one of them is critical to the mission and the 
need to keep them and their families healthy has never been greater.
    We must deliver ready capabilities to the operational commanders, 
maintain the clinical currency for our medical forces, and effectively 
integrate technology to improve the health and readiness of Sailors and 
Marines. We recognize that our collective efforts are strengthened 
given every uniformed member of Navy Medicine has a contingency 
assignment to an operational unit and, as such, has a distinct and 
important role in supporting our mission.
    Navy Medicine, in conjunction with the Army and Air Force, is 
leveraging joint opportunities with the Defense Health Agency (DHA). 
The DHA provides support to the Services in the form of shared services 
including: facilities planning; medical logistics; health information 
technology; health plan; budget and resource management; contracting; 
pharmacy; research, development and acquisition; medical education and 
training; and, public health. Their efforts in delivering shared 
services support and common business practices across the Military 
Health System (MHS) are focused on efficiencies and savings. The work 
is important to the Services' missions as well as the Defense Health 
Program as we work to ensure optimal resource efficiency in our 
mission.
    We are grateful to the Committee for supporting continued resource 
requirements and placing trust in us to provide outstanding care to our 
beneficiaries. Navy Medicine is committed to sound fiscal stewardship 
at all levels of our enterprise and this includes sustaining our active 
audit readiness posture to validate we are being good stewards of these 
resources. The President's fiscal year 2017 budget adequately funds 
Navy Medicine to meet its medical mission for the Navy and Marine 
Corps. The President's budget for fiscal year 2017 also contains key 
TRICARE proposals which are needed to modernize the Department's 
healthcare program. I support these reform proposals as they will 
continue to sustain military readiness, improve beneficiary choice, and 
improve access as well as help realize cost savings. In addition, these 
initiatives will simplify TRICARE while encouraging the use of military 
treatment facilities (MTFs)--vital for medical readiness. These 
proposals will strengthen the Military Health System (MHS) and support 
sustainable healthcare benefits for all our beneficiaries.
    The proposed legislative changes must be supplemented by important 
work within the MHS to create opportunities for even greater 
exceptional care to our patients. We must aggressively assess the 
transformative opportunities presented in today's environment to 
provide value-based care and employ technologies that make good 
clinical and mission sense. These efforts must include improving 
standardization of clinical, non-clinical and business processes while 
reducing variation. Within Navy Medicine, we are committed to 
continuous performance improvement with keen focus on access, quality 
and safety throughout our enterprise. Our collective efforts in 
measuring key performance improvement metrics, as well as our strategic 
collaborative partnerships with leading civilian organizations such as 
the Joint Commission and the Institute for Healthcare Improvement 
(IHI), are necessary as we establish Navy Medicine and the MHS as a 
high reliability organization (HRO).
                        our mission is readiness
    Navy Medicine is an agile integrated, rapidly deployable health 
system. We protect and restore the health of Sailors and Marines around 
the world, ashore and afloat, in all warfare domains. Our personnel, 
including those organic to the operational forces and those working in 
our MTFs, must be capable of providing life-saving and health 
sustaining specialized capabilities to the warfighters in all domains 
and locations. The spectrum is wide, but the mission is 
straightforward: Provide force health protection anytime, anywhere. 
This is what sets us apart from civilian medicine.
    We must recognize that the direct care system--our CONUS military 
treatment facilities (MTFs)--are our most important readiness training 
platforms. These facilities are critical to sustaining the vital skills 
and clinical competencies for our medical personnel who are saving 
lives on the battlefield. As a former commander of a deployed 
expeditionary combat medical facility, I cannot overstate the 
importance of robust clinical experience to having a fully trained and 
ready medical force capable of sustaining unprecedented survival on the 
battlefield. Fifteen years of combat with the highest combat survival 
in recorded history by medical personnel who got their training and 
preparation in these MTFs proves their value and critical role in 
combat survival. From physicians to nurses to corpsmen, our personnel 
want to deliver healthcare and need that strong clinical experience to 
sustain and enhance their skills in preparation for the next 
deployment. Our CONUS MTFs provide important surge capabilities, while 
our OCONUS facilities support our forces operating forward much like 
our expeditionary medical capabilities onboard ships.
    As a ready medical force, we have a responsibility to ensure we are 
as ready for the next mission or conflict. The improved battlefield 
survival rates we realized over the last 15 years of war were the 
result of highly trained, properly equipped medical personnel from our 
MTFs who had the capabilities to rapidly implement combat casualty care 
best practices and lessons learned. These outcomes were achieved and 
then sustained by the collective hard work of the men and women of 
military medicine and the critical support provided to us by Congress. 
Our challenge remains holding these important gains moving forward.
    We are leaning forward to improve the effectiveness and efficiency 
of our CONUS MTFs to provide that robust clinical experience to 
preserve skills and competencies by moving more workload in-house, 
growing our patient enrollment, rebalancing staff and investing in our 
graduate training programs. This also has a side benefit of reducing 
overall private sector care expenditures. An example of our efforts is 
the Navy CONUS Hospital Optimization Plan which we executed over the 
last 2 years to better sustain the operational readiness skills of our 
providers and optimize primary and specialty care. These efforts 
resulted in changes in services at nine MTFs and realigned our graduate 
medical education (GME) pipeline.
    I believe an erosion of our direct care system would have 
significant adverse consequences on our ability to sustain medical 
force skills and competencies. This will have direct negative impact on 
our medical readiness capabilities and also potentially degrade our 
ability to recruit and retain our medical professionals who seek a 
professionally rewarding clinical experience. We also need to recognize 
that comprehensive beneficiary care in our MTFs is directly linked to 
skills sustainment of our medical force and, from that, survival on the 
battlefield. Our beneficiaries, by agreeing to get their care in our 
MTFs, are helping to ensure we save lives on the battlefield in the 
next conflict.
    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 in support of Operations 
RESOLUTE SUPPORT and FREEDOM'S SENTINEL. As troop levels in Afghanistan 
remain constant, the forward deployed NATO Role 3 Multinational Medical 
Unit continues to provide high-level evaluation, resuscitation, 
surgical intervention, post-operative care, physical therapy, 
behavioral health, and patient movement services expected of Navy 
Medicine by our combatant commanders. The Role 3 maintains 12 trauma 
bays, four operating rooms, six intensive care beds and six 
intermediate care beds, with a staff of 87 personnel.
    Global Health Engagement (GHE) is an important component of 
sustaining readiness since Navy Medicine is uniquely positioned to 
support Humanitarian Assistance/Disaster Relief (HA/DR) missions. Our 
hospital ships, USNS MERCY (T-AH 19) and USNS COMFORT (T-AH 20) are 
capable of getting underway quickly to support HA/DR efforts here and 
around the world as evidenced by relief efforts along the Gulf Coast 
following Hurricane Katrina, Indonesia in the aftermath of the tsunami 
and in Haiti following the devastating earthquake. We provide the full 
range of medical skills including primary and trauma care, public 
health, and disease management.
    Our participation in humanitarian civic action (HCA) missions and 
military-to-military exercises provides unmatched training 
opportunities for our personnel and builds important joint, interagency 
and international relationships. These missions support training for 
crisis conditions and focus on enhancing clinical expertise and 
preventive medicine and improving disaster preparedness in 
collaboration with host nation, partner nation, non-governmental 
organizations (NGOs) and interagency partners. In fiscal year 2015, 
both MERCY and COMFORT were underway and participated in HCAs. MERCY 
was part of Pacific Partnership 2015, the largest HCA in the Pacific 
Command area of responsibility. The medical team provided medical and 
dental care ashore to patients in seven countries in the Pacific Rim/
East Asia and performed nearly 700 surgeries aboard MERCY. COMFORT, 
operating as part of Continuing Promise 2015 in South America/
Caribbean, delivered care in 11 countries and conducted over 1,200 
surgeries onboard.
    Our MTFs are also filling a vital role in preparing Navy Medicine 
to respond to both naturally occurring public health emergencies. Our 
larger MTFs regularly rehearse their pandemic response plans, and 
response when needed, to include the dispensing of vital pharmaceutical 
countermeasures and antivirals from both the Navy stockpile and state 
level Strategic National Stockpile supplies to DOD installation 
populations at Closed Points of Dispensing (CPODs).
    Our force health protection mission is also evident in response to 
the Zika virus. In support of these efforts, our Navy Liaison Officers 
assigned to the Centers for Disease Control and Prevention (CDC), 
United States Agency for International Development (USAID), Department 
of Health and Human Services (HHS) and the World Health Organization 
(WHO) are actively engaged to ensure DOD is coordinated with the whole 
of United States Government (USG) response. We are continuously 
educating our Sailors, Marines and family members along with Fleet and 
USMC commanders about the Zika virus and the importance of prevention 
and taking appropriate precautions. Our providers are following CDC 
clinical guidance and collaborating with public health partners to 
protect our patients and staff. The Navy Marine Corps Public Health 
Center (NMCPHC) continues to provide updated guidance to Navy and USMC 
installation commanders regarding the most effective methods to reduce 
virus-spreading mosquito populations. In addition, Navy Medicine now 
has in-house testing capabilities for Zika virus infection in humans at 
the Naval Medical Research Command (NMRC) and at our laboratory in 
Lima, Peru, the Naval Medical Research Unit Six.
             optimizing care to impact health and readiness
    There is a transformation underway in healthcare. We are witnessing 
rapid changes in clinical care brought about by innovations in disease 
diagnosis and treatment. Advances in areas such as digital imaging, 
genetics, precision medicine, pharmaceuticals and therapeutics are all 
having significant impact on the delivery and cost of patient care.
    In addition, we know that our patients want convenience and, where 
possible, use of virtual technology to support their healthcare needs. 
This is the impact of the millennials on healthcare and it is not 
unique to the military although we are more impacted by it because of 
our patient demographics: Based on our most recent available data, 72 
percent of enlisted Sailors and 85 percent of enlisted Marines are 30 
years old or younger. They and their families are very comfortable with 
digital technology and expect to incorporate their smart phones and 
tablets into their daily healthcare transactions whenever possible. 
Moving forward, traditional portals of care within our direct care 
system and the supporting TRICARE networks must be complemented with 
innovative and interconnected technological approaches to provide 
virtual outreach and care, including handheld device applications, 
telehealth and other venues of virtual care.
    Ready access to safe, high quality care is foundational to our 
primary care delivery model. Within Navy Medicine, our focus areas 
include promoting additional options for accessing care, streamlined by 
standardized appointing processes. Nearly all of Navy Medicine's 
790,000 MTF enrollees are receiving care in a National Committee for 
Quality Assurance (NCQA)-accredited Medical Home Port (MHP). These 
patients have seen an improvement in same-day healthcare access with 
their MHP team, augmented by virtual access via e-mail communications 
with providers and access to a 24/7 Nurse Advise Line (NAL). We have 
increased our same-day appointments by 20 percent and 91 percent of our 
patients indicated satisfaction with getting care when needed. There 
has been a 40 percent increase in the number of beneficiaries utilizing 
secure messaging over last year and survey respondents indicated 97 
percent overall satisfaction with this capability. As a result of this 
enhanced access, providing nearly five million outpatient visits each 
year, readiness, continuity, health outcomes and patient satisfaction 
have improved while unnecessary emergency room usage has decreased. We 
are also expanding our Marine-Centered Medical Homes (MCMHs) and Fleet-
Centered Medical Homes (FCMHs) to enhance access and care for our 
operational forces. We currently have 23 MCMHs and five FCMHs with 
efforts under way to expand to additional locations in 2016.
    We have an unwavering commitment to patient safety and eliminating 
iatrogenic harm and while fostering an ethos of trust, reporting and 
improvement. Our MTF commanding officers know my expectations: Navy 
Medicine leaders must be directly engaged in creating and sustaining a 
culture of patient safety at their commands, including conducting 
weekly leadership rounds, providing formal recognition for speaking up 
and promoting the ongoing use of TeamSTEPPSTM (Team Strategies and 
Tools to Enhance Performance and Patient Safety). We continue to see 
progress in our patient safety efforts and I am pleased that three of 
our MTFs were recognized by DOD Patient Safety Awards in 2015.
    Navy Medicine supports Operational Stress Control (OSC) initiatives 
and post-traumatic stress disorder (PTSD) prevention and education 
efforts for both medical and line-led educational and assessment 
programs. A comprehensive and inclusive approach to building and 
preserving resilience is fundamental to developing the capacity to cope 
with challenges and stressors associated with military service. We 
continue to provide timely and evidenced-based mental healthcare for 
our Sailors, Marines and their families. Our psychological health 
programs support the prevention, diagnosis, mitigation, treatment and 
rehabilitation of the full spectrum of mental health conditions 
utilizing the most current DOD and the Department of Veterans Affairs 
(VA) Clinical Practice Guidelines.
    Improving access and reducing stigma associated with reaching out 
for help remain important priorities. The Behavioral Health Integration 
Program (BHIP) integrates mental health providers into our primary care 
settings to identify and manage issues not requiring specialty care as 
well as facilitate referrals (and smooth handoffs) for more serious 
conditions. Within operational settings, we continue to embed mental 
health providers to provide support where and when they are most 
needed. The Operational Stress Control and Readiness (OSCAR) program 
provides mental health expertise directly in USMC units. Similar 
programs exist on Navy's large afloat platforms as well as Navy and 
Marine Special Operations units. Embedded mental health providers 
reduce stigma, increase access to care and help detect operational 
stress reactions and injuries early before they lead to decreased 
mission capabilities. These embedded mental health providers are making 
a real difference where and when it matters and we are working with 
Fleet Forces Command and USMC to expand this important capability.
    Navy Medicine remains committed to supporting the psychological 
health needs of Navy and Marine Corps reservists and their families. 
The Navy and Marine Corps Reserve Psychological Health Outreach Program 
(P-HOP) provided 11,973 outreach contacts to demobilized service 
members and provided behavioral health screenings to 10,700 reservists 
in fiscal year 2015. The program also provided 440 visits to reserve 
units and made 702 presentations to 40,648 reservists, family members 
and commands. Over 1,700 service members and family members 
participated in 15 Returning Warrior Workshops (RWWs) in fiscal year 
2015. RWWs assist demobilized service members and families in 
identifying issues that often arise during post-deployment 
reintegration.
    Navy Medicine has made significant progress in recruiting mental 
health providers to meet the demand for services. At the end of fiscal 
year 2015, active component (AC) social worker and mental health nurse 
practitioner communities are fully manned; while the percentages for 
psychiatrists and clinical psychologists are 94 and 89, respectively.
    Suicide is a tragedy that destroys families and impacts our 
commands. The goal is to reduce suicide risk by equipping Sailors with 
information, training, tools, practices and policies to be 
psychologically healthy, resilient and mission ready. We support the 
Navy's Suicide Prevention Program on multiple fronts, including the in-
depth review of Navy suicides. These reviews are helping to identify 
those who may be at increased risk of suicide and emphasize the 
importance of engaged and proactive leadership, particularly when 
individuals are undergoing personal or professional transitions. We are 
also working with the Defense Suicide Prevention Office (DSPO) to 
advance prevention efforts. Throughout Navy Medicine, we recognize the 
importance of supporting our shipmates and ensuring we focus on every 
Sailor, every day.
    We are continuing our strong focus on management of traumatic brain 
injuries (TBI) throughout Navy Medicine including standardizing a 
system of care in our MTFs that includes prevention, education, 
treatment and tracking of these injuries. These efforts help ensure 
that care provided at our MTFs is consistent, incorporates best 
clinical practices and leverages advances realized over the last 
several years in the treatment of TBI in the deployed setting. We know 
that 84 percent of TBIs in the military occur in non-deployed settings, 
highlighting the need for the care and treatment of these injuries in 
our facilities. In fiscal year 2015, we executed $10.6 million in DHP 
funding for the care and management of TBI.
    Our Intrepid Spirit Concussion Recovery Center is operational 
onboard Marine Corps Base, Camp Lejeune. Intrepid Spirit is part of the 
consortium with the National Intrepid Center of Excellence (NICoE) and 
provides advanced evaluation and care for service members with acute 
and persistent clinical symptoms following a TBI. The center averages 
50 monthly referrals with 12--18 new service members in the program per 
week. Approximately 90 percent of patients are ready to return to full 
duty after treatment. Another Spirit Center is planned for Naval 
Hospital Camp Pendleton.
    I am pleased with the continued progress of our Navy Medicine's 
Reintegrate, Educate and Advance Combatants in Healthcare (REACH) 
Program in helping our recovering service members. REACH provides an 
opportunity for our wounded warriors to learn and engage in various 
healthcare fields through hands on training at Navy Medicine activities 
and develop skills and qualifications for healthcare careers. REACH is 
currently active at Naval Hospital Jacksonville, Naval Medical Center 
Portsmouth, Naval Medical Center San Diego, Naval Hospital Camp 
Lejeune, Naval Hospital Camp Pendleton, Walter Reed National Military 
Medical Center and Naval Health Clinic Annapolis. To date, there have 
been over 200 program graduates, with more than half obtaining Federal 
employment in healthcare or pursuing college education. As the program 
continues to produce successful outcomes for our recovering service 
members, we will look to additional expansion opportunities.
    DOD, in conjunction with the Services and Uniformed Services 
University of the Health Sciences, continues to pursue robust research 
efforts in support of innovative treatment solutions. Our collaborative 
efforts with leading academic and research centers are vital to these 
efforts to advance our understanding of TBI and define best practices. 
Navy Medicine recently established research collaborations with the 
University of Pittsburgh's world-renowned Sports Concussion program.
    The Navy Comprehensive Pain Management Program (NCPMP) is also 
integrated with MHP in an interdisciplinary approach focusing on 
prevention, clinic practice guideline compliance, telehealth, and 
provider and patient education. In fiscal year 2015, NCPMP began 
implementation of the Stepped Care approach to pain management 
providing a framework to standardize pain patient classification, 
increase access to subspecialty care, and improve coordination between 
primary and specialty providers. NCPMP also completed the first year of 
Project ECHOTM, a telemedicine program that uses a secure, Internet-
based audio-visual network to connect MHP providers with a team of 
specialists in an educational, mentoring-based model.
    Complementary and Alternative Medicine (CAM) modalities are 
provided throughout the Navy at various MTFs, dependent upon provider 
training, background, and clinic capacity. The most commonly available 
therapies to our active duty personnel include acupuncture and 
chiropractic services. Acupuncture is currently provided in ten MTF-
associated clinics and is used to treat chronic pain, migraine 
headaches, back and neck pain, anxiety, depression, insomnia, auricular 
pain and a wide variety of other conditions. In fiscal year 2016, the 
NCPMP is scheduled to expand to include full-time licensed 
acupuncturist positions at four of our MTFs.
    Navy Medicine supports an integrated substance abuse strategy, 
providing access to high quality services for active duty service 
members and their families across the diagnostic spectrum, including 
individuals with complex or comorbid conditions. Navy Medicine's 
Substance Abuse Rehabilitation Program (SARP), with 53 sites, supports 
the prevention, diagnosis, mitigation, treatment and rehabilitation of 
substance use disorders and other mental health conditions, using 
evidence-based care in accordance with DOD/VA Clinical Practice 
Guidelines. We incorporate the most current, evidence-based treatments 
and use innovative information technology approaches to continue 
supporting those in recovery, even after completion of the acute phase 
of treatment. The Navy MORE (My Ongoing Recovery Experience) program is 
an online and telephone-based recovery and support program for patients 
recovering from moderate to severe substance disorder. MORE offers 
individually tailored patient education and support over a secure web-
based system with world-wide access, 24 hours a day, 7 days a week. 
Access is available to all individuals who complete a SARP program. To 
date, over 14,000 patients have taken advantage of Navy MORE content 
and support services.
    Navy Medicine, along with the Army and Air Force, has a strong 
commitment to expanding our telehealth capabilities in order to provide 
care beyond traditional care settings and eliminate treatment barriers 
of time and distance, maximizing the availability of finite resources. 
Telehealth is particularly important to us because our Navy and Marine 
Corps forces are forward-deployed around the world, aboard ship and 
ashore. We support the recent ASD (HA) policy change aimed at enabling 
healthcare at the patient's location (virtual visits), as well as other 
priority objectives of remote health monitoring and global expansion of 
the asynchronous teleconsultation system. These expanded capabilities 
also support our efforts to recapture workload into our MTFs. Naval 
Medical Center Portsmouth (NMCP) initiated the Health Experts on-Line 
Portsmouth (HELP) program, a secure asynchronous service providing a 
24-hour subspecialty consultation for providers at CONUS and OCONUS 
MTFs and afloat commands within the Navy Medicine East area of 
responsibility. The program connects NMCP specialists and 
subspecialists with geographically-dispersed providers and supports 
important clinical consultations. HELP is also providing higher levels 
of clinical evidence to support decisionmaking regarding the medevac of 
patients from both ships and submarines. During its first year, HELP 
provided support to 585 cases and prevented 39 medevacs--efforts that 
improved patient care and readiness. Pilot studies are also underway to 
evaluate use of the system to reduce wait time for specialty consults, 
increasing availability of rapid intervention.
    We are also expanding the successful Telecritical Care Unit (TCCU) 
program operated by Naval Medical Center San Diego. TCCU now supports 
critical care consultations at both Naval Hospitals Camp Pendleton and 
Camp Lejeune. This capability allows Navy high-demand intensive care 
physicians to consult directly with providers at these facilities to 
ensure the right care at the right place at the right time. Split 
second decisions can be made in caring for our critically ill patients, 
avoiding transport or exacerbation of deteriorating conditions.
    The Department of the Navy (DON) does not tolerate sexual assault 
and has implemented comprehensive programs that reinforce a culture of 
prevention, response, and accountability for the safety, dignity, and 
well-being of Sailors and Marines. Navy Medicine is committed to the 
success of the sexual assault prevention and response program and to 
ensuring the availability of sexual assault medical forensic exams at 
shore and afloat settings. Consistent with the requirements contained 
in the fiscal year 2015 National Defense Authorization Act, section 
539, the Services' Medical Departments adopted the Sexual Assault 
Medicine Forensic Examiner (SAMFE) course as the framework for uniform 
training and certification for providers of sexual assault patient 
care. As of December 2015, Navy Medicine has trained 331 providers 
under this new standard. SAMFE providers are trained and available to 
ensure timely and appropriate medical care for sexual assault victims 
at all appropriate military platforms served by Navy Medicine.
    We appreciate your continued support of our military construction 
requirements as we ensure that our patients have access to outstanding 
facilities in which to seek their care. In September 2015, we opened 
the new Clinic Annex at Naval Hospital Camp Lejeune. This new 45,000 
square foot clinic leverages the latest advances in healthcare and 
evidenced-based design to provide a world-class environment. The new 
clinic delivers pediatrics, dermatology, educational and developmental 
intervention services and optical fabrication. The pediatric spaces 
house MHP teams, with 29 exam rooms, two treatments rooms as well as 
support spaces. The dermatology clinic provides care in six exam rooms, 
two laser treatment rooms, an ultraviolet booth treatment room and 
clinic support spaces. The clinic also includes spaces for a four bed 
sleep study suite.
    Navy Medicine continues to participate in a wide variety of unique 
collaborations, sharing agreements and partnerships with the VA. This 
relationship is important as we continue to assess innovative ways to 
efficiently and cost effectively share services and work together to 
meet the needs of both beneficiary groups. Our efforts are evident at 
the Captain James A. Lovell Federal Health Care Center (FHCC) Great 
Lakes, a joint use facility with the VA and DOD staff working together 
to support a single, combined mission. Navy Medicine and the VA 
continue to support this demonstration project and a thorough 
evaluation is underway by both agencies with the Report to Congress 
required by the fiscal year 2010 National Defense Authorization Act 
(NDAA) to be submitted later this year.
    Navy Medicine continues to support our injured Sailors and Marines 
through the Integrated Disability Evaluation System (IDES). IDES is a 
combined DOD/VA program where DOD determines the fitness for continued 
service, VA provides a proposed disability rating for use by DOD and a 
VA letter containing a proposed estimate of the amount of VA benefits 
to which the member may be due. In many cases, VA's decision on a 
veteran's claim, which is issued after receipt of the veteran's DD-214, 
reflects the proposed rating. As a result, the service members 
transition to civilian life with minimal gaps in benefits or 
healthcare. Navy Medicine has primary responsibility to oversee and 
implement the Navy Medical Evaluation Board (MEB) phase which 
encompasses the first 100 days of the IDES process. In collaboration 
with our VA counterparts, Navy Medicine has met the 100-day MEB phase 
goal consecutively the last 4 years for Navy service members and 3 
years for Marine Corps service members.
    In an effort to improve the treatment of Sailors and Marines on 
limited duty, we conducted a pilot project at Naval Health Clinic 
Cherry Point. Initiated in June 2015, the pilot provides for a multi-
disciplinary team evaluation for every limited duty case each month. 
This quality assurance review confirms we have the correct diagnosis, 
an appropriate treatment plan, an aggressive and timely decision 
regarding return to duty, or referral to the Disability Evaluation 
System. Preliminary results during this period are promising. With an 
average of 300 service members on limited duty, 57 service members were 
either returned to duty or referred to IDES prior to 6 months, avoiding 
a potential additional 147 cumulative months on limited duty. The pilot 
project will be expanded to additional sites in fiscal year 2016 to 
include Naval Hospital Twenty-nine Palms, Naval Hospital Oak Harbor, 
Naval Health Clinic Quantico, and Naval Health Clinic Patuxent River.
    The contract for the modernization of the electronic health record 
(EHR) was awarded by DOD in July 2015 and it will have a 
transformational impact on military medicine. This new EHR will be used 
in our MTFs and operational environments, onboard our vessels and in 
the field with Marine forces. It will reduce variation while providing 
a single platform to access accurate healthcare data worldwide. The 
Services, in conjunction with DHA, are fully engaged in the joint 
implementation efforts to assure the needs of the functional community 
are well defined and met in this acquisition led by the Program 
Executive Office (PEO) within Under Secretary of Defense (Acquisition, 
Technology and Logistics). Navy Medicine Initial Operating Capability 
(IOC) sites include: Naval Hospitals Bremerton and Oak Harbor and Naval 
Branch Health Clinics Bangor and Everett. Deployment to these 
facilities will begin by the end of calendar year 2016.
    The health of the force, their families, and all those we serve 
remains our priority. This commitment is not volume-based or supply-
driven. It's a patient-centered and readiness-focused strategy to help 
ensure that our service members and their families get the care they 
need, when they need it, and in the venue most appropriate and 
convenient to get and keep them healthy. I continue to reinforce this 
point within Navy Medicine: In order to be the provider of choice for 
our beneficiaries and provide that strong clinical experience to 
prepare our staff for the next deployment, we must use every 
opportunity to enhance patient experience and breakdown any barriers to 
convenient, patient-centered care. We do that best when they are 
enrolled to us and we have both the visibility and responsibility for 
their care in our facilities.
                          a mission-ready team
    I am proud of our Navy Medicine team--our active and reserve 
personnel, our Navy civilians and their families--whose work is vital 
to our mission. Whether serving with the operating forces, delivering 
care in our CONUS or OCONUS MTFs, conducting research, providing 
training or supporting important mission-specific activities, Navy 
Medicine personnel are serving with pride and demonstrating Navy Core 
Values of honor, courage and commitment around the world. We are 
committed to recruiting, training and retaining a talented and diverse 
workforce.
    Active component (AC) and reserve component (RC) recruiting and 
retention remains a top priority. It is our pipeline to ensure we are 
mission-ready. In fiscal year 2015, Navy Recruiting attained 100 
percent of AC medical department officer goal. Through concerted 
recruiting and retention initiatives, we reached 100 percent overall AC 
officer manning. However, we are continuing to monitor some specialty 
shortfalls including general surgery, oral maxillofacial surgery and 
critical care nursing.
    At end of fiscal year 2015 our overall RC officer manning is 95 
percent, with Navy Recruiting attaining 78 percent of the officer 
recruiting goal. RC Medical Corps recruiting consistently continues to 
be a challenge, with manning at 83 percent and persistent shortfalls in 
the specialties of anesthesiology, orthopedic surgery and general 
surgery. The Nurse Corps is manned at 97 percent while the Dental Corps 
and Medical Service Corps are fully manned. Higher AC retention has 
resulted in a smaller pool of medical professionals leaving active 
duty, thereby contributing to the need for greater reliance on the 
Direct Commission Officer pathway as a means to increase RC medical 
personnel assets. We continue to work hand in hand with Navy Recruiting 
Command and the Navy Reserve Force to implement important recruiting 
and retention incentives, as well as exploring other opportunities to 
recruit RC medical personnel.
    Navy attained 100 percent of the fiscal year 2015 recruiting goal 
for both the AC and RC Hospital Corps. While overall manning for both 
components is healthy, we continue to monitor AC Fleet Marine Force 
Reconnaissance Corpsman specialty shortages primarily due to billet 
growth driven by Special Operations requirements and training 
constraints.
    I am grateful for your support of accession and retention 
incentives which have enabled us to realize manning improvements over 
the last several years. Continued funding has supported these gains and 
remain critical for the success of AC and RC recruiting and retention. 
Our efforts are also important as we work to meet our increased Navy 
Medicine manpower requirements in support of the Marine Corps.
    Throughout our system, our Federal civilian workforce provide 
patient care and deliver important services in our MTFs, research 
commands, and support activities as well as serve as experienced 
educators and mentors, particularly for our junior military personnel. 
They provide stability and continuity within our system, particularly 
as their uniformed colleagues deploy, change duty stations or 
transition from the military. We continue to emphasize the importance 
of attracting and retaining talented civilian personnel within Navy 
Medicine and use the authorities available to us to meet our 
requirements.
                    excellence in medical education
    The Naval Medicine Education and Training Command (NMETC) leads our 
important education and training efforts along with its subordinate 
commands: Navy Medical Operational Support Center (NMOTC); Navy Medical 
Professional Development Center (NMPDC); and Navy Medical Training 
Support Center (NMTSC). Their collective efforts support the full 
spectrum of relevant and responsive military training and medical 
education that directly support our readiness and professional 
development. Our goal is to apply cost-effective learning solutions, 
fully leveraging partnerships and joint initiatives.
    We ask a lot of our hospital corpsmen and it is critical that their 
training prepare them for their demanding responsibilities. I recently 
traveled to the Medical Education Training Campus (METC) onboard Joint 
Base San Antonio-Fort Sam Houston to see firsthand our corpsmen 
training alongside their Army and Air Force counterparts. The METC is a 
state-of-the-art center delivering basic and advanced medical education 
and providing unmatched opportunities for collaboration in a joint 
training environment. In fiscal year 2015, we had over 3,500 Sailors 
train as hospital corpsmen with another 1,400 trained in advanced 
technician programs. I am also pleased that 29 Navy Medicine METC 
instructors obtained either their associate or bachelor degrees and 89 
qualified as Master Training Specialists.
    Navy is participating in the Uniformed Services University of the 
Health Sciences Enlisted to Medical Degree Program (EMPD2). The program 
provides an opportunity for our highly-motivated, academically 
promising service members to obtain a medical degree. EMDP2 consists of 
intensive coursework, preparation and mentoring to prepare students for 
application to medical school. Upon completion of the 24 month advanced 
educational program, successful students will be competitive for 
acceptance to medical school. The first Marine cohort of two students 
is currently excelling in their first year of the program. Our first 
Navy cohort will begin their studies later this year.
    The Navy Trauma Training Center (NTTC) is an important program to 
help our personnel hone and sustain their combat trauma skills. NTTC 
operates at the Los Angeles County + University of Southern California 
Medical Center (LAC+USC), a renowned Level 1 trauma center. Our medical 
personnel participate in 21-day course in operational combat casualty 
care using traditional didactics, team building, battlefield trauma 
resuscitation and hands-on patient care at LAC+USC. NTCC hosts 11 
iterations per year with 24 rotators per course. Since the program's 
inception in 2002, we have trained approximately 2,900 medical 
department personnel.
    Navy graduate medical education (GME) is critical to our mission of 
maintaining a tactically proficient and combat-ready medical force--a 
force of fully trained, clinically competent physicians who are ready 
to deploy wherever needed. Their training, and the care they provide in 
our teaching facilities, directly supports our readiness. Strong GME is 
the hallmark of Navy Medicine and our performance continues to 
demonstrate the quality of our programs. Our 3 year average first time 
board certification pass rate for Navy trainees is 93 percent, 
exceeding the national average of 88 percent. Our overall pass rates 
meet or exceed the national average in virtually all primary 
specialties and fellowships. Our Navy-trained Medical Corps officers 
are exceptionally well-prepared to provide care to all members of the 
military family, and in all operational settings and through all 
echelons of care--from the battlefield to the bedside at our MTFs.
    Military GME is critical since we recognize that the civilian 
sector does not have the capacity to provide the residencies needed to 
maintain our medical specialty requirements. In addition, advanced 
training is essential to the recruitment and retention of medical 
specialists. Navy Medicine works to ensure that our GME training 
pipeline is adequate to meet our current and projected requirements, 
including having qualified candidates for all our programs. Specialties 
that we continue to monitor closely include: general surgery, family 
medicine, psychiatry and aerospace medicine. Our Dental Corps, Medical 
Service Corps and Nurse Corps officers also participate in their 
respective graduate dental and health education program designed to 
support specialty requirements.
 navy medicine research and development: countering threats of tomorrow
    Navy Medicine maintains an important global research and 
development (R&D) program. Led by the Naval Medical Research Center 
(NMRC), this eight laboratory, four continent enterprise runs numerous 
joint Service initiatives and executes a well-established cooperative 
infrastructure working with universities, industry and, in countries 
around the world to improve health and advance science. The mission is 
focused on biomedical research supporting the warfighter and ongoing 
research and development ensures service members' health is better 
protected, operational tempo is more effectively maintained and 
rehabilitation of the ill and injured is continuously improved. NMRC 
and the seven subordinate laboratories collectively form a Navy Medical 
R&D enterprise that is the Navy's and Marine Corps' premier biomedical 
research, surveillance/response, and public health capacity-building 
organization.
    Our research remains operationally focused with important 
priorities including: traumatic brain injury and psychological health; 
medical systems support for maritime and expeditionary operations; 
wound management throughout the continuum of care; hearing restoration 
and protection; undersea and aerospace medicine; and endemic, emerging 
and deliberate infectious diseases prevention, detection and response. 
These efforts fully support our readiness by developing R&D products 
that preserve, protect, treat, or enhance the health and performance of 
Navy and Marine Corps personnel.
    The diverse capabilities and geographical distribution of the eight 
laboratories reflect the broad mission and vision of this enterprise. 
On any given day, researchers at the OCONUS labs may be working with 
host national government collaborators to assess the threat of emerging 
infectious diseases. CONUS laboratory researchers may be evaluating 
methods to mitigate the effects of stressful physiological or 
psychological environments on human health and performance. Other 
investigators may be conducting human or animal trials for experimental 
vaccines, molecular determinants of wound healing, or regenerative 
medicine procedures. The work is operationally focused and highly 
regarded throughout the U.S. and international scientific community.
    Navy Medicine R&D is actively engaged in global health security 
efforts including a focus on mitigating the spread of antimicrobial 
resistance and emerging and re-emerging infectious diseases. Our labs 
work with partners around the world to enhance detection of emerging 
disease threats and bio-surveillance capabilities, to improve reporting 
systems and to build host-country response capacity.
    The Navy Malaria Program, headquartered at the NMRC, collaborates 
with the Walter Reed Army Institute of Research (WRAIR), the DOD OCONUS 
medical research laboratories, as well as government, academia, private 
foundations and biotechnology partners to develop a malaria vaccine to 
prevent malaria morbidity and mortality in military personnel and in 
vulnerable populations worldwide. NMRC is collaborating with a 
biotechnology partner and the WRAIR to design and conduct FDA-regulated 
clinical trials of a highly promising malaria vaccine that consists of 
a weakened form of the Plasmodium falciparum malaria parasite. This 
vaccine is easily administered, well-tolerated, and shown to provide 
high protective efficacy against infection with the parent malaria 
strain from which the vaccine was derived. The vaccine also protected 
against infection with a genetically unrelated malaria strain. This 
year the NMRC will conduct a follow-on clinical trial with this vaccine 
to evaluate an improved dosing regimen designed to induce the high 
levels of long-lasting, broad protection that are required for a 
malaria vaccine to protect deployed military personnel.
    The NMRC Malaria Department also maintains a state-of-the-art 
discovery research program focused on identifying unique proteins on 
the malaria parasite that can be used to develop next generation 
malaria vaccines. The Malaria Department's concept development program 
uses animal models and transgenic malaria parasites to evaluate new 
malaria vaccine candidates and improved vaccine formulations before 
moving them to human clinical trials. They recently completed the 
initial phase of a Bill and Melinda Gates Foundation-supported clinical 
trial designed to determine the specific human immune responses 
involved in generating protection against malaria infection. Analysis 
of the data generated by this clinical trial is due in the coming year 
and will help guide the development of more efficacious malaria 
vaccines.
    Collaborative efforts are important to sustaining our research 
efforts. During fiscal year 2015, our labs executed 95 Cooperative 
Research and Development Agreements (CRADAs) and had a total of 215 
active CRADAs delivering over $15 million in research funding. In 
addition, we have 91 active formal agreements with other governmental 
agencies.
    Navy Medicine also has active Clinical Investigations Programs 
(CIPs) in place at our teaching MTFs to support our post-graduate 
healthcare training programs. These investigations, in addition to 
satisfying program accreditation requirements, also support the need to 
develop new knowledge and advanced interventions to better treat 
service members with combat injuries, to prevent training injuries and 
to provide better care beneficiaries. In fiscal year 2015, our programs 
received an additional $4.72 million in external grants for clinical 
research, an increase of 18 percent over the prior year. Navy MTFs 
conducted a total of 510 clinical research projects resulting in 373 
publications in high-impact, peer-reviewed medical and scientific 
journals and 907 presentations at both national and international 
scientific meetings.
                            our way forward
    Our Sailors and Marines know that military service can be 
professionally rewarding, physically demanding, and potentially 
dangerous. They and their families expect us to protect their health, 
prevent injury and disease as best we can, and heal them when they're 
wounded or injured. Equally important, they want that same support for 
their families by having access to high quality healthcare when they 
are deployed and at home. In addition, our retirees and their families, 
through service and sacrifice, have earned a healthcare benefit that is 
both comprehensive and affordable. A strong and vibrant direct care 
system allows us to do those things while providing that exceptional 
clinical experience for our staff, from sickbay to medical center, 
augmented by vibrant R&D and top quality education and training so that 
we can ensure we will have done all we can to save lives on the 
battlefield and return home safely America's sons and daughters.
    Moving forward, all of us recognize the formidable work ahead 
during these transformation times. We must sustain the gains we made 
over the last decade and a half in delivering unmatched combat casualty 
care, and redouble our efforts to provide high quality, accessible and 
convenient care to our patients. I believe that the special fidelity we 
share with our patients makes us well positioned to meet these 
challenges.

    Senator Cochran. Thank you.
    We'll now hear from Lieutenant General Mark A. Ediger, who 
is the Surgeon General of the Air Force.
    General Ediger.
STATEMENT OF LIEUTENANT GENERAL MARK A. EDIGER, SURGEON 
            GENERAL, DEPARTMENT OF THE AIR FORCE
    General Ediger. Chairman Cochran, Ranking Member Durbin and 
distinguished members of the Subcommittee, thank you for this 
opportunity to discuss Air Force medicine and our role in the 
military health system.
    We fully support the Committee's work to ensure the 
military health system provides those we serve with the best 
possible care in all the environments in which our military 
serves.
    We have 683 medical airmen deployed today. We have asked 
our medical airmen, as part of the joint team, to stretch their 
already considerable capabilities to support the Air Force and 
the joint team across the full range of military operations. As 
such we owe these incredible young men and women our very best 
efforts in capturing the hard lessons learned from their 
experiences and putting those lessons to work.
    Their ingenuity and accomplishments drive our research in 
identifying gaps and improvements in our programs, our 
operational procedures and are overall readiness.
    I will focus my comments today on our work in Air Force 
medicine in researching operational medical issues identified 
in the past 15 years of support to combat operations. In order 
to continue advancements in our capability to provide trauma 
care, treat operational health conditions and safely transport 
ill and injured servicemembers across, in many times, across 
great distances.
    I will also describe how we have changed our processes for 
sustaining a ready, deployable medical force.
    Since the early 1990s the Critical Care Aeromedical 
Transport Teams, known as the CCATTs, have evolved to become an 
international benchmark for safe, critical care patient 
movement. We adapted this capability and expanded it 2 years 
ago to 4 years ago to create the Tactical Critical Care 
Evacuation Team to meet combatant command requirements for 
Intra Theater Tactical Critical Care Transport. We are now 
assessing means of enhancing this capability to include some 
aspects of trauma stabilization during transport in order to 
meet the changing operational scenario.
    The Air Force deployable hospital is scalable to 
operational and medical scenarios. We call it the Expeditionary 
Medical Support Health Response Team or EMEDS. This capability 
is postured in eight Air Force hospitals and also embedded in 
one U.S. Army hospital. This capability provides emergency care 
within 1 hour of arrival and surgery with critical care within 
6 hours of arrival.
    The focus on this system is on agility with modest 
capacity.
    Our research programs include in route care pertaining to 
aeromedical and critical care evacuation, expeditionary medical 
operations and care for operational health conditions. These 
programs pursue new knowledge and trauma care in transport 
environments through investigations of impacts to injury and 
disease during transport. This knowledge is being used to 
develop new treatment guidelines and employ new technology to 
improve outcomes.
    Many of the needs in the area of medical research and 
development come directly from deployed military medical 
personnel as collected by the joint trauma system. Such a 
requirement led to the current work to develop the multi-
channel, negative pressure wind device. Now being tested, this 
device will improve wound care while reducing the logistics 
footprint and power utilization during transport of wounded.
    Another operationally driven requirement led to the 
development of the Trauma Specific Vascular Shunt developed to 
improve mortality and limb salvage, function and quality of 
life for those with major extremity wounds.
    Air Force researchers and scientists at the 711th Human 
Performance Wing at Wright-Patterson Air Force Base, Ohio, have 
made great strides in the research to enhance human performance 
in the employment of new technological systems such as the F35 
helmet mounted display. This research has yielded advances such 
as the operationally based vision assessment, the air crew 
mounted physiologic sensor suite, an assessment tool for pilot 
physiologic and cognitive performance.
    In response to the new generation of fighter aircraft the 
711th Human Performance Wing created a laboratory that 
evaluates the performance of aircraft oxygen systems that 
enabled the development of mask sensors to monitor the cardio 
respiratory response of pilots in high performance, next 
generation aircraft.
    As a health system we know we must continuously improve.
    In 2015 Air Force medicine implemented a revised 
performance management system. And we are seeing indications of 
performance against national benchmarks but we know we still 
have work to do in this area. And we are focused on 
continuously improving in the areas of quality, safety and 
access to care.
    To ensure the readiness of our medical force we have 
evolved to a model in which Air Force surgeons and critical 
care clinicians devote a portion of their time to provision of 
care in partner institutions such as VA Medical Centers and 
Level One Trauma Centers with Baltimore Shock Trauma as being a 
prime example of a very productive partnership.
    However, the bedrock of our readiness remains the military 
hospital. The broad scope of care we provide to retired 
military members, their families and veterans is key to our 
readiness.
    The Air Force has 48 sharing agreements with the VA 
including nine master sharing agreements by which all clinical 
services at specialty facilities are available for referral 
from the VA. This provides the complex cases needed to maintain 
clinical currency of our deployable teams while also enhancing 
access to care for veterans at a savings to the government.
    VA referrals to the Air Force hospitals grew steadily. 
However, we did see a decline in 2015 under the Veteran's 
Choice Act. We are concerned about this and working closely 
with our VA colleagues and the Department of Defense leadership 
to map a process to reverse that trend.
    I thank the Committee for its resolute support and 
dedication to the welfare of the airmen, soldiers, sailors and 
marines, their families and veterans whom we are honored to 
serve.
    Thank you.
    [The statement follows:]
        Prepared Statement of Lieutenant General Mark A. Ediger
    Chairman Cochran, Vice Chairman Durbin, and distinguished members 
of the subcommittee, thank you for inviting me to testify before you 
today.
    The United States Air Force, in concert with our sister Services, 
has answered our Nation's call over the past decade and a half in 
executing demanding missions in defense of the Nation. Readiness has 
been, and remains the key factor in all we do. We have asked our Airmen 
to stretch their already broad range of capabilities to accomplish 
their missions, and as always, they have exceeded our expectations. As 
such, we owe these incredible young men and women our very best efforts 
in capturing the hard earned lessons learned from their experiences; 
and putting those lessons to work. Their ingenuity and accomplishments 
drive our research in identifying gaps and improvements in our 
programs, operational procedures, and overall readiness. One such vital 
lesson we have gleaned is, as we prepare for future success, we must 
ensure the Air Force continues to field both Medically Ready Airmen and 
Ready Medical Airmen. I will focus my comments today on the Air Force 
Medical Service's (AFMS) work in researching operational requirements 
from the field, and advancements in how we medically treat and 
transport ill and injured service members. I will describe the 
tremendous benefit we have derived from sharing agreements between our 
military treatment facilities, and other Federal and non-government 
agencies; allowing increased access to care for veterans and all the 
beneficiaries we have the honor of serving, while improving skill sets 
that may otherwise be degraded. The military medical research advances 
we have made over the past 15 years are saving the lives of our 
uniformed members, our veterans, and in some cases, have the potential 
to save countless civilian lives. Also, work such as casualty 
evacuation and enroute care, in which the Air Force is the natural 
lead, has provided great insight into how we evacuate the injured but 
also when it is the safest to transport over great distances. We are 
still learning, for instance, how the transport environment affects 
specific types of injuries and the body's physiologic reaction to 
injury.
    Our programs include enroute care research pertaining to 
aeromedical and critical care evacuation, expeditionary medical 
operations, and care for operational health conditions. Under the 
umbrella of ``Optimal Time to Transport'' and cabin altitude 
restriction, the AFMS is conducting research to diminish the impact of 
transport and to determine the optimal time to transport patients. The 
purpose of this program is to provide foundational knowledge on 
transport environments and investigate the impact of factors on injury 
and disease states to mitigate any harmful impacts. Another project in 
this program is studying outcomes of patients transported with or 
without cabin altitude restrictions. We need evidence to validate what 
conditions benefit by restricting the cabin altitude during transport. 
This research is important to ensure the best possible clinical 
outcomes, as well as the best possible mission execution. As the world 
leader in this area, the Air Force is well positioned to set the 
standards for critical patient movement.
    In the early 1990s, Critical Care Air Transport Teams (CCATTs), 
were developed and have become the international benchmark for safe 
Intensive Care Unit (ICU)-level patient movement. We applied the 
effectiveness of CCATT to create the Tactical Critical Care Evacuation 
Team (TCCET). This capability consists of teams of medical personnel 
equipped with specialized skills and tools to meet combatant command 
requirements for intra-theater enroute tactical critical care transport 
in rotary-wing or other tactical aircraft. Moving forward, our TCCET 
has advanced to a new TCCET-Enhanced, or TCCET-E, a new capability to 
evacuate patients while trauma stabilization procedures are conducted. 
This capability is employed in the EUCOM and USAFRICOM theaters today.
    The Expeditionary Medical Support Health Response Teams (EMEDS-
HRT), an evolution of our combat-proven and scalable Expeditionary 
Medical Support (EMEDS) teams, are postured across Air Force medical 
units and embedded in two Army hospitals. They provide emergency care 
within minutes of arrival, surgery and intensive critical care units 
are operational within six hours, and full ICU capability is available 
within 12 hours of arrival. The HRT also helps tailor clinical care to 
the mission, adding specialty care such as OB-GYN and pediatrics for 
humanitarian assistance or disaster relief missions. This evolved 
expeditionary HRT capability has been successfully deployed and is on 
track to replace the previous generation of EMEDS.
    Readiness is always at the forefront of any discussion on how to 
prioritize research and development. Many of the needs in the area of 
medical R&D come directly from Medical Airmen in the field. For 
example, one need identified resulted in the development of the Multi-
Channel Negative Pressure Wound Device. Though still in the 
developmental stage, this device will improve wound care while reducing 
the logistics foot print and power utilization during transport. 
Another example is the advances our medical researchers have made in 
the use of Extra Corporeal Life Support equipment and training. 
Commonly used in civilian hospital settings and referred to as 
Extracorporeal Membrane Oxygenation, its use can be lifesaving, working 
as a substitute set of lungs, processing oxygen and releasing carbon 
dioxide for the body, when the patient has suffered devastating lung 
injury or even assisting the body in oxygenation during procedures such 
as heart bypass surgery. This procedure is challenging in any hospital 
setting. The challenge multiplies when the patient is an injured 
service member minutes away from the battlefield, in an air medevac 
taxiing down an expeditionary runway.
    Medical research in support of Expeditionary Medicine takes the 
common medical procedures, especially those procedures that our 
warfighters have identified as gaps, and applies our best research and 
development talent to solving those problems; often resulting in a 
solution that meets the needs of both the military and civilian medical 
community. One prominent example of this is the Trauma Specific 
Vascular Shunt. AFMS researchers developed this shunt as part of a 
program aimed at developing solutions to capability gaps to enhance 
surgical and pharmacological interventions required to achieve 
improvements in mortality, limb salvage, functionality, and quality of 
life for traumatically injured patients.
    The research that helps us to provide the best possible critical 
care is, and should remain, a top priority: however, other 
operationally relevant research that fills the gaps and answers 
requirements from the field are important and valuable as well.
    As an illustration, Air Force researchers and scientists with the 
711th Human Performance Wing at Wright-Patterson Air Force Base, Ohio 
have made great strides in the areas of Operationally Based Vision 
Assessment (OBVA), Aircrew-Mounted Physiological Sensor Suite (AMPSS) 
equipment, Pilot Physiologic and Cognitive Performance, and Aeromedical 
Operational Psychology. Examples of OBVA use in the field can be found 
in the KC-46 remote vision system (RVS) boom operator (Airmen who 
physically control the aerial refueling mechanism) visual performance 
research. This research examines medical and selection standards needed 
for KC-46 RVS stereoscopic display use. The OBVA program also 
researches the F-35 Helmet-Mounted Display (HMD) vision testing, which 
is vital for setting the medical and vision standards for F-35 HMD, and 
identifies potential improvements to Air Force vision standards and 
screening for optimized pilot performance. The operational and medical 
readiness requirement of fighter pilots prompted our research into the 
AMPSS equipment. Its origins are in the lessons learned from F-22 
testing and investigations. The 711th HPW had a large role in the early 
F-22 investigations, which prompted creation of a laboratory to 
evaluate performance of aircraft oxygen generation systems and 
development of mask sensors, now known as the Aircrew-Mounted 
Physiologic Sensor Suite. Researchers developed these sensors to 
monitor the cardiorespiratory response of high-performance pilots. 
AMPSS is also a component of a larger fighter-pilot centric effort, 
called Pilot Physiologic and Cognitive Performance (P2CP). The sensors 
associated with P2CP monitor the performance of fighter pilots can also 
be expanded to Remotely Piloted Aircraft/Distributed Common Ground 
System (RPA/DCGS) operators as well.
    We are also conducting other psychological health surveillance 
research to assist in monitoring the readiness of remote warriors (RPA, 
DCGS, and Intelligence). Our intent is to improve aeromedical 
psychology procedures for early identification and outreach of Airmen 
flying with untreated distress and negative changes in their 
psychological (emotional, behavioral, and social) functioning. These 
procedures will enable our military mental health professionals to 
examine and predict psychological reactions to key sources of 
occupational stress for the early identification of aircrew at risk for 
medically significant health problems (e.g., psychological distress, 
post-traumatic stress disorder, suicidal ideation, alcohol abuse, 
etc.). Our research results have been utilized to modernize training 
and procedures for medical and mental health providers tasked with the 
outreach to aircrew spread across 40 Air Force aircrew squadrons within 
the continental United States. This research also transitions easily to 
our Air Force ground operators.
    Collaboration with the Department of Veterans Affairs (VA) through 
sharing agreements enhances our providers' clinical currency, saves 
Federal dollars, and maintains readiness. Because of our efforts to 
encourage participation in the DOD-VA Health Care Resource Sharing 
Program, we now have 49 Air Force-VA sharing agreements with 9 Master 
Sharing Agreements covering all available clinical services at nine 
MTFs. Our relationship with the Department of Veterans Affairs (VA) 
extends to clinical currency opportunities for both entities. By 
enhancing clinical skills through partnerships with busy, high acuity 
civilian medical centers regular sustainment training for all team 
personnel, and developing new medical capabilities, we are committed to 
being better prepared when the next contingency presents itself.
    The growth of VA patients in our facilities support veterans in 
need of services, but also greatly enhances our readiness by providing 
the acuity and volume of patient care that cannot be found in the 
active duty and active duty family member population. Growth in our 
outpatient care to veterans stagnated in fiscal year 2015 over fiscal 
year 2014 due to issues in the 3rd quarter with the implementation of 
the Veterans Access, Choice and Accountability Act of 2014. Growth in 
inpatient care for veterans also slowed in fiscal year 2015.
    In contrast to decreasing inpatient and outpatient growth, one of 
our newer sharing sites, the 88th Medical Group at Wright-Patterson 
AFB, Ohio saw a 46 percent increase in VA inpatient dispositions from 
fiscal year 2012 (2,949) to fiscal year 2015 (4,300). This is 
significant in that it is instrumental in providing the complex cases 
needed to maintain clinical currency of deployable teams while 
enhancing access to care for veterans. WPMC has increased their VA 
outpatient workload from fiscal year 2013 (270) to fiscal year 2015 
(2,827) by 947 percent and inpatient dispositions by 2,763 percent for 
the same time period (fiscal year 2013--2018; fiscal year 2015--229). 
Likewise, VA/DOD sharing agreements save the VA a minimum of 10 percent 
over the cost of care in the community. At our largest sharing site, 
David Grant Medical Center, Travis Air Force Base, California, that 
savings is bumped up to 25 percent as that is the discount rate agreed 
upon at that site. Other sites with increased discount rate include 
Keesler Medical Center, Mississippi; Eglin Air Force Base, Florida; and 
Wright-Patterson Medical Center (WPMC), Ohio. All of these sites are 
among the top six Air Force VA/DOD sharing sites that see the majority 
of VA patients across the AFMS.
    Much of the success at WPMC in providing specialty care to veterans 
can be attributed to the WPMC and Veterans Integrated Service Network 
(VISN) 10 leadership. To facilitate discussions and move the sharing 
initiative forward, the team formed the Buckeye Federal Healthcare 
Consortium (BFHC) in 2015. Membership consists of representatives from 
the VA Medical Centers in the VISN, WPMC, and VISN 10. The BFHC 
construct is based on the DOD's Quadruple Aim of Readiness, Better 
Care, Better Health, and Best Value and supports maintenance and 
expansion of clinical currency; provides for convenient, efficient, 
quality care; increases access to care for veterans; and seeks to 
reduce cost by eliminating duplication of services amongst Federal 
agencies. Since the formation of the BFHC, outpatient encounters have 
increased more than 250 percent and Relative Value Units have grown 
more than 500 percent. Inpatient admissions have grown more than 400 
percent and relative weighted product over 5000 percent.
    Another program important to the AFMS and entire Military Health 
System is graduate medical education (GME). The Air Force has 85 GME 
programs, in 31 specialties to develop the knowledge, skills and 
attitudes of highly qualified medical personnel to support the missions 
of the AFMS. These training programs help ensure the competency and 
currency of medical personnel by providing healthcare to deployed 
military personnel and other beneficiaries.
    In contrast, the civilian sector does not have the capacity to 
provide the residency and fellowship training needed to maintain our 
medical specialty requirements. As a result, approximately 15 percent 
of the overall physicians in the workforce today graduated from 
military GME platforms. Participation in GME, to include leadership, 
research, teaching, and mentorship, is vital to maintaining the 
competency and currency of all medical corps in the AFMS. Moreover, 
advanced training is essential to the recruitment and retention of 
medical specialists.
    The overall volume of active duty and civilian GME training, 
coupled with the medical school pipeline, are necessary to maintain the 
current AFMS delivery of health readiness to DOD personnel and their 
families, health service support to combatant commanders and high-
reliability care to all beneficiaries.
    Thank you for this opportunity to discuss how the AFMS is taking 
the hard-learned lessons of the past 15 years of real-world medical 
support to the forces, and transforming those lessons into 
requirements-driven research and resource sharing that maximizes 
benefit to all we serve. Our medical forces must stay ready through 
their roles in patient-centered, full-tempo healthcare services in our 
medical treatment facilities that translate to deployed environments; 
that ensure competence, currency, and satisfaction of practice and 
foster innovation. We are committed to providing the most effective 
prevention and best possible care to a rapidly changing Air Force, both 
at home and deployed. I wish to thank the committee for its steadfast 
support and dedication to the welfare of the Airmen, Soldiers, Sailors, 
Marines, their families and veterans.

    Senator Cochran. Thank you, General Ediger.
    We will now hear from Mr. Chris Miller, Program Executive 
Officer of the Defense Health Care Management Systems.
STATEMENT OF CHRIS MILLER, PROGRAM EXECUTIVE OFFICER, 
            DEFENSE HEALTHCARE MANAGEMENT SYSTEMS
    Mr. Miller. Chairman Cochran, Ranking Member Durbin and 
distinguished members, thank you for the opportunity today to 
address the Subcommittee on Defense of the Senate 
Appropriations Committee. I am honored to represent DOD as a 
Secretary's Program Executive responsible for our Department's 
efforts to modernize our electronic health records and to make 
them interoperable with those of the VA and our private sector 
providers.
    Our servicemembers, veterans and their families deserve 
nothing less than the best possible healthcare and services 
that the DOD and VA can provide. Our mission is to 
fundamentally and positively impact the health outcomes of our 
active duty military, veterans and eligible beneficiaries. To 
this end, DOD is committed to two equally important objectives.
    Improving data interoperability with both the VA and our 
TRICARE health partners.
    And successfully transitioning to a state of the market EHR 
that leverages advances in the commercial health IT and is cost 
effective to the American taxpayer.
    Ultimately this means that up to date and comprehensive 
healthcare information is available whenever and wherever it is 
needed to facilitate decisions.
    I am proud to say that we have made significant progress in 
achieving both of these objectives.
    Today DOD and VA share a significant amount of health data, 
more than any other two major health systems. DOD and VA 
clinicians are currently able to use our existing software 
applications to view more than 7.4 million shared patients. 
This data is available in real time and the number of records 
continues to increase.
    A tangible product of this work can be seen in a joint 
legacy viewer which provides an integrated display of DOD, VA 
and TRICARE provider health data. Originally developed in 2014 
it's a pilot program with just 275 users at nine sites, it has 
now been fielded to every major medical facility, all major VA 
Medical Centers and every Veteran's Benefit Administration 
regional site and supports over 70 thousand registered users.
    As a result of this progress DOD certified it to Congress 
in November of 2015 that we have complied with the fiscal year 
2014 NDA requirement of interoperability with the VA.
    DOD's modernization effort is also well underway.
    In July 2015 the competitive contract for a new EHR 
(electronic health record) was awarded to a team led by Leidos 
that includes 34 other partners.
    At the core of this modernization will be Cerner 
Millennium, one of the most widely used and trusted EHRs on the 
market today. It is used at nearly 18 thousand facilities 
worldwide. Henry Schein's Dentrix will provide the dental 
component of the new EHR and is also an industry leading 
capability.
    Our new EHR system will be open architecture and continue 
to provide industry leading interoperability with the VA, other 
Federal agencies and the private sector by using recognized 
Office of the National Coordinator standards. This system is 
currently beginning testing and we remain on track to bring the 
system live later this year in the Pacific Northwest.
    DOD and VA remain in mutual agreement that interoperability 
with each other and our private sector care partners remains a 
top priority. We agree that this broader interoperability does 
not depend on a single system. This strategy makes sense for 
both Departments and provides the most effective approach 
moving forward to care for our service members, veterans and 
their families.
    This is the last time I'll appear before you today as DOD's 
Program Executive for Defense Healthcare Management Systems. In 
the coming weeks I will begin transitioning out of my current 
role and will assist in bringing in a new acquisition executive 
to continue our important mission. I am honored to have spent 
the last 30 months working for our veteran servicemembers and 
their families and I am proud of the accomplishments we have 
made during that time.
    It has not been easy. But our commitment and our focus was 
unwavering.
    Most importantly, I would like to thank my family 
supporting me these last few years. This job has required me to 
spend far too much time away from home and so I look forward to 
returning to Charleston to spend time with my family very soon.
    Chairman Cochran and Ranking Member Durbin, thank you again 
for the opportunity to testify today. DOD has taken very 
seriously its responsibility to provide modern health IT 
solutions that make a difference and to enable seamless sharing 
of integrated health records with the VA and our TRICARE 
network providers.
    We fully recognize that our mission is not complete and 
there will be challenges ahead.
    This is a unique opportunity for the military health 
system. We have the opportunity to save money, save time and 
most importantly, save lives.
    The Department greatly appreciates the Congress' continued 
interest and efforts to help us deliver the healthcare that our 
Nation's veterans, servicemembers and their dependents deserve 
whether it's on the battlefield or at home with their families 
or after they have faithfully concluded their military service, 
the Department of Defense and our colleagues at the Department 
of Veterans Affairs will continue to work closely together in 
partnership with the Congress to deliver the benefits and 
services to those that sacrifice so willingly for our Nation.
    Again, thank you for this opportunity and I look forward to 
your questions today.
    [The statement follows:]
              Prepared Statement of Christopher A. Miller
    Chairman Cochran and Ranking Member Durbin, thank you for the 
opportunity to address the Subcommittee on Defense of the Senate 
Appropriations Committee. I am honored to represent DOD as the 
Secretary's program executive responsible for the Department's efforts 
to modernize our electronic health records (EHRs) and to make them 
interoperable with those of VA and our private sector providers.
    Our service members, veterans, retirees, and their families deserve 
nothing less than the best possible healthcare and services that DOD 
and VA can provide. Our mission is to fundamentally and positively 
impact the health outcomes of active duty military, veterans, and 
eligible beneficiaries. To this end, DOD is committed to two equally 
important objectives: improving data interoperability with both VA and 
our private sector healthcare partners, and successfully transitioning 
to a state-of-the-market electronic health record that is interoperable 
with VA and the commercial healthcare systems used by our TRICARE 
network providers. Ultimately, this means that up-to-date and 
comprehensive healthcare information is available whenever and wherever 
it is needed to facilitate decisions.
    I am proud to say that we have made significant progress in 
achieving both of these objectives. Today, DOD and VA share a 
significant amount of health data--more than any other two major health 
systems. DOD and VA clinicians are currently able to use their existing 
software applications to view records of more than 7.4 million shared 
patients who have received care from both Departments. This data is 
available today in near real time and the number of records viewable by 
both Departments continues to increase. Both Departments' healthcare 
providers and VA claims adjudicators successfully access data through 
our current systems nearly a quarter of a million times per week. As a 
result of this progress, DOD certified to Congress in November 2015 
that it has complied with the fiscal year 2014 National Defense 
Authorization Act (NDAA) requirement of interoperability with VA.
    On a parallel path, DOD's modernization effort is well underway. In 
July 2015, the competitive contract for a new EHR was awarded to a team 
led by Leidos that includes 34 other partners. At the core of this 
modernization will be Cerner's EHR, one of the most widely used and 
trusted EHRs on the market today, used in nearly 18,000 facilities 
worldwide. Henry Schein will support the dental component of the new 
EHR, and is also an industry-leading capability. In addition to 
utilizing the Cerner and Henry Schein suite of solutions, this new EHR 
system will continue to provider industry leading interoperability with 
the VA, other Federal agencies, and the private sector by using 
federally recognized Office of the National Coordinator (ONC) 
standards.
    DOD and VA remain in mutual agreement that interoperability with 
each other and our private sector care partners remains a priority. We 
agree that this broader interoperability is not dependent on a single 
system. This strategy makes sense for both Departments and provides the 
most effective approach moving forward to care for our service members, 
veterans, retirees, and their families. We continue to have direct 
senior-level oversight from both Departments as well as rigorous 
oversight from both Congress and the Executive Branch.
Goal 1: Provide Seamless Integrated Sharing of Standardized Health Data 
        Among DOD, VA, and Private Sector Providers
    In November 2015, DOD formally issued a letter to Congress 
certifying that it has met the requirement of interoperability in the 
fiscal year 2014 National Defense Authorization Act (NDAA) by mapping 
all data in DOD's AHLTA outpatient EHR system to existing national 
standards. Based on the recommendations of DOD and VA functional 
representatives, DOD also integrated data from other DOD health IT 
systems, including inpatient, theater and pharmacy. We fully recognize 
that health IT continues to evolve and that we must continue to improve 
our capabilities. The complexity of our interoperability mission takes 
time and steadfast commitment. This process involves two of the world's 
largest healthcare providers, with hundreds of thousands of users, more 
than three hundred systems, and millions of data elements. This 
requires strong communication, collaboration, and technical leadership.
    A tangible product of this work can be seen in the Joint Legacy 
Viewer (JLV), which provides an integrated display of DOD, VA, and 
TRICARE network provider data for clinicians and other users. For DOD 
clinicians, JLV is embedded directly into AHLTA, allowing any 
registered user to easily view a comprehensive picture of a 
beneficiary's health record, regardless of whether the data resides in 
AHLTA, VISTA, or a TRICARE network provider's EHR. JLV has received 
considerable praise from both DOD and VA users, with many commenting on 
its ability to save time in clinical interactions and to allow benefits 
adjudicators to cross-reference retiree records with the more 
comprehensive medical record in JLV. Because of this positive feedback, 
DOD and VA have sought to rapidly expand access to JLV. Originally 
developed as a pilot program with 275 users at 9 sites in 2014, JLV has 
now been fielded to nearly every DOD medical facility, all major VA 
medical centers, and every Veterans Benefits Administration regional 
site, supporting over 70,000 registered users. Throughout this process, 
JLV has undergone rigorous testing, consistently scoring high marks for 
functionality and usability. Additionally, in its most recent 
assessment, DOD's Operational Test and Evaluation (OT&E) office 
verified that all previously identified defects have been corrected in 
the newest release, which will also be tested in the near future. As 
JLV usage has become more widespread, the Department has phased out 
existing legacy viewers as they become obsolete.



    Over the last 30 years, information technology has revolutionized 
industry after industry, dramatically improving the customer experience 
and driving down costs. Today, in almost every sector besides health, 
electronic information exchange among different systems is a common way 
to do business. A cashier scans a bar code to add up our grocery bill. 
We check our bank balance and take out cash with a debit card that 
works in any ATM machine across the globe--regardless of who manages 
the ATM.
    Achieving this type of seamless data integration is dependent on 
achieving a common set of technical standards across all healthcare 
venues, not on sharing the same software system. Since 2008, DOD and VA 
have been exchanging a significant amount of electronic information. 
Unfortunately, most of the information had not been standardized so 
that it could be used for automated reminders or clinical decision 
support. As an example, DOD and VA may have had different names for 
``heart rate'' in their software systems, making it difficult for 
clinicians to integrate and track this vital sign across the 
Department. For data sharing and interoperability to be meaningful and 
useful to clinicians, healthcare data must be mapped to standard codes 
and displayed in a user-friendly way. Since the majority of care comes 
from outside of DOD, this is equally important for sharing data with 
our TRICARE network providers, who use a variety of different health IT 
systems.
    Much of this work has been accomplished with the assistance of the 
DOD/VA Interagency Program Office (IPO), which leads and coordinates 
the two Departments' adoption of and contribution to national health 
data standards to ensure seamless integration of health data between 
DOD, VA and private healthcare providers. To ultimately map the data to 
national standards, DOD and VA identified 25 prioritized data domains, 
such as allergies, immunizations, vital signs, and family history. 
Three of these domains contain no structured data to map, and one, 
radiology images, already exists in a common industry format. With the 
assistance of the IPO, DOD has completed the initial mapping of the 
remaining 21 domains requiring national standard terminologies, 
representing more than 1.8 million unique DOD clinical terms, thereby 
establishing the foundation for our seamless data integration. Over the 
past year, we have completed six additional mapping deliveries. DOD 
subject matter experts and the IPO conducted independent quality 
assurance reviews of these mappings to ensure their accuracy. 
Additionally, DOD has established a data governance process to actively 
manage and continually improve utilization of national standards as 
they evolve in the future. Further, virtually all clinically relevant 
data is now mapped to national standards, increasing the ability to 
share this information with many different health IT systems in use by 
our TRICARE network providers. In the ``heart rate'' example mentioned 
previously, both VA and DOD clinicians will now see a common, 
standardized name for a patient's heart rate that can also be matched 
up with data from the private sector. Moving forward, we recognize that 
interoperability requires continual improvement. To this end, we plan 
to regularly update our data maps to further improve the portability of 
healthcare information between EHR systems.
    We are leveraging our knowledge and expertise with the VA to 
exchange health information with our TRICARE network providers. Today, 
more than sixty percent of all service member, dependent, and 
beneficiary healthcare is provided outside a military treatment 
facility through TRICARE network providers. DOD exchanges its 
electronic patient health data with the public and private sector 
through its connection to the national e-Health Exchange. DOD is 
focused on deploying private sector interoperability to our military 
treatment facilities around the country that have an associated private 
sector Health Information Exchange (HIE) that is connected to the 
eHealth Exchange. DOD is currently connected to 11 HIEs, and is one of 
109 participants in the eHealth Exchange. DOD plans to connect to an 
additional 14 HIE partners in the coming year, with additional HIE 
partners possible throughout the year.
    Our service members overseas face unprecedented challenges in some 
of the world's most hostile environments, and an important part of 
preparing our Soldiers, Sailors, Airmen and Marines to face these 
challenges is the reassurance that we are committed to taking care of 
them once they return home safely. It is incumbent upon DOD and VA to 
ensure that our clinicians have access to accurate and timely data to 
fundamentally and positively impact the health outcomes of active duty 
military, veterans, and eligible beneficiaries. DOD has a steadfast 
commitment to maintaining and enhancing our interoperability efforts. 
Interoperability requires continual improvement, innovation, and 
collaboration to ensure our users have the right information at the 
right time to provide the best healthcare decisions for our service 
members, veterans, and their families.
Goal 2: Modernize the Electronic Health Record (EHR) Software and 
        Systems Supporting DOD and VA Clinicians
    In addition, DOD's acquisition of a modernized EHR system reflects 
our unwavering commitment to providing our community with the best 
healthcare tools available and to further our Departments' 
interoperability efforts. In July 2015, following a robust open 
competition, DOD awarded a $4.3 billion contract for a new EHR to a 
team led by Leidos that includes 34 other partners. At the core of this 
modernization is Cerner's EHR, one of the most widely used and trusted 
EHRs on the market today, used in nearly 18,000 facilities worldwide. 
This contract was awarded without protest and ultimately resulted in 
significant cost savings over original estimates. When DOD established 
the DHMSM Program Office, the initial rough order of magnitude cost 
estimate was around $11 billion. However, through the rigor of our 
competitive acquisition process, the cost estimate has been revised 
downward to less than $9 billion today. Moving forward, we are 
continuing to look for ways to further reduce the cost of the program 
across its life cycle to provide maximum value to our service members 
and the American taxpayer.
    The new EHR will support our military's operational readiness by 
addressing the increasing demands across the spectrum of military 
operations and will be used in both garrison and operational 
environments. It will provide advanced healthcare decision support 
capabilities and will have the capability to integrate with medical 
devices and allow the use of mobile technologies to support our dynamic 
mission requirements. This will result in unprecedented patient 
engagement and promote user involvement for beneficiaries. 
Additionally, the product being provided by the Leidos Partnership for 
Defense Health (LPDH) can be configured to fit DOD's evolving needs, 
eliminating the timely and costly process of customizing systems to 
various requirements.
    As part of our acquisition strategy, we have just finalized our 
system hosting strategy. DOD has decided to initially host data for the 
new EHR in Cerner's data centers. This decision allows DOD to take 
advantage of valuable proprietary Cerner health analytic and decision 
support tools and expands the population of calculable healthcare data 
beyond DOD, leading to more accurate and meaningful analysis of 
healthcare trends. This ultimately aligns with the larger overall 
commercial-off-the-shelf strategy, pairing a commercial product with a 
commercial hosting solution.
    The modernized EHR system will be rigorously and independently 
tested prior to and throughout deployment to ensure it meets 
operational requirements for effectiveness, suitability and 
interoperability with VA and TRICARE network providers. Testing will 
also ensure that the new EHR conforms to current DOD cybersecurity 
requirements under the Risk Management Framework, as required in the 
RFP, and that data is able to be securely shared across VA Trusted 
Internet Connection Gateways (TIC GWs), providing secure communication 
between VA and DOD networks. The system is currently undergoing 
contractor testing which is scheduled to be conducted from February 
2016 through December 2016.
    Our early engagement with industry reinforced the value of 
establishing a realistic deployment timeline that supports effective 
user adoption. Our aggressive timeline is consistent with similar EHR 
modernization efforts in the commercial industry. The program has 
tailored its acquisition strategy to streamline documentation and gain 
schedule efficiencies. We are committed to collaborating with industry 
and pursuing this modernization in a transparent and fair way that 
maximizes competition. As we speak, pre-deployment testing of the new 
EHR is nearing its end. In accordance with the NDAA, deployment is 
scheduled to start later this year at the Initial Operational 
Capability (IOC) sites in Washington State representing all three 
services. DHMSM leadership has completed the executive kickoff sessions 
at these locations to ensure all sites are fully prepared. Full 
Operational Capability (FOC), currently estimated for fiscal year 2022, 
will include deployment to medical and dental services of fixed 
facilities worldwide. Deployment will occur by region (three in the 
continental U.S. and two overseas) in 23 waves plus the IOC ``wave.'' 
Each wave will include an average of three hospitals and 15 physical 
locations, and last approximately 1 year. This approach allows DOD to 
take full advantage of lessons learned and experience gained from prior 
waves to maximize efficiencies in subsequent waves, increasing the 
potential to reduce the deployment schedule in areas where it is smart 
to do so.
    The biggest challenge to deploying this new EHR is not technology, 
but gaining support for our new business processes. Over 550 DOD 
experts across the Services have spent the past 5 months participating 
in enterprise product design sessions to review, update, and validate 
more than 750 workflows, 2,500 enterprise design decisions, 300 
enterprise content sets, and over 450 enterprise order sets. 
Ultimately, the new EHR represents a fundamental business 
transformation within DOD, and the bulk of our work moving forward is 
making sure our end-users and the DOD community as a whole are prepared 
to begin using this system once it comes online. Throughout our 
history, each service has had the ability to develop many of their own 
processes and procedures, especially when it came to the delivery of 
healthcare. Now, for the first time ever, the new EHR will merge all of 
the unique workflows and business cultures throughout the Military 
Health System (MHS), creating uniform business processes and workflows 
across the Department that will encompass more than just documenting 
medical conditions and clinical interactions. The new EHR will also 
drive scheduling, registration, financial, and patient engagement. This 
will require over-the-shoulder training at over 1200 locations 
worldwide, making it incumbent upon our program to ensure all 
stakeholders understand the significance of this cultural change and 
are prepared to move forward with it when the time comes.
Conclusion
    Chairman Cochran and Ranking Member Durbin, thank you again for the 
opportunity to testify today. DOD has taken very seriously its 
responsibility to provide first-class healthcare to our service members 
and their beneficiaries, and to enable the seamless sharing of 
integrated health records with VA and our TRICARE network providers. 
Looking forward, we will continue to improve data sharing efforts with 
VA and the private sector to create an environment in which clinicians 
and patients from both Departments are able to share current and future 
healthcare information for continuity of care and improved treatment 
outcomes.
    The Department greatly appreciates the Congress' continued interest 
and efforts to help us deliver the healthcare that our Nation's 
veterans, service members, and their dependents deserve. Whether it is 
on the battlefield, at home with their families, or after they have 
faithfully concluded their military service, the Department of Defense 
and our colleagues at the Department of Veterans Affairs will continue 
to work closely together, in partnership with Congress, to deliver 
benefits and services to those who sacrifice so willingly for our 
Nation. Again, thank you for this opportunity, and I look forward to 
your questions.

    Senator Cochran. Thank you very much, Mr. Miller, 
appreciate your cooperation and assistance to the Committee.
    Let me now call on the distinguished Ranking Minority 
Member of the Committee, distinguished Senator from Illinois, 
Richard Durbin.
    Senator Durbin. Thank you, Mr. Chairman.
    And Mr. Miller, let me join in the chorus of gratitude for 
your work over the last several months and whatever your future 
may be.
    I don't think I have to ask because I believe being medical 
professionals we'd all agree that the use of tobacco is a 
negative thing.
    If you have a person in your family or patient or a friend, 
you would counsel them, don't do it. You're running the risk of 
cancer, heart disease and a myriad of other medical challenges. 
If you're injured as a smoker, you're going to recover more 
slowly and there will be many complications in your life that 
can be avoided if you can avoid tobacco.

                            TOBACCO PRODUCTS

    That would seem very obvious. And when we use the word 
readiness in every other sentence talking about our military, 
the obvious question is why is it that the rate of tobacco 
usage in the military is significantly higher than it is in the 
civilian population? It's about 24 percent overall, but in the 
military it's 32 percent, 32 percent, despite the fact that the 
men and women who come into the military and go through Basic 
Training, during that period of time are told, flat out, you 
cannot use tobacco products for weeks on end.
    And that is the standard. And that is a rule. A rule which 
was lifted for reasons I can't understand when it came to AIT, 
Advanced Training. That was done about 10 years ago. Why, I 
don't know?
    So the obvious question to our public health and health 
leaders in the military, why are numbers so bad when it comes 
to tobacco usage in our military?
    Lieutenant General West.
    General West. Thank you, Vice Chairman, for that question.
    And I concur. As a medical professional I understand and 
believe, as I'm sure my colleagues here do, there is no minimum 
daily requirement for tobacco.
    I don't know of any benefit at all for that to a person.
    However, you know, as a medical advisor to my leadership, 
we continue to stress the need for healthy behaviors on all 
fronts and tobacco is part of that.
    We have efforts on our healthy base initiatives, our 
performance triad and all those areas to try to improve the 
health and other aspects and tobacco is one of those. And we're 
pushing as health professionals, smoking cessation, abilities 
to----
    Senator Durbin. Is it working?
    General West. Well based upon those numbers, you know, 
Senator, it appears not. But it doesn't mean we won't continue 
to try and redouble our efforts, maybe get after the cultural 
reasons why tobacco appears to be something that's, you know, 
that's in our military.
    But as I mentioned, as a healthcare professional, it's my 
obligation to ensure that our senior leadership understands the 
negative impact that this has. This is, as you mentioned----
    Senator Durbin. A substantial portion.
    General West. Absolutely.
    Senator Durbin. A substantial percentage of our military 
start smoking when they enter the military.
    General West. Right.
    Senator Durbin. We're missing something here.
    Why is the rest of the United States and many parts of the 
world catching on?
    Vice Admiral, why?
    Admiral Faison. Sir, that's a question that vexes us as 
well.
    I don't think you'll find stronger proponents of anti-
smoking than the folks at this table. My secretary specifically 
has been an outspoken proponent of smoking cessation. I 
personally had a father who smoked and had lung cancer. So 
we're aggressively working on smoking cessation.
    We don't have the answer to why people start when they 
enter the military. But I will tell you, our efforts have been 
aggressive in getting them to stop.
    If you look at the numbers in the Navy, the numbers of 
folks that are actually smoke and use smokeless tobacco are 
actually on a downward trend.
    Where we're having challenges right now is with E-
cigarettes. And those, regrettably, are on the rise. We're 
trying to get after that and figure out why that is.
    Senator Durbin. I have one other question I mentioned at 
the outset.
    We are asked, the Chairman and I are asked to sign 
reprogramming letters regularly and do them routinely. Along 
comes a reprogramming letter, two of them in fact, a few months 
ago to reprogram $2 billion. And I said, what is this all 
about?
    Well, it turned out to deal with compound pharmaceuticals. 
It is incredible what happened in our military. The amount of 
money being spent on compound pharmaceuticals skyrocketed from 
several hundred million to two billion dollars.
    And then they took a close look and found out fraudulent 
pharmacies were using food trucks and other ploys to attract 
servicemembers near bases, sign up for a compound prescription 
you don't need and you get a free lunch. And we ended up 
passing along, literally billions of dollars for sometimes 
worthless compounds.
    Now I'm told that everyone is aware of that and it's not 
going to happen again. Can you give me that assurance and tell 
me why I should trust it?
    Either one. Anyone.
    General Ediger. Senator Durbin, yes, this was a very high 
concern issue for the Department of Defense last year. The 
controls that the Defense Health Agency put in place last year 
were very effective in terms of stopping this. But the behavior 
was absolutely fraudulent and reprehensible by those that were 
marketing this to our servicemembers.
    And I would add that they were also marketing to our 
healthcare providers within our facilities. And we put a stop 
to that.
    Most of the prescriptions that were being written for 
compounded drugs came out of the private sector. The few that 
came out of our hospitals we quickly got under control and 
those were instances where providers with the best intentions 
were trying to take care of their chronic pain patients and 
prescribing medications that would help but had no idea what 
these companies were charging the government for these 
prescriptions.
    So we now have that under control. The DHA put in a process 
through express scripts by which all compounding prescriptions 
are reviewed before they are filled. And that's had a dramatic 
effect. And so we do believe that across the DOD we do have the 
controls in place now so that this will not recur.

                              TELEMEDICINE

    Senator Cochran. The distinguished Senator from Missouri, 
Senator Blunt.
    Senator Blunt. Thank you, Chairman.
    General West, let's talk first about the General Leonard 
Wood Army Community Hospital at Fort Leonard Wood. This was to 
be replaced originally in fiscal year 2016. I see it's now 
deferred again until fiscal year 2021. It's been 40 years since 
there's been any substantial reworking or rehabilitation of 
that facility.
    Your predecessor, General Horoho, last year said that it 
was still the number one, top military construction priority. I 
know at a Senate hearing just a few days ago you talked about 
this hospital and the advances they were making in 
telemedicine.
    I guess I'm just hoping for some reassurance that this 
isn't going to continue to get pushed forward. Not many 
alternatives for the active duty, the retirees or the families 
that are served by this hospital. And 40 years is a long time 
not to do much to a hospital.
    General West. Thank you for that question, Senator.
    And yes, I understand from General Horoho's commitment it 
was an honest commitment to placing that in the fiscal year 
2016 as a number one priority.
    My understanding is that that was due to budgetary 
constraints, you know, basically removed from that. It was 
reprioritized, not by the Army Medicine but other projects that 
were deemed to be more, you know, have a higher priority.
    Senator Blunt. Is it still the top medical military 
construction priority?
    General West. For the 2017-2021, yes, it is, Senator. We 
put that back in. We have assurances that it is in the cycle. 
It's a, assuming no other, external requirements to remove 
that, we are committed to move that forward for our, for the 
fiscal year 2017-2021 cycle.
    In the interim though, I want to stress that the--we were 
making sure that the current facility is, maintained and still, 
receiving upgrades.
    In fact, just recently in fiscal year 2009 there was $21.9 
million spent on renovating and expanding the primary care 
clinic and several other initiatives to ensure that the current 
facility is maintained for, to provide safe healthcare, a high 
quality healthcare to our beneficiaries while we're waiting 
for, the facility to be constructed.
    Senator Blunt. Well, we're going to continue, I hope you 
continue to keep an eye on it. It is a facility----
    General West. Absolutely, Senator.
    Senator Blunt [continuing]. That serves a lot of people 
including lots of retirees and their families as well as 
families of those currently serving.
    We're debating on the Senate Floor a bill on opioid and 
heroin abuse. In every set of figures I see, particularly 
veterans and veterans who are recently out of the military, 
have a higher level of muscular, skeletal pain, have a higher 
likelihood to have used opioids and a higher likelihood to 
still be dependent on opioids.
    I'd like all three of you, any thoughts you might have on 
whether we're looking for other ways to manage pain, having any 
success finding non-opioid alternatives to manage pain.
    And what are we doing to help those who serve so that 
whether it's a IED attack or a training accident or just the 
wear and tear of full time service, that they're having the 
pain they're having because of their service to us and this 
doesn't need to be a prolonged thing, hopefully after they 
leave the military that they not continue to really suffer from 
the pain, or the addiction that they have received, at least 
from the pain medicine.
    Let's start, General Ediger, with you.
    General Ediger. Yes, Sir.
    In the Department of Defense we have a pain management 
strategy. And each of services have established pain management 
services and clinics in our hospitals. And I know in the Air 
Force we are actively pursuing the addition of more integrated 
medicine capability to the way we practice.
    And so we have a very active acupuncture training program 
in progress. And we've trained almost two thousand clinicians 
in terms of use of acupuncture and other integrated medicines, 
tools, are being evaluated for implementation.
    And the interest here is on helping servicemembers find a 
way to manage pain without necessarily depending on the use of 
opioids to do so.
    We know there is a place for opioids and they should be 
used judiciously but we know that there are a lot of other 
tools we can use in pain management in order to give them an 
effective way to move forward with their lives without the high 
concern about opioid dependence.
    Senator Blunt. Admiral, do you have anything to add to 
that?
    Admiral Faison. Yes, Sir.
    We also, in the Navy and the Marine Corps, are very 
concerned about pain management, therefore we invested heavily 
in this. We have established comprehensive pain management 
services in many of our larger facilities to include putting 
physicians through pain management fellowships and established 
telemedicine capabilities for our smaller facilities for 
consultation for patients with pain.
    So we've worked on this very hard to provide a safety net 
of educated providers who can manage pain successfully.
    In addition, we have ongoing education programs for not 
only physicians, but our nurses and others in pain management 
and alternatives that we routinely use. Many of our pain 
management patients are case managed and we're blessed with 
electronic systems that allow us to look at the medications 
that a patient is on. If it's paid for by the Department of 
Defense it shows up in our systems, we routinely review those 
as part of case conferences.
    Finally, we've invested heavily in Alternative Medicine. We 
have trained over 100 providers in complementary and 
acupuncture and other alternative therapies, allowing us to 
position those teams in places where there is high demand. As a 
result of our efforts, we are seeing a downward trend in our 
need to use opioids or other pain management medications.
    Senator Blunt. General, I assume your answer is similar and 
I'm out of time.
    But this is an area that, obviously, the Congress is very 
attentive to. We made a big increase in the amount of money 
available to these programs last year. And now giving more 
direction, legislatively, to it and too many of our veterans 
are impacted and too many veteran suicides involve opioids and 
heroin and we need to stop this.
    Thank you, Chairman.
    Senator Cochran. Thank you, Senator Blunt.
    The distinguished Senator from Maryland.
    Senator Mikulski. Thank you very much, Mr. Chairman, for 
holding this hearing on the Department of Defense Health 
Program Appropriations request.
    It's one of my favorite hearings because it goes right to 
the heart of the active duty military, the retired military and 
their families. And we hear how this benefit is one, essential 
to meet our obligations to those serving and in the line of 
fire and then their families. You don't only send someone to 
war, there are families involved as well.
    And so we always look forward to hearing what they're doing 
and how we can help them but do it effectively and have meaning 
in the lives of our people.
    I want to thank you all for your service, for what you do 
every day in terms of ensuring this delivery of service. And 
Mr. Miller, you too, have been in, kind of, your own line of 
fire with the mine fields of interoperability.
    Mr. Chairman, we're very proud of military medicine in 
Maryland. We're the home to Walter Reed Naval, Bethesda and 
anyone who hasn't visited I really encourage you to come and 
see this spectacular institution meeting the needs of our 
military. It's the home of a medical school uses. Admiral 
Faison, you served there.
    And we also have our relationships, like with the Air Force 
residency program, where we use institutions in our State, the 
University of Maryland Shock Trauma involved with you and the 
Air Force's surgical residency program and they're delighted 
with it.
    And also when we look, Fort Detrick that does very 
important research in protecting us from biological and 
chemical warfare and then also helping with other research 
activities too classified to talk about here. And then it's 
work in extramural research.
    We're so pleased that Johns Hopkins was able to get a grant 
to do something that was almost like a moon shot in the 
survival of amputees in which they actually, gentlemen, did a 
limb transplant to a military man, Brian, who lost both arms. 
And they did limb transplant. This man has the use of his arms. 
He has the use of his hands. He might not be able to play a 
concerto, but he can play ball with his child and he can be 
involved in the workforce. He can feel like a human being and 
live fully.
    And it was important not only for those who bear these 
permanent wounds of war, but the research also showed he didn't 
have rejection, you know, the whole thing about a transplant is 
the whole drug regime.
    So we're really proud of what goes on there. And I want to 
thank you because I think it accrues to our military population 
and our civilian population. So we want to thank you for what 
you do and don't forget Maryland when I'm not here.
    So, but also, you know, just the volume and velocity of 55 
hospitals, 360 clinics, 147 employees. It's just amazing what 
you do.
    But let me get to my questions. It goes to readiness and 
resiliency, readiness and resiliency. And that's what you all 
talked about.
    I was so pleased to hear that you're using complementary 
modalities and integrative health and would like to encourage 
you.

                        HEALTHY BASE INITIATIVE

    Well let me get to where I think the military and their 
families should be well fed. I feel like I'm at war with the 
DOD budgeteers over the shrinking of commissaries. My question 
to you is this. Are you aware that they're trying to cut the 
commissary budget that nobody is paying attention to something 
called the Healthy Base Initiative?
    Are you aware of that?
    General West, are you? You are.
    Admiral.
    [Heads nod.]
    Senator Mikulski. And with Jessica Wright going it's kind 
of wandering in the wilderness.
    This initiative is twofold.
    One use the commissary to introduce fruits and vegetables, 
also to be able to enable the commissary to do things like 
farmer's markets which my garrison commander at Fort Meade 
tells me has been really a building where Officer Corps and 
Enlisted Corps and so on across the ranks are mingling.
    And then also the way you change you feed active duty 
military. Nobody wanted to eat at Fort Meade until they had the 
Healthy Base Initiative. They were serving liver and onions at 
like three o'clock in the afternoon and wondering why was 
everybody running to Burger King.
    So what do you think? Don't you think the Army runs on its 
stomach and the Army, the military, ought to help them. And 
could you all mount a battle with the budgeteers and help out 
these families?
    General West. Absolutely.
    Senator Mikulski. And how are you going to say no on this. 
I mean----
    [Laughter.]
    General West. Absolutely. That's right. Absolutely, 
Senator.
    And I appreciate your efforts of ensuring that Fort Meade, 
along with Bragg and Fort Sill, which are the other 
installations that in the Healthy Base Initiative. And 
absolutely, there were some initiatives just to change the 
placement in our dining facilities, putting salads up front, 
putting more healthy foods closer so you had to pass by them 
before you got to some of the more unhealthy choices really 
made a difference and the selection of more healthy choices.
    So just placement and all those initiatives ensuring that 
on our installations.
    Senator Mikulski. I know what they do.
    General West. Right.
    Senator Mikulski. I'm afraid that it's not going to 
survive.
    Are you aware that in the budget they're cutting 
commissaries again?
    General West. I'm not aware of the specific cut. I know 
that was something----
    Senator Mikulski. Well I say that really to the three of 
you, okay?
    And commissaries in some ways are a nutritional settlement 
house.
    General West. Yes, so we----
    Senator Mikulski. You're nodding your head. Admiral.
    Admiral Faison. Ma'am, I was not aware of the commissary 
initiative. I will tell you with Healthy Base Initiative, 
though, we have taken the principles from that and exported 
that across our Navy.
    In our Navy, on ships, we have a long tradition of what are 
called sliders. They're burgers. We've replaced those.
    Senator Mikulski. Oh, I know what a slider is.
    Admiral Faison. Yes, Ma'am. So, we've replaced the sliders.
    I personally just made a video this week on the importance 
of activity and proper eating and things like that. We're 
taking those initiatives and exporting those across the Navy 
and the Marine Corps because it does lead to better health. 
Obesity is a challenge in our Nation right now.
    Senator Mikulski. But it is about readiness and prevention.
    Admiral Faison. Exactly. Yes, Ma'am, absolutely.
    Senator Cochran. Senator, your time is expired.
    General Ediger. Yes, Senator, we are aware that there have 
been discussions in terms of the commissary benefits and the 
changes to that in the interest of saving costs.
    Through our health promotion programs, we are focused on 
anticipating how we can better deliver information and 
knowledge to the families that we support in terms of healthy 
nutrition understanding that where they actually purchase their 
food may change over time. But we agree the commissary is a 
great opportunity for us to deliver information and encourage 
families in terms of healthy choices.
    Senator Mikulski. Check it out and help me out.
    My time is expired.
    And thank you, once again, we love you in Maryland and we 
love what you do every day to help our military and its 
families.
    Senator Cochran. Thank you, Senator.
    And the distinguished Senator from Montana, Mr. Daines.

                      MISUSING PRESCRIPTION DRUGS

    Senator Daines. Thank you, Mr. Chairman.
    And I extend a very warm welcome to you today. Thank you 
for your dedication to the health and safety of our 
servicemembers. It's very much appreciated.
    This week on the Senate Floor we're debating the 
Comprehensive Addiction and Recovery Act. As you know, members 
of our military and veterans are not immune to the substance 
abuse disorders that impact the rest of our Nation. This is 
also a serious issue in Montana.
    The VA cites that about one in five veterans have PTSD, 
also have a substance abuse disorder.
    And according to the latest Department of Defense survey, 
11 percent of active duty servicemembers reported misusing 
prescription drugs which is up significantly over the past 
decade.
    I introduced a couple of amendments this week to highlight 
that and to open up more treatment options for those who have 
served our country. But I think the impact the substance abuse 
is having on our Nation is a sign that it's going to continue 
being an issue for us, for our servicemembers, for the 
foreseeable future.
    So my question, maybe we'll start with General West, what 
trends are you seeing right now with substance abuse and 
members of the military?
    General West. Mr. Senator, our substance abuse, it's, you 
know, one person or one family member abusing substances is too 
many for us. The trends that we see, I'll have to get back with 
you for the exact numbers of where we are on that, but we do 
have programs to address that with our beneficiaries, our 
active duty servicemembers and our beneficiaries.
    [The information follows:]

    The primary reason for Active Component Soldier enrollments in Army 
Substance Abuse Program rehabilitation is for alcohol and substance use 
disorders. Drug and Alcohol Management Information System (DAMIS) data 
for fiscal year 2011-2015 shows that 75 percent of Soldier enrollments 
for treatment in fiscal year 2011 were related to alcohol issues 
increasing to 79 percent in fiscal year 2015. 27 percent of Soldier 
enrollments were for substance abuse in fiscal year 2011 decreasing to 
21 percent in fiscal year 2015.
    According to DAMIS data, the rate for drug positives by Soldiers 
has decreased across all Army Components from fiscal year 2011-2015. 
Drug positives include prescription drug abuse and illicit drug abuse. 
The rate of drug positives for Active Component Soldiers decreased from 
1.01 percent in fiscal year 2011 to 0.86 percent in fiscal year 2015; 
for Army National Guard Soldiers the rate decreased from 2.55 percent 
in fiscal year 2011 to 2.07 percent in fiscal year 2015; and for the 
Army Reserve the rate decreased from 2.15 percent in fiscal year 2011 
to 1.71 percent in fiscal year 2015.

                           BEHAVIORAL HEALTH

    General West. In order to address the behavioral health 
reasons sometimes that lead to that, we have increased our 
behavioral health assets to help address, not only with our 
servicemembers, but our families, any issues that they may have 
that would lead to that.
    We have embedded behavioral health with our units to make, 
you know, seeking help for behavioral health reasons or seeking 
help less stigmatized by ensuring that they have access in 
their unit areas to professionals that can help, at least be 
the first line of them reaching out and discussing any issues 
that they may have.
    So ensuring that we have enough assets to allow them access 
to, as a first step in, in ensuring they have access to that is 
one of the things that we do.
    We also have treatment programs, you know, outpatient 
treatment programs, intensive inpatient programs, depending on 
the nature of the addiction.
    Senator Daines. Right, thank you. And I just, based on what 
we're seeing around the country this has got to be one of those 
trends that we want to try to get out in front of as best we 
can, particularly for our servicemembers. But thank you for 
that answer.
    One of the other complaints I'm hearing as I travel across 
Montana and hearing from our veterans is the problem of the 
medical records, medical records transferring to the VA. 
Something that should be a seamless transition somehow turns 
into veterans going months, even sometimes years without having 
the medical records from their time in service.
    I know that DOD has been working to provide seamless, 
integrated sharing of health data among DOD, VA and the private 
sector. But I'm concerned about how long this is taking, as 
well as how much this is--how much it costs.
    In 2013 the joint single integrated electronic healthcare 
system was abandoned and now we're on a current $11 billion 
program, the DOD Healthcare Management System Modernization 
Program. I spent a lot of years in the software business and 
always get a little nervous when you see folks walk in with 
expensive suits and shoes here running the meter at very, very 
high levels and how that can run price tags up as well as 
schedules getting missed, delayed or projects fail.
    My question, Mr. Miller, how is this new program actually 
going to solve the problems with medical records of our active 
duty men and women who are transferring to the VA once and for 
all.
    Mr. Miller. Thank you very much, Sir.
    A couple quick comments there in the life cycle estimate of 
our programs are actually not $11 billion anymore. Competition 
works, as you probably well know, Sir. Where our estimates are 
now between fiscal year 2014 and fiscal year 2032 is roughly 
somewhere between $8.6-$8.7 billion. And so we're--we continue 
to apply pressure, moving the direction the right way.
    As far as our electronic health records, you know, I think, 
it's a couple things we need to recognize.
    One is that we deal with information that spans decades 
here. So depending on who you talk to, Sir, and who you engage 
with, you can find yourselves with very different situations.
    I will give you a personal experience. My father was an 
Agent Orange pilot in the Air Force. He's trying to file a 
claim with the VA right now. He has nothing. And so, you know, 
we're trying to work and trying to work with the American 
Legion and some other people to help there.
    But at the same time I could show you a veteran that's 
leaving today and his information is electronically at the VA 
before he ever leaves. I could give you a demo anytime, Sir, in 
your office, wherever you'd like to see it. And we can show you 
where that information is seamlessly flowing.
    So I think it's important that we recognize not all of our 
information that supports those decisions is electronic today. 
But as we get more and more of our population in a fully 
electronic way, we will continue to improve that.
    Senator Daines. Well, I'm pleased to see it's gone from $11 
billion down to $8.7 billion. It's obviously still very much 
real money.
    I guess and I need to wrap up here, but what--how do we 
make sure that we don't run into the same problems with this 
next phase we're going into versus what happened in 2013?
    Mr. Miller. Yes, Sir.
    So on that point I would say, you know, I tell people 
successful programs come down to three things.
    It comes down to the people.
    It comes down to the tools.
    And it comes down to our processes and how we want to use 
these things.
    And so what I tell everybody is with a big program like 
this you have to, kind of, get back to basics.
    We have to make sure we get our requirement right. And 
that's why the Surgeons up here are personally all involved.
    We have to make sure that our people are ready. And that's 
where we engage them. We have to have an effective 
communications and change management programs.
    And we have to make sure the tool is actually working 
correctly and is ready to go.
    And so, we have very much a very aggressive strategy. And 
we have spent a lot of time learning from many failed projects. 
I could go down a list of people we've talked to and learned 
from. I don't want to recreate those. You know, we are trying 
to learn from those as well as some of our previous experiences 
in the DOD with some of our previous efforts there.
    So it takes a concerted effort. There's not a magic recipe. 
But I think it kind of gets down to some basics of good project 
management and running an effective program.
    Senator Daines. Thanks, Mr. Miller.
    Senator Cochran. Thank you, Senator.
    The distinguished Senator from Hawaii, Mr. Schatz.
    Senator Schatz. Thank you, Mr. Chairman.
    Thank you all for your work, for your commitment to public 
health among our servicemembers.
    General Ediger, my question is following up on Senator 
Durbin's line of questioning regarding the $2 billion in 
overbilling for compound pharmaceuticals.
    And something caught my ear that you said. You used the 
word fraudulent. And I'm wondering, it seems to me, it's not 
sufficient for this Committee or for the taxpayer to say that 
this won't happen again.
    If you believe that these were improperly done do we have a 
remedy to recoup some portion of that money spent? Is the IG 
(Inspector General) involved? Is GAO (Government Accountability 
Office) involved? What is our remedy?
    General Ediger. Sir, it's our understanding the Federal 
Bureau of Investigation (FBI) is involved and there have been 
arrests and there have been charges filed. And so, it is being 
handled as a criminal manner in many cases.
    Senator Schatz. Anything to add from the other Surgeons 
General?
    Admiral Faison. That's our understanding as well, Sir.
    When we asked about this, we understood there were dozens 
of fraud investigations going on, being managed with the FBI 
and our own criminal investigative services to both, go after 
these folks and to recoup the money.

                          COMPOUNDING PHARMACY

    General West. And one other comment just to ensure that 
there's vigilance and this doesn't happen again, my 
understanding also is that now there are processes in place 
where if new compounds, because there are always attempts to 
try to get at seams and go around loopholes.
    So they're, actually the pharmacy community, is monitoring 
any new medications that come online and that there seems to be 
a price differential of a certain compound that's within or a 
certain chemical within the compound, they'll actually alert, 
make sure that it's not outside of the normal range of prices 
and then actually, tamp it down before it gets too far out of 
hands.
    So there's multiple layers to try to prevent that from 
happening again.
    Senator Schatz. Thank you.
    And we'll just go down the line starting with General West 
on this question.
    You know, I know you've done a lot of work on 
destigmatization of mental illness and I know that you've done 
a lot of work in terms of staffing up and increasing access. 
And I think those are the two most critical aspects.
    But there is this unique problem, I think, in the military 
concerning readiness and you have to strike the balance in 
terms of encouraging an individual servicemember to avail 
themselves of mental health services but also you've got to 
make hard nose decisions about readiness.

                          MENTAL HEALTH STIGMA

    So take a pilot who says they're experiencing service 
connected anxiety and then the commander officer, wants to 
provide that person with the mental health services they need 
and you don't want to discourage anybody from availing 
themselves to those services. But they know that they may be 
deemed, as a result, not ready.
    And so, I'm wondering, whether you have well-articulated 
policies, if this is, sort of, game time, decision-making at 
the CO level. How do you strike that balance because it seems 
to me, I come from a mental health services background so I 
want to destigmatize mental health as health?
    On the other hand, I know how tough these choices are if 
you're determined--you're determining whether someone is 
actually ready to fight. And so how do you strike that balance?
    General West.
    General West. Sir, thank you for that question. And I think 
it's really important because we invest a lot, quite a bit, to 
train all of our soldiers. And I know my colleagues with their 
various specialties.
    So we want to make sure that we provide care up to the 
point where we don't lose that asset because we say that you 
don't want to conserve. So we will provide whatever treatment 
that's available to ensure that we can keep them in their 
particular MOS (Military Occupational Specialties) because 
they're all valuable members of the team.
    Senator Schatz. But doesn't it go into the servicemember's 
file, sort of, concurrently? In other words, you really are 
running the risk of being, not ready for a promotion, not ready 
to fly.
    Am I misunderstanding how this works?
    General West. Well, there are some--there's policy change 
as far as what people are asked to put on their security 
clearances because that's another thing individuals are 
concerned about; any reporting might get viewed as a way to not 
have them progress to the next level or be considered for 
important jobs.
    But we've changed policy on asking questions on security 
clearance making sure that we don't broaden it too much so we 
miss things that are very concerning but at least people that 
have gotten grief counseling, for example, or things that are 
normal being a human being what you need to do.
    We also have our senior leaders in the Army, I know, and 
there's other services that have actually come forward, put 
public service announcements where they have actually sought 
behavioral healthcare. We've had flag officers, general 
officers, that have done that to help, destigmatize it for 
their----

                        OVERPRESCRIBING OPIOIDS

    Senator Schatz. Thank you.
    And I want to ask one final question in my remaining 
seconds, yes or no, for each of the Surgeons General.
    In your professional opinion are we still currently 
overprescribing opioids, yes or no?
    Admiral Faison. Sir, I don't think we are.
    The investments we've made in other programs, I think, have 
allowed us to get off opioids.
    General Ediger. Sir, I would say not in the direct care 
system.
    Senator Schatz. Right.
    General Ediger. Within our hospitals and clinics I believe 
we are using the full range of options.
    Senator Schatz. General West.
    General West. No, Sir. I do not believe we're 
overprescribing it. We've got other alternative therapies that 
we're using now in adjunct.
    Senator Schatz. Thank you.
    Senator Cochran. Thank you, Senator.
    Let me ask a couple of questions.

                            MEDICAL RESEARCH

    General West, the Committee has consistently recommended 
funding for medical research, for instance in the fiscal year 
2016 Defense Appropriations Bill Congress appropriated more 
than $1.9 billion for medical research, which was a 5 percent 
increase over fiscal year 2015 levels.
    Can you give the Committee any examples of how this medical 
research funding has contributed to breakthroughs or positive 
outcomes that benefit our servicemen and women and society as a 
whole?
    General West. Senator, thank you for that question. And we 
have, I mean, there are a myriad of benefits that have come 
from our research and our team at Fort Detrick that the Senator 
mentioned that have directly contributed in every area.
    One of the ones that we can talk about is regenerative 
medicine, our advances in trauma care, our advances in 
infectious disease research, for example, malaria. We're 
actually participating with our interagency colleagues on 
providing advances in, determining or developing a vaccine for 
the Zika virus which is currently on now. Cancer research, ALS, 
TBI, there are so many.
    Senator, are there any areas that you'd like me to focus on 
that you'd like to hear about, in particular?
    Senator Cochran. We'll submit those for the record.
    General West. Yes, Senator, we'll submit all of those for 
the record.
    [The information follows:]

    Research and development funded by Defense appropriations has made 
a profound impact on healthcare and quality of life for Service-
members, Veterans, and society as a whole. Numerous breakthroughs and 
products have been incorporated into practice and/or improved clinical 
care along the entire spectrum from prevention, detection, diagnosis, 
treatment, and rehabilitation. Examples of prior DOD appropriation 
supported breakthroughs for both injured Service members and the 
general population include advancements in novel diagnostics and 
prognostics, improved treatments and therapies, and better 
rehabilitation strategies.
    In the area of novel diagnostics and prognostics, the Ahead 100/
200 and EYE-SYNC systems offer portable and rapid assessment of 
traumatic brain injury. CareGuideTM, a portable sensor 
system, was developed for detection of internal bleeding. 
OVA1TM is the only Food Drug Administration approved blood 
test to help determine if an ovarian mass is malignant prior to 
surgery.
    We have improved treatments and therapies for a number of diseases. 
Due to DOD-funded research in Prazosin, there is now an evidence-based 
treatment option for combat trauma nightmares and daytime hyperarousal 
symptoms. Symptoms-based treatment with Coenzyme Q10 is successfully 
being used for Veterans with Gulf War Illness. The Elekta Synergy 
system revolutionized image-guided radiotherapy for prostate cancer. 
Additional new drug, device, and immunologic therapeutics are currently 
in clinical trials and advanced development for Amyotrophic Lateral 
Sclerosis, spinal cord injury, wound healing, infectious disease, 
neurofibromatosis, many cancer types, psychological health, and trauma 
care. Standard of care drug treatments were developed for patients with 
breast cancer (Herceptin; Ibrance) and prostate cancer (XGEVA; 
XTANDI; ZYTIGA, VELCADE).
    In the area of rehabilitation, the Embrace Bandage is a wound 
dressing that can significantly reduce scar formation. 
KickstartTM is a novel orthosis device used to improve 
mobility and walking. Force Limiting Auto Grasp is a device to enhance 
prosthetic gripping capability. BrainPort V100/V200 is a non-surgical 
assistive device that provides visual information through sensory 
substitution. Several other products have been incorporated into 
practice or are in advanced development for orthopedic, spinal cord, 
vision, and other traumatic injuries.

    General West. But all the research is, has contributed, not 
only to our readiness, but also to benefit our civilian 
population as well.
    I can give you one example, if you like, on ALS research.
    Some question why do we do ALS research in the military. 
Well, we found that the military members have a 60 percent 
higher rate of having ALS than the civilian population. And the 
research that was conducted in that area actually leads to 
other research for, that's collateral for other areas, 
traumatic brain injury, other neurological advancements.
    So that's just one example of how the research is done in 
our military at MRMC, for example, is transportable to, not 
only our civilian population but also directly related to 
operational readiness of our servicemembers and family members.
    Senator Cochran. Well, we appreciate your leadership in 
these areas.
    General West. Thank you.
    Senator Cochran. Very important.
    General West. Thank you, Sir.
    The distinguished Senator from Alaska, Ms. Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    I apparently came in just at the right time, Chairman, as 
you were speaking about that.

                            MEDICAL RESEARCH

    Major General West, I appreciate you specifically 
highlighting the ALS research and the advancements that have 
been made. This is an issue that I have been greatly interested 
in and focused on. And recognizing that the VA regards ALS as 
presumptively service connected, I think, really make sure that 
there is this focus to better understanding how and why and 
what we deal with it.
    I appreciate the efforts that have been made. Some have 
suggested, wait, we don't see what the connection is here and 
why it should be funded through the Department of Defense. So I 
appreciate you specifically highlighting that.
    Last year this Subcommittee allocated $10 million for the 
ILS--ALS research program that was cut back then to $7.5 
million in the Omnibus. In your judgement are there a 
sufficient number of meaningful research proposals to support 
funding for ALS research in excess of the seven and a half 
million?
    General West. Yes, Senator. There are, right now, there 
have been 35 awards to different institutions to assist with 
research in that, determining if there are genetic biomarkers, 
preclinical development of therapeutics. I mean there is a wide 
range of areas that those research dollars are, could be used 
for.
    Senator Murkowski. Good.
    General West. So there are multiple, very well vetted, to 
make sure they're scientific sound inside the scientific merit 
to ensure that there's use for these funds.
    Senator Murkowski. Good.
    Well I appreciate that and just appreciate what you do 
there. Know that you've got a real advocate in me working to 
try to help advance some better understanding of this just 
horribly insidious disease.
    You know, when we think about the costs that we're putting 
into the research here, it's miniscule in terms of the care for 
the individual as they live and unfortunately die with this 
extraordinarily debilitating disease. And so those that would 
question the costs, I think, need to look to just the full 
brutal impact of this disease and the cost to the individuals 
and their families.
    General West. Yes, Senator.
    Senator Murkowski. Let me switch topics here and it relates 
to Alaska because we always think of Alaska as being that cold 
place. Right now it's not as cold as we would want, but we 
recognize that our soldiers, our men and women, when they 
experience harsh winter environmental conditions such as we 
have in the Arctic that it can be very challenging physically 
and health wise.

                              COLD WEATHER

    What cold weather research efforts would benefit our 
soldiers conducting Arctic operations?
    I'm specifically interested in cold weather research 
efforts from the U.S. Army Research Institute of Environmental 
Medicine.
    I was with several of our military leaders at a social 
event and the discussion was about how in a cold weather 
environment simple tasks like writing a note are almost 
impossible. That pen that you are holding, Vice Admiral, you 
wouldn't be able to get it out of your pocket. You'd have to 
take your gloves off.
    If it's 50 below, holding on to that pen is difficult in 
the first place, much less getting a pen to work in 50 below, 
not that we're talking about the operational capacities of a 
pen. But just recognizing the challenges that present in cold 
weather environments.
    Can you speak to some of the research that's going on?
    General West. Yes, Ma'am.
    And thank you so much for identifying those great 
professionals at the U.S. Army Research Institute for 
Environmental Medicine for what they're doing. Those scientists 
there are world class, world experts, over 120, research 
projects and papers have come out of that, those scientists 
from that unit.
    Some of the projects that they're working on is, just as 
you mentioned, Senator, increasing the blood flow to the 
fingertips, the digits, so you can increase the dexterity and 
decrease the, the lack of it for medics, for example, having 
the fine dexterity of the fingers is very important. And so the 
research is how do we increase blood flow to the digits?
    Also, areas of how do we increase thermal comfort in those 
environments where it's zero degrees by increasing, facial 
warming, forearm warming. So there's several research projects 
that are going on to determine how to mitigate the 
physiological effects of cold weather.
    It also informed the types of cold weather gear that might 
be available to our soldiers and our servicemembers, all of 
them that are asked to serve in those and work in those 
environments.
    So, again, quite a bit of research. And as I mentioned, 
over 120, great information to add to the literature to improve 
that.
    Senator Murkowski. Well, it's vitally important.
    As we look to, again, changes in the Arctic, recognizing 
that in terms of different threats coming at us. Great deal 
more attention being focused on Russia right now. Russia also 
has some very Arctic like conditions and is an Arctic nation as 
well. So recognizing that we need to be more cold weather 
capable and an understanding from a research perspective is 
important.
    I'll just note for the Chairman's edification coming from 
the South here, right now one of the ways that if you're a 
snowmachiner and you want to keep your face from getting 
frostbit and you've got a little gap in your helmet and your 
goggles, not very high tech, but it's duct tape that you put to 
your face. Works, but taking it off afterwards, I don't know.
    [Laughter.]
    Senator Murkowski. So if we can improve on some of these 
technologies, I think that it would be much more comfortable 
for many.
    But thank you for what you do in your various capacities. 
We know that these advancements in research whether it's 
medical research, like finding a cure or a treatment for ALS or 
what we're doing in better understanding dealing with cold 
weather environments. This helps, not only those who are 
serving our country, but everyone, everywhere.
    So we appreciate.
    Thank you, Mr. Chairman, for allowing me to jump in.

                            MEDICAL RESEARCH

    Senator Cochran. Thank you, Senator Murkowski, for your 
leadership on these issues and your contribution to the debate, 
and the providing of needed support for drugs that can be used 
for malaria, for example.
    We understand that some of the research that's being done 
has uncovered problems that were not readily understood, such 
as malaria prevention and treatment. I wonder if the side 
effects of drugs for malaria are limiting their safe and 
effective use in some populations. And if so, what efforts are 
being made by the Department of Defense to develop new and 
safer drugs to reduce side effects?
    General West, is that something you are familiar with?
    General West. Yes, Sir.
    Again, I appreciate the question.
    Our great team at the Medical Research and Material Command 
at Fort Detrick are involved as well as I know there's efforts 
with our other service colleagues on looking for other counter 
measures for vaccines, also for malaria, as well as just the 
traditional, the permethrin impregnated uniforms, the vector 
control and then the other counter measures, with tented nets 
and tentage.
    But there is research on anti-malarial drugs because, as 
you mentioned, the side effects that some cannot tolerate. And 
so we definitely are involved and also with our other nations 
and labs overseas that are collecting the vectors to see how we 
can come up with a different--with additional countermeasures 
and drugs for that.
    Admiral Faison. Yes, Sir.
    Our focus has been very much on vaccine development. We 
have three clinical trials going on right now at our research 
labs. One with sporozoites of falciparum which is the worst 
kind of malaria.
    We're doing clinical trials that's a direct venous 
inoculation.
    We've got another clinical trial that we're doing in 
partnership as a backup.
    And then we just finished clinical trials with the Bill and 
Melinda Gates Foundation to look at malaria vaccines.
    That's the gold standard that we'd like to pursue.
    In parallel we are working very closely with the 
pharmaceutical industry to look at side effect profiles of the 
current drugs that we've got to minimize those.
    Very active efforts right now.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Cochran. Thank you, Admiral and thank you, General. 
We appreciate so much the work of the members of this panel. 
And our Committee is going to continue to pursue information 
that we hope will be helpful in the process.
    Senators are authorized to submit additional questions for 
the record. So we would request that you respond to these 
within a reasonable time.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
          Questions Submitted to Lieutenant General Nadja West
              Questions Submitted by Senator Thad Cochran
               training for military orthopedic surgeons
    Question. How many surgeries do military service members (active 
and retired) and their family members undergo annually?
    Answer. The total number surgical procedures performed for Army 
beneficiaries for fiscal year 2015 was 306,934. Of these, 102,435 were 
orthopedic procedures.
    Question. What is the annual cost to the Military associated with 
these MSK injuries both direct cost (i.e. medical care) and indirect 
cost (i.e. costs associated with disability and separation from 
service)?
    Answer. For fiscal year 2015, the Army had over 48,700 inpatient 
and outpatient orthopedic patient encounters related to musculoskeletal 
injury. These included patient interactions for sprains, strains, joint 
disorders, fractures and dislocation of limbs or hips, as well as, 
surgical procedures, outpatient surgery, and outpatient visits. The 
total Army Defense Health Program costs attributed to musculoskeletal 
injury was $426.8 million in fiscal year 2015. Direct Care costs were 
$145.3 million and Purchased Care costs were $281.5 million.
    Further analysis is required to determine indirect costs for 
musculoskeletal injuries, such as costs associated with disability and 
separation from service. The Army will provide this data as soon as the 
analysis is completed.
    Question. Please provide any additional data that further 
establishes the significant impact that sports related injuries/MSKI 
have on the Department of Defense and its military readiness.
    Answer. MSKI and MSKI-related, chronic musculoskeletal conditions 
greatly impact the Army in terms of Soldier and unit readiness, 
healthcare costs, and attrition. In fiscal year 2014, MSKI-related, 
chronic conditions resulted in 7710 disability discharges, accounting 
for 54 percent of all disability discharges among active duty Soldiers.
            breakthroughs through military medical research
    Question. During the hearing, I asked about breakthroughs that have 
come as a result of military medical research. I let you know to expect 
questions for the record regarding breakthroughs for specific research 
categories. How has military medical research contributed in the 
following areas? Prostate cancer, lung cancer, spinal cord injury, 
multiple sclerosis, and influenza.
    Answer. The military medical research funded through the 
Congressionally Directed Medical Research Programs has provided 
breakthroughs and new knowledge that has changed the practice of 
medicine for both the military beneficiary and civilian healthcare 
communities.
    The Prostate Cancer Clinical Trials Consortium has rapidly advanced 
13 therapeutic candidates to phase-III clinical testing, including 2 
FDA approved drugs, Zytiga and Xtandi, which have become standard of 
care for the treatment of advanced Prostate Cancer.
    The Lung Cancer Research Program established the Detection of Early 
Lung Cancer Among Military Personnel Clinical Consortium, which is 
designed to develop and improve the early detection of lung cancer 
among military personnel, military family members, and Veterans 
believed to be at high risk for developing lung cancer. Two clinical 
studies have been initiated. The first is focused on validating a 
number of airway and blood-based molecular biomarkers that can 
distinguish benign vs. malignant lung diseases among smokers with 
indeterminate pulmonary nodules found on chest Computed Tomography The 
second study is looking at identifying molecular biomarkers of 
preclinical disease and disease risk in minimally invasive and non-
invasive biospecimens to improve lung cancer surveillance in high-risk 
individuals.
    The Spinal Cord Injury Research Program developed a wireless, 
implantable neuroprosthetic device to normalize bladder function after 
spinal cord injury. Funding also supported development and testing in a 
rat model from proof-of-concept to beginning of preclinical testing for 
submission of an Investigational Device Exemption to the FDA. Advanced 
development work is being supported with funding through the Joint 
Warfighter Medical Research Program.
    The Multiple Sclerosis Research Program developed a functional MRI 
method of passively mapping brain function in pediatric study 
participants. The program also developed a promising new technique/tool 
for the clinical setting by combining advanced MRI techniques with high 
resolution PET imaging, and demonstrated that the degree of 
inflammation detected in the cortex of Multiple Sclerosis patients is 
related to neurological disability and impaired cognition.
    Influenza research support in the fiscal year 2014 Peer Reviewed 
Medical Research Program funded a $9.5 million Focused Program Award 
under the Respiratory Health topic area entitled ``Anticipating 
Influenza Resistance Evolution (AIRe): Pathways and Strategies.'' 
Establishment of this program is anticipated to provide technical 
innovations to increase surveillance speed and guidance on the best 
effective treatments for circulating influenza strains and complement 
the DOD's Global Emerging Infectious Surveillance and Response System 
which monitors influenza at 500 sites and 70 countries. Also, the 
military laboratories conduct influenza surveillance in both CONUS and 
OCONUS. These efforts have led to the detection of novel influenza 
strains (e.g., Pandemic H1N1 in 2009) and annually contribute data 
toward the selection of influenza strains for the seasonal influenza 
vaccine formulation. The influenza serology core lab at the Naval 
Medical Research Center supported a Phase 2 clinical trial to evaluate 
the safety and efficacy of high-titer anti-influenza convalescent Fresh 
Frozen Plasma (FFP), which demonstrated impressive reductions in 
morbidity and mortality in patients with severe influenza and initiated 
a Phase 3 trial. Should the Phase 3 study validate earlier results, a 
new indication for FDA-regulated FFP will be sought to allow for the 
rapid production of a low-cost, effective anti-influenza therapeutic 
for severe seasonal and pandemic influenza.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
    Question. Since 2000, there have 177,000 reported incidents of 
PTSD. That is roughly the size of the Marine Corps.We have made a lot 
of progress to help those who are suffering find treatment options that 
work for them. One promising area involves specially trained services 
dogs. Senator Al Franken worked hard to provide the VA funding for 
clinical research. I know the VA is currently conducting research to 
see whether service dogs can provide therapeutic relief to those 
suffering from PTSD. The Defense Health Agency is also researching this 
under the Therapeutic Service Dog Training Program, in part as result 
of interest from this committee.
    Can you offer your medical opinion on what opportunities and 
potential challenges these services dogs could create as we explore 
treatment options for these individuals?
    Answer. The U.S. Army and U.S. Army Medical Command (MEDCOM) 
support the use of evidence based treatment for PTSD and other medical 
conditions. MEDCOM continually explores new technologies, modalities 
and adjunct treatments, including Animal Assisted Therapy and Animal 
Assisted Activities, to determine their value, quality and safety. 
While various initiatives, that include animals, have not yet yielded 
definitive outcome data, the Army remains interested in the impact of 
these animals on the function and well-being of Soldiers and other 
beneficiaries.
    Question. Over the last several years, we have refocused our 
attention on the threat of emerging infectious diseases and the risks 
that they pose to public health. Men and women in the military often 
find themselves in these hot zones where emerging infectious diseases 
are endemic. In the Asia Pacific, for example, malaria, dengue, TB, and 
other emerging infectious diseases pose a risk to our soldiers, 
sailors, airmen, and Marines in the region, whether they are stationed 
there or are supporting theatre security cooperation exercises. And 
while we can protect them from some of these diseases, some of the 
diseases we cannot--at least not yet.
    What are we doing to reduce the risk that service members face from 
diseases where there are no vaccines or other protections?
    Answer. The Army continues to invest in the surveillance, research 
and development of emerging infectious diseases across the globe. The 
military collects and scientifically characterizes these infectious 
agents, screens for potential available treatments and studies new 
approaches for prevention or treatment.
    The Army ensures deployed units issue and monitor the use of 
Personal Protective Equipment, such as, sleeping under bednets, use of 
appropriate repellents, and wear of deet impregnated uniforms. The Army 
also emphasizes the use of available prophylactic drugs (antimalarial 
drugs).
    Question. How is DOD aligning its research efforts to address the 
threat of emerging infectious diseases in high risk areas where our 
service members are exposed?
    Answer. The DOD responds to emerging infectious disease threats 
through focused research, innovative partnerships, and a worldwide 
network of laboratories and field sites. Critical capabilities 
includes: global lab infrastructure; history of world-class infectious 
disease research within Army & Navy CONUS and OCONUS laboratories (i.e. 
Thailand, Kenya, Georgia, Peru, Egypt, and East Africa); partnerships 
with other Federal agencies, academia, non-governmental organizations, 
industry and foreign Governments which leverage collaborative science 
and funding; clinical trial sites for testing drugs, vaccines, 
diagnostic devices and vector control products (insecticides, 
repellents) in endemic disease areas; and collection and analysis of 
epidemiological data for threat assessment and development of disease 
control strategies
    These relationships leverage resources for continued development of 
endemic infectious disease treatments, preventive drugs, vaccines, 
vector control, and diagnostic tools essential to preserving the 
readiness of the force and protecting populations globally.
    Question. It seems to me this is an area [the threat of emerging 
infectious] where we share some common interests with partners, allies, 
and even some countries we might not consider too friendly.
    Are we working with our partners, allies and others to streamline 
our research efforts so that we are not duplicating research efforts?
    Answer. The U.S. Army Medical Research and Materiel Command and the 
Naval Medical Research Command have a decades long legacy of military 
to military cooperation in several overseas military medical research 
laboratories which have a primary focus on infectious disease research.
    In addition to overseas laboratories, the medical research 
community also has ongoing information exchange agreements and 
scientist exchange programs with eleven allied governments. These 
agreements enable research and development cooperation and information 
sharing. They also provide opportunities for allied scientists to work 
in our laboratories and for our scientists to participate in allied 
government research.
    In particular, the Army has very strong relationships with years of 
cooperation with the United Kingdom (UK), France, South Korea and 
Israel. We have engaged for 45 years with annual meetings and 
information exchange with the Korean military. We have a strong 
collaborative relationship with Israel and have participated since 1988 
in the bi-annual Shoresh conference. We are working on product 
development with France. We also participate in a US-UK Task Force.
                                 ______
                                 
       Questions Submitted to Vice Admiral C. Forrest Faison III
              Questions Submitted by Senator Thad Cochran
               training for military orthopedic surgeons
    Question. Lieutenant General West stated in her written testimony 
stated, more than 57,000 Soldiers across all Components [of the Army] 
were medically non-deployable as of January 31,2016. In the Active 
Component alone, 29,800 were medically non-deployable, equivalent to 
approximately 6.5 Brigade Combat Teams worth of soldiers . . . 
.Seventy-six percent of the non-deployable Soldiers have a related 
musculoskeletal injury (MSKI). Many MSKI are preventable; 80 percent 
are the result of physical training overuse and sports related 
injuries.''
    Do the other branches have similar ``non-deployable'' rates, 
especially within similar Component forces within the Marine Corps, the 
Navy and Air Force?
    Answer. Just over 10,000, or approximately 2.9 percent, of active 
duty Sailors are considered medically non-deployable. Navy is not 
tracking specific diagnoses associated with Sailors who are medically 
non-deployable, nor have we engaged in a study of this sort to date. 
Consequently, we are unable to ascertain the number of Sailors on 
Limited Duty associated with musculoskeletal injury (MSKI).
    Approximately 964, or 0.4 percent, of Marines across all components 
are currently categorized as medically non-deployable; 705, of which 
are active-duty Marines--less than 0.4 percent. The USMC does not track 
specific diagnoses associated with these Marines to identify those 
affected by musculoskeletal injuries (MSKI), nor are we engaged in a 
study of such to date.
    Question. What are the specific numbers for the Navy (and its 
Marine Corps Component) and the Air Force on these types of injuries?
    Answer. At the headquarters level, the Navy is not tracking 
specific diagnoses associated with Sailors who are medically non-
deployable. These are tracked and managed locally. The Navy has funded 
development of an information system to provide enterprise views of 
these in the future.
    Question. How many surgeries do military service members (active 
and retired) and their family members undergo annually?
    Answer. Navy/USMC (active and retired) personnel had 278,455 
surgeries related to musculoskeletal diagnoses in fiscal year 2015. The 
breakdown of the cases is as follows:
  --Navy/USMC personnel (active and retired) and their family members 
        had 31,455 surgeries performed, requiring inpatient stays in 
        fiscal year 2015 due to musculoskeletal diagnoses inclusive of 
        both MTF and network care.
  --Navy/USMC (active and retired) personnel and their families had 
        247,000 surgeries performed as ambulatory outpatient procedures 
        in fiscal year 2015 due to musculoskeletal diagnoses inclusive 
        of both MTF and network care.
  --Retirees over 65 often receive care outside of the MHS, using 
        solely their Medicare benefit; this would not be included in 
        the numbers above.
    Question. What is the annual cost to the Military associated with 
these MSK injuries both direct cost (i.e. medical care) and indirect 
cost (i.e. costs associated with disability and separation from 
service)?
    Answer. Direct Medical Cost.--Data represents a Full Cost burden 
(unit costs based on respective FYMedical Expense stepdown (MEPRS 
expenses)). The Navy/USMC incurred $1.18 billion in costs for care due 
to musculoskeletal (MSK) diagnoses in fiscal year 2015. Of that amount, 
$394 million was for services provided to Active Duty members.
    Indirect Costs.--We do not have an estimate of the indirect costs 
associated with MSK injuries. The myriad assumptions and variables 
associated with such a complex calculation would require extensive 
study, analysis, and coordination with the VA.
    Question. Please provide any additional data that further 
establishes the significant impact that sports related injuries/MSKI 
have on the Department of Defense and its military readiness.
    Answer. Not all musculoskeletal injuries (MSKI) are sports related. 
The active physical nature of readiness training can also, even when 
done correctly, cause MSKI. The impact of sports related/MSKI on the 
DOD and on military readiness in particular, is well recognized by Navy 
Medicine; however, we do not have any additional data to provide at 
this time.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
    Question. Since 2000, there have 177,000 reported incidents of 
PTSD. That is roughly the size of the Marine Corps.We have made a lot 
of progress to help those who are suffering find treatment options that 
work for them. One promising area involves specially trained services 
dogs. Senator Al Franken worked hard to provide the VA funding for 
clinical research. I know the VA is currently conducting research to 
see whether service dogs can provide therapeutic relief to those 
suffering from PTSD. The Defense Health Agency is also researching this 
under the Therapeutic Service Dog Training Program, in part as result 
of interest from this committee.
    Can you offer your medical opinion on what opportunities and 
potential challenges these services dogs could create as we explore 
treatment options for these individuals?
    Answer. As Senator Schatz noted, there are currently efforts 
underway at the VA and DHA to determine what type of role, if any, 
service dogs have in the treatment of individuals suffering with mental 
health conditions, including PTSD. There are two ways in which animals 
may play a part: as service animals, which are specially trained and 
assigned to individuals in order to perform tasks that the individuals 
are unable to do due to disability; and animal-assisted therapy (AAT), 
where a provider harnesses the human-animal interaction in order to 
further an individual's therapeutic goals.
    At this point, there is still no definitive scientific evidence or 
large studies that service dogs in any scenario provide benefit to 
those experiencing PTSD. There are plenty of self-reports that 
companion animals/service dogs decrease anxiety, but this is anecdotal. 
Also, in contrast to a service animal for a mobility- or sight-impaired 
individual, the service animal for someone with a mental health 
diagnosis is not performing specific tasks for the individual, but 
providing a soothing presence (as they do for most people whether or 
not they have mental health conditions)--but the goal of treatment is 
to provide the patient with tools to be able to self-soothe and manage 
their anxiety or other symptoms. Additionally, there have been 
situations where individuals will obtain an animal from an unknown 
source, have the animal certified over the Internet by a suspect 
organization, and then bring the animal into the barracks/clinic/
hospital, causing significant disruptions to those in the area.
    There is limited literature regarding Animal Assisted Therapy in 
the treatment of PTSD, but there is some evidence it has benefit as 
adjunct therapy. The limited literature focuses on child sexual abuse 
with no robust studies addressing military related PTSD due to combat.
    DODI 1300.27 is the instruction governing service animals, but 
primarily pertains to the logistical issues of having the animal-- 
specific conditions (other than generic mention of ``physical or mental 
disability'').
    In summary, we are in favor of further study particularly for 
Animal Assisted Therapy for PTSD. However, we recommend caution when 
considering policy and implementation in the absence of evidence that 
this is an effective intervention/treatment, particularly given the 
logistical issues with supporting the presence of animals in military 
facilities.
    Question. Over the last several years, we have refocused our 
attention on the threat of emerging infectious diseases and the risks 
that they pose to public health. Men and women in the military often 
find themselves in these hot zones where emerging infectious diseases 
are endemic. In the Asia Pacific, for example, malaria, dengue, TB, and 
other emerging infectious diseases pose a risk to our soldiers, 
sailors, airmen, and Marines in the region, whether they are stationed 
there or are supporting theatre security cooperation exercises. And 
while we can protect them from some of these diseases, some of the 
diseases we cannot--at least not yet.
    What are we doing to reduce the risk that service members face from 
diseases where there are no vaccines or other protections?
    Answer. The Naval Medical Research and Development (NMR&D) 
Enterprise CONUS and OCONUS laboratories work with partners around the 
world to enhance detection of emerging infectious disease threats and 
bio-surveillance capabilities in an effort to quantify infectious 
diseases risks to operational forces deployed to a given area. To 
protect personnel determined to be at risk for mosquito and tick borne 
diseases where no vaccines exist, we emphasize the use of 
countermeasures such as the use of prophylactic medications (for 
malaria) and personal protective measures including insect repellents 
and bed nets and we make it a leadership responsibility to ensure 
compliance with those measures.
    For more traditional protective countermeasures, our emerging 
infectious disease research efforts to protect the warfighter focus 
mostly on developing vaccines for malaria, dengue fever, and causes of 
enteric diseases such as viral and bacterial diarrhea.
    Question. How is DOD aligning its research efforts to address the 
threat of emerging infectious diseases in high risk areas where our 
service members are exposed?
    Answer. The diverse capabilities and geographical distribution of 
the eight NMR&D laboratories reflect the broad mission and vision of 
the Navy Medicine R&D Enterprise. On any given day, researchers at our 
OCONUS labs are working in collaboration with host national governments 
to assess and address the threat of emerging infectious diseases 
globally. NMRC researchers, with other DOD and interagency 
collaborators, are advancing efforts towards the development of a 
malaria vaccine as well as developing measures to counter transmission 
and drug resistance for comprehensive malaria elimination.
    Navy investigators at the OCONUS labs use state-of-the art 
diagnostics to assess the threat of infectious diseases including Zika 
virus, Middle East Respiratory Syndrome Coronavirus (MERS CoV), Ebola 
Virus Disease (EVD) and Chikungunya virus.
    Additionally, collaborative work is being conducted in our CONUS 
labs with industry to develop medical countermeasures, including 
antibody-based products that can be used for prevention and therapy 
against these infectious agents.
    Question. It seems to me this is an area [the threat of emerging 
infectious] where we share some common interests with partners, allies, 
and even some countries we might not consider too friendly.
    Are we working with our partners, allies and others to streamline 
our research efforts so that we are not duplicating research efforts?
    Answer. Our global presence requires close collaboration across the 
DOD, USG, industry and academia. Navy and Army scientists work closely 
together to develop vaccines and other countermeasures for emerging 
infectious diseases. Many of our research projects are conducted in 
close collaboration with other USG agencies, industry, and universities 
and involve the pooling of scientific information and resources. This 
collaborative research approach greatly fosters our ability to 
efficiently and effectively meet infectious diseases research goals and 
maximizes opportunities for sharing of data, tools, and methodologies 
with little risk of duplication of effort.
                                 ______
                                 
        Questions Submitted to Lieutenant General Mark A. Ediger
              Questions Submitted by Senator Thad Cochran
               training for military orthopedic surgeons
    Question. Lieutenant General West stated in her written testimony 
stated, more than 57,000 Soldiers across all Components [of the Army] 
were medically non-deployable as of January 31,2016. In the Active 
Component alone, 29,800 were medically non-deployable, equivalent to 
approximately 6.5 Brigade Combat Teams worth of soldiers . . . 
.Seventy-six percent of the non-deployable Soldiers have a related 
musculoskeletal injury (MSKI). Many MSKI are preventable; 80 percent 
are the result of physical training overuse and sports related 
injuries.''
    Do the other branches have similar ``non-deployable'' rates, 
especially within similar Component forces within the Marine Corps, the 
Navy and Air Force?
    Answer. As of March 22, 2016, 27,399 Air Force Active Duty, 8,102 
Air Guard, and 5,423 Air Reserve Service members are not medically 
qualified for worldwide deployment. These numbers include all personnel 
who are not worldwide qualified due to pregnancy, chronic illness, 
acute illness, and injuries in accordance with Department of Defense 
Instruction 6490.07, Deployment-Limiting Medical Conditions for Service 
Members and DOD Civilian Employees.
    Historically, Air Force Total Force medically non-deployable rates 
have typically ranged between 6 and 10 percent at any one time.
    Question. What are the specific numbers for the Navy (and its 
Marine Corps Component) and the Air Force on these types of injuries?
    Answer. In fiscal year 2015, 4,684 Air Force Total Force members 
suffered injuries or had musculoskeletal damage significant enough to 
warrant surgical intervention. This number reflects all Air Force 
members, including Active Duty, Guard, and Reserve. Factoring in 
service members' family members, retirees, and retiree family members, 
this number increases to 24,337. Please see the table below for 
additional historical data. Note that this does not include surgical 
cases performed by AF orthopedic surgeons at partnership institutions 
such as Level 1 trauma centers or while deployed.

----------------------------------------------------------------------------------------------------------------
                             Persons                                   2013            2014            2015
----------------------------------------------------------------------------------------------------------------
Active Duty Family Members......................................           2,542           2,546           2,483
Active Duty Service Members.....................................           5,071           4,767           4,684
Retiree.........................................................           6,593           6,303           6,230
Retiree Family Member/Other.....................................          11,682          11,166          10,940
    Sum.........................................................          25,888          24,782          24,337
----------------------------------------------------------------------------------------------------------------

    Question. How many surgeries do military service members (active 
and retired) and their family members undergo annually?
    Answer. In fiscal year 2015, there were 26,183 inpatient and 
outpatient orthopedic surgeries on 24,337 people identified as Air 
Force (either active duty, retired, or their family members). This care 
occurred in the direct care system (in one of the three Services' 
military treatment facilities) or in the network.

----------------------------------------------------------------------------------------------------------------
                            Surgeries                                  2013            2014            2015
----------------------------------------------------------------------------------------------------------------
Active Duty Family Members......................................           2,740           2,782           2,654
Active Duty Service Members.....................................           5,471           5,169           5,071
Retiree.........................................................           7,023           6,708           6,654
Retiree Family Member/Other.....................................          12,633          12,052          11,804
    Sum.........................................................          27,867          26,711          26,183
----------------------------------------------------------------------------------------------------------------

    Question. What is the annual cost to the Military associated with 
these MSK injuries both direct cost (i.e., medical care) and indirect 
cost (i.e., costs associated with disability and separation from 
service)?
    Answer. In fiscal year 2015, the approximate cost to the government 
for the approximately 26,000 surgeries was $117.5 million. These 
surgeries were either completed on an inpatient or outpatient basis on 
people identified as Air Force (either active duty, retired, or their 
family members). This care occurred in the direct care system (in one 
of the three Service's military treatment facilities) or in the 
network.

----------------------------------------------------------------------------------------------------------------
                              Cost                                     2013            2014            2015
----------------------------------------------------------------------------------------------------------------
Active Duty Family Members......................................      $9,282,009      $9,849,105      $9,905,931
Active Duty Service Members.....................................      24,721,701      24,332,035      24,655,677
Retiree.........................................................      32,201,997      31,284,663      31,238,969
Retiree Family Member/Other.....................................      53,839,377      52,372,288      51,682,002
    Sum.........................................................    $120,045,084    $117,838,091    $117,482,579
----------------------------------------------------------------------------------------------------------------

    Question. Please provide any additional data that further 
establishes the significant impact that sports related injuries/MSKI 
have on the Department of Defense and its military readiness.
    Answer. Military members work in demanding conditions requiring a 
high level of musculoskeletal performance while facing numerous threats 
of injury. Consider a special operations unit with dozens of service 
members each carrying a heavy rucksack over uneven mountainous terrain 
in Afghanistan. Next, visualize a fighter pilot who is experiencing 
nine times the force of gravity while wearing a heavy helmet and 
turning her neck to check her six o'clock position. Military members 
are well trained and remarkably capable of enduring unique 
biomechanical stresses, but it should not come as a surprise that 
musculoskeletal injuries are common in the face of these and other 
demanding environments. In fact, by almost any measure, musculoskeletal 
injuries are highly relevant for military readiness within the 
Department of Defense.
    According to data published by the Armed Forces Health Surveillance 
Center, counting only injuries occurring at a specified site to the 
upper and lower extremities, there were still over 1.7 million medical 
encounters and over 13,000 inpatient bed days for the Armed Forces in 
2014. Excluding musculoskeletal back pain, rheumatoid arthritis, and 
osteoarthritis, the other non-injury musculoskeletal disorders 
comprised another 700,000 medical encounters and approximately 10,000 
inpatient bed days from knee, shoulder and other musculoskeletal 
disorders. Over one-third of all lost work time from any medical cause 
was attributable to the two broad categories containing injuries and 
non-injury musculoskeletal disorders. When specified by site, knee, 
foot/ankle and arm/shoulder injuries each accounted for about 5 percent 
of all lost work time from any medical cause in 2014, which means 
injuries at each of these three anatomical sites accounted for about 
50,000 lost work days (or 150,000 work days combined) in 2014.
    Musculoskeletal injuries play a large role in numerous operational 
military environments, including the deployed environment, the flight 
environment, and the military training environment. A window into the 
deployed environment can be seen with the overall causes of medical 
evacuation as well as smaller unit level assessments. Here again, the 
leading broad categories of medical diagnoses causing evacuation are 
highly relevant. Specifically, from October 2001 to December 2012 there 
were over 12,000 evacuations from Afghanistan for battle injury, non-
battle injury, and other musculoskeletal diagnoses. These three 
categories were the three leading causes of evacuation. The same 
pattern existed in Iraq, where from October 2001 to September 2010, 
there were over 7,000 evacuations from these three leading causes. 
Smaller scale evaluation can provide more a more granular look at the 
nature of injuries. One study of a single Army Brigade Combat Team 
showed there were incident rates of 15.3 ankle sprains, 3.3 anterior 
cruciate ligament ruptures, and 1.2 shoulder dislocations per 1,000 
soldiers deployed for 1 year, and that musculoskeletal injuries 
accounted for over 50 percent of non-battle casualties. The flight 
environment is also crucial for military operations. According to the 
Human Performance Resource Center, about 85 percent of aircrew and 
pilots serving on helicopters report back, neck, and leg pain that they 
find is related to the flight environment.
    Likewise, injuries occurring during training operations are also 
important for maintaining readiness as these injuries can clog the flow 
of the trainee population through a pipeline. The Accession Medical 
Standards Analysis and Research Activity (AMSARA) evaluated injuries 
during the first year of training among non-prior service Army recruits 
and found over 30 percent had a pain related injury, about 18 percent 
had other diagnoses of sprains and strains, and about 3 percent had 
stress fractures.
    In summary, there is a significant impact of sports related 
injuries and other musculoskeletal injuries with the Department of 
Defense.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
    Question. Since 2000, there have 177,000 reported incidents of 
PTSD. That is roughly the size of the Marine Corps. We have made a lot 
of progress to help those who are suffering find treatment options that 
work for them. One promising area involves specially trained services 
dogs. Senator Al Franken worked hard to provide the VA funding for 
clinical research. I know the VA is currently conducting research to 
see whether service dogs can provide therapeutic relief to those 
suffering from PTSD. The Defense Health Agency is also researching this 
under the Therapeutic Service Dog Training Program, in part as result 
of interest from this committee.
    Can you offer your medical opinion on what opportunities and 
potential challenges these services dogs could create as we explore 
treatment options for these individuals?
    Answer. While there is limited research in this area, the research 
has shown that therapy dogs may be beneficial as an adjunctive 
treatment for PTSD and offers an opportunity for low cost and low side 
effect intervention. These specially trained dogs may help patients 
lower their autonomic arousal, increase social engagement, and improve 
their level of physical activity which is consistent with the desired 
outcomes for PTSD treatment. However, despite these positive findings, 
there are a number of challenges associated with utilizing therapy dogs 
in a military environment most notably, the impact of animals in the 
operational work environment. In addition, symptoms indicative of the 
need for a therapy dog would likely affect active duty member world-
wide qualifications and may warrant a medical evaluation board, thus 
this therapy option appears more appropriate for those receiving 
service through the Veterans Administration. The Air Force is committed 
to considering all techniques that demonstrate reliable improvement in 
patient functioning in general and PTSD symptoms in particular.
    Question. Over the last several years, we have refocused our 
attention on the threat of emerging infectious diseases and the risks 
that they pose to public health. Men and women in the military often 
find themselves in these hot zones where emerging infectious diseases 
are endemic. In the Asia Pacific, for example, malaria, dengue, TB, and 
other emerging infectious diseases pose a risk to our soldiers, 
sailors, airmen, and Marines in the region, whether they are stationed 
there or are supporting theatre security cooperation exercises. And 
while we can protect them from some of these diseases, some of the 
diseases we cannot--at least not yet.
    What are we doing to reduce the risk that service member's face 
from diseases where there are no vaccines or other protections?
    Answer. Multiple force health protection measures are available to 
commanders to protect Service members against endemic diseases in 
overseas locations, even if vaccines, chemoprophylaxis (such as anti-
malarial medications), or other specific medical countermeasures are 
not available.
    Most force health protection measures are instituted at the command 
level with medical and line personnel support. These measures are 
diverse and significantly reduce Service members' risk of endemic 
disease. They include use of personal protective equipment; enforcement 
of proper field sanitation; appropriate handwashing protocols; 
provision of approved food and water sources exclusively and 
restriction of food and water consumption on the local economy (unless 
not feasible due to mission constraints); restricting contact with 
local animals; and provision and enforcement of integrated pest 
management and pest control measures against disease-carrying insects, 
rodents, and feral animals, including environmental measures to reduce 
harborage or breeding areas for such pests.
    Service members traveling into areas with a threat of insect-borne 
diseases are briefed on the disease threat and steps they can take to 
protect themselves at an individual level. The Air Force endorses the 
Department of Defense guidance for using personal protective measures 
to prevent insect bites. This guidance, uses several simple methods, 
that when combined, provide maximum protection from insect bites. 
Methods include wearing insect repellent treated uniforms, using insect 
repellent such as DEET on exposed skin, and wearing the uniform loosely 
and with the sleeves covering the arms and the pants tucked into the 
boots. Service members should also sleep inside bed nets when insect-
borne diseases are a threat. This is not typically a requirement when 
Service members are sleeping in hardened facilities with fitted doors, 
windows, and temperature control allowing them to sleep with the doors 
and windows closed.
                                 ______
                                 
                Questions Submitted to Mr. Chris Miller
              Questions Submitted by Senator Thad Cochran
                          compounding pharmacy
    Question. It is my understanding that Walter Reed National Military 
Medical Center is pursuing a safety and efficacy study entitled 
``Efficacy Study Comparing Compounded Topical Pain Creams vs Placebo 
for Treating Pain Symptoms.''
    What is the current status of this study?
    Answer. The study is ongoing at the Walter Reed National Military 
Medical Center.
    Question. When is it expected to be completed?
    Answer. Undetermined, the original expected duration is 30 months 
from June 2015.
    Question. Once this study is completed, how does the DHA intend to 
utilize these results to inform TRICARE policy on compounded 
treatments?
    Answer. The DHA evaluates the comparative clinical and cost-
effectiveness of products based on available literature for 
incorporation into existing prior authorization policies, as 
appropriate.
    Question. What is the latest monthly expenditure for compounds 
within the DOD?
    Answer. $3.2 million per month (all compounds) billed under the 
pharmacy benefit.
    Question. What is the total dollar amount for compounds made 
specifically for pain management?
    Answer. The DHA does not receive diagnosis information on compound 
claims and the total dollar amount for pain compounds is unknown.
    Question. To be credentialed by the National Association Boards of 
Pharmacy (NABP), pharmacies must prove during an ``unannounced 
inspection'' that day-to-day operations meet the most up-to-date 
standards and policies for safety in compounding.
    Has DHA considered partnering with pharmacies credentialed by the 
National Association Boards of Pharmacy (NABP) as DHA continues to 
evaluate compounding?
    Answer. The DHA has worked closely with Express Scripts, who is 
responsible for developing and maintaining the retail pharmacy network. 
What the NABP makes available is an inspection program for pharmacies 
to assist them in license renewal, especially if the pharmacy serves 
other States and is required to hold multiple licenses. It is not an 
accreditation program. Also, the NABP does not publish or provide a 
list of pharmacies that participate in the program. Although NABP 
certification implies safe day-to-day operations, it does not validate 
safety and efficacy of the compounded product in combinations and 
routes of administration that have not been clinically proven in a 
peer-reviewed nationally recognized study. The DHA's Prior 
Authorization process allows physicians the opportunity to present 
clinical justification for the use of the compound.
    Question. What other ideas or strategic approaches have been 
considered by DHA to identify and partner with the ``good actors'' 
within the compounding industry?
    Answer. The DHA has interviewed multiple third parties on various 
approaches to dealing with the complexities and potential fraud now 
occurring in the compound space. The DHA has worked closely with 
Express Scripts, who is responsible for developing and maintaining the 
retail pharmacy network. The resulting strategy has not only ensured 
that legitimate compound prescriptions are filled, but also has 
restored compound spending to historic norms.
                                 ______
                                 
               Question Submitted by Senator Jerry Moran
    Question. Will the administration's proposal to transform Tricare 
Prime and Standard into Tricare Select and Tricare Choice have any 
effect on the timeline for implementing T2017? Will the transformation 
require a modification to the contract, and if so, does DOD have an 
estimate on the additional cost or savings this modification may 
provide?
    Answer. Yes, the administration's proposal to transform Tricare 
Prime and Standard into Tricare Select and Tricare Choice would have an 
impact on the timeline to implement T-2017. The timeline would be 
impacted because requirements associated with the implementation of 
TRICARE Select and TRICARE Choice must be developed to incorporate into 
the contract. Once the requirements are developed, they will need to be 
incorporated into the T-2017 contracts, requiring contract 
modifications. Thus implementation Tricare Select and Tricare Choice 
would require a delay in implementation of T-2017.
    DOD has not conducted a cost analysis to determine the cost or 
savings impact of modifying the T-2017 contract to implement the 
TRICARE Select and TRICARE Choice options.
                                 ______
                                 
               Question Submitted by Senator Brian Schatz
    Question. Mr. Miller, DOD is working to improve the 
interoperability of its electronic health record with the VA. We've 
been hoping for progress, but the GAO testified last fall that the VA 
and DOD are not on track to complete the modernization of their 
electronic health record systems with interoperable capabilities until 
after 2018.On Maui, the Pacific Joint Information Technology Center has 
untapped potential to support DOD's interoperability mission. The 
Pacific JITC actually created the Joint Legacy Viewer that has allowed 
the DOD and VA to share read-only electronic health records.
    Given its demonstrated success in this space, would you consider 
using the Pacific JITC for pilot demonstrations as DOD works toward 
full interoperability of its electronic health record with the VA?
    Answer. We recognize that Pacific JITC contributed success stories 
to the Military Health System over the past 15 years; however, the 
Department continues to identify areas in which to streamline and 
achieve economies of scale in order to continue operations under 
existing fiscal constraints. As part of these efforts, the Defense 
Health Technology Review (DHTR) Team was established to identify 
opportunities for efficiencies and savings through standardization and 
consolidation while meeting the needs of the MHS and improving the tie 
between IT investments and mission outcomes.
    As part of this review the Department plans to stand down Pacific 
JITC in fiscal year 2017. Health Information technology (IT) research 
will continue to be executed by the Department's Joint Program 
Committee 1 (JPC-1), through the U.S. Army Medical Research and 
Materiel Command, Telemedicine and Advanced Technology Research Center 
(TATRC) and other DOD research facilities.

                          SUBCOMMITTEE RECESS

    Senator Cochran. The Subcommittee will reconvene on 
Wednesday, March 16 at 10:30 a.m. to receive testimony from the 
National Guard and Reserve leadership.
    Until then, the Subcommittee stands in recess.
    Thank you.
    [Whereupon, at 11:47 a.m., Wednesday, March 9, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]