[Senate Hearing 117-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2022
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TUESDAY, APRIL 20, 2021
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 9:31 a.m. in room SD-192, Dirksen
Office Building, Hon. Jon Tester (chairman) presiding.
Present: Senators Tester, Baldwin, Shelby, and Boozman
DEPARTMENT OF DEFENSE
Defense Health Program
STATEMENT OF DR. TERRY ADIRIM, ACTING ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
opening statement of senator jon tester
Senator Tester. I am going to call this committee meeting
to order. I want to welcome Dr. Adirim, General Dingle, General
Hogg, Admiral Gillingham for your testimony here today and
especially for your service to this country. Thank you all.
Nearly 9.5 million Americans from private to general, from
servicemember to spouse, from recruit to retiree depend on you
for healthcare services that you oversee. Your job is a
difficult one because so many people are depending on you to
have the right medical professionals, and the right treatment
at the right time because their lives count on it.
Over the last few years, the Department of Defense and
Congress have made significant investments in our military's
readiness, but there is no readiness issue more important than
continuing to ensure the physical and mental health of the
force.
Like our witnesses, this subcommittee is committed to doing
our part to ensure that the military force we have is as
healthy as possible. This means meeting the medical needs of
servicemembers and their families at home and abroad.
This challenge is even more important as we are dealing
with a global pandemic. I would like to know more about how the
DOD is dealing with COVID, both in the terms of impact to
troops and their families and whether the military healthcare
system is adequately funded for this emergency.
Once again, I want to thank you for your service and for
your work to better the lives of our personnel entrusted to
your care. It is an essential part of maintaining a ready
force, and I look forward to your testimony.
Senator Shelby.
statement of senator richard c. shelby
Senator Shelby. Thank you, Mr. Chairman. Thank you for
holding this hearing.
I want to, like you, welcome our witnesses today, and I
want to thank them for being here today to review the Defense
Health Program.
The pandemic has tested our military and its health system
profoundly, and I would like to applaud the Defense Health
Program's work and achievements during this extremely trying
time.
Our warfighters, I believe, are our greatest defense asset,
and their readiness and capabilities depend on a strong and
sustainable military healthcare system. Our military's health
system is responsible for providing care to 9.5 million
servicemembers and their beneficiaries who deserve the best
quality of care that we can provide.
In order to guarantee that standard, Mr. Chairman, we must
ensure that the system is appropriately resourced, something
this committee has prioritized. The military health system has
undergone substantial transformation over the last several
years, and I look forward to hearing about the challenges each
of you have faced in this transition and how you have worked
together to overcome them.
In addition to providing healthcare, our military's health
system also conducts medical research on a wide variety of
topics such as cancer, infectious diseases, traumatic brain
injury, and burn research, just to name a few. Funding for
these important research efforts has grown from $210 million in
1992 to nearly $1.5 billion last year. That is a substantial
investment and I believe one that does not take into account
the billions of dollars that we also provide annually to the
National Institutes of Health to conduct research in many of
the same areas.
What is more, the President's budget request proposes to
create the Advanced Research Projects Agency for Health at NIH
(National Institutes of Health). This new $6.5 billion
federally funded research agency will focus on cancer research
and other diseases such as diabetes and Alzheimer's. With all
this seeming duplication of research dollars, I question at
times whether DOD's (Department of Defense) medical research
investments are truly focused on addressing our warfighters'
health and readiness concerns or simply investing in scarce
defense resources and medical research that is also underway at
NIH.
So, while we can all agree that this research is necessary,
I hope our witnesses can provide a clear explanation regarding
defense medical research dollars, what they are doing that NIH
funding cannot or is not doing. In other words, is there
duplication here, and if so, how do we get away from it?
Thank you for holding this hearing, Mr. Chairman.
Senator Tester. Thank you, Senator Shelby.
Now we will go to opening statements. I would ask that each
of you limit your opening statement to 5 minutes each. Your
entire written statement will be put in the record, and we will
start with you, Dr. Adirim. You have the floor.
summary statement of dr. terry adirim
Dr. Adirim. Good morning. Chairman Tester, Vice Chairman
Shelby, distinguished members of the subcommittee, I am honored
to represent the military and civilian medical professionals in
the Military Health System who are serving around the world and
here at home, delivering healthcare in support of our 9.6
million beneficiaries as well as support to millions of
Americans throughout the United States.
My testimony will provide the subcommittee with information
on major activities that will inform our budget proposal for
the coming fiscal year. The most significant issue looming over
all of our projections is the national response to the COVID-19
pandemic.
Secretary Austin has made clear that the greatest proximate
challenge to our Nation's security is the threat of COVID-19.
The Department has, and will continue to, act boldly and
quickly to support Federal Government efforts to defeat this
disease.
My written testimony provides a comprehensive review of the
critical health support the Military Health System is providing
worldwide in support of our primary mission and as part of the
whole-of-government response to the COVID crisis.
We remain deeply appreciative of the fiscal year 2020
supplemental appropriation of $2.2 billion as part of the CARES
Act that covered the significant costs incurred during the
initial months of the response.
In fiscal year 2021, however, costs attributable to the
pandemic continue to accumulate. As of March 31, 2021, our
midyear review of the Defense Health Program identified likely
shortfalls as part of the ongoing pandemic response projected
at over $1.8 billion, $1 billion of which is private-sector
costs.
In addition, the financial impact of our military support
to the FEMA (Federal Emergency Management Agency) missions,
which remains ongoing, are still being assessed. We are working
within the Department to try and mitigate these shortfalls that
are challenging.
The Department continues to focus on internal business
process improvements to find greater efficiencies and remains
vigilant about variation in year-to-year expenditures. We are
appreciative that Congress continues to grant the Department
carryover authority each year. We are also grateful for this
committee's long-term advocacy and support for our military
medical research program. Military medical research advances
the state of medical science in those areas of most pressing
need and relevance to today's emerging threats, which includes
the COVID pandemic.
When released, our fiscal year 2022 budget will present a
balanced, comprehensive strategy that aligns with the
Secretary's priorities to include the ongoing response to the
pandemic. We look forward to working with you over the coming
months to further refine and articulate our objectives in a
manner that improves value for everyone: our warfighters, our
combatant commanders, our patients, our medical force, and the
American taxpayer.
Thank you for inviting me here today to speak with you
about military medicine, our response to the global pandemic,
the essential integration between readiness and health, and
about our plans to further improve our health system in support
of the National Defense Strategy on behalf of our uniform
servicemembers and the families we serve.
Thank you.
[The statement follows:]
Prepared Statement of Dr. Terry Adirim, MD, MPH, MBA
Chairman Tester, Vice Chairman Shelby, distinguished Members of the
Subcommittee, I am pleased to represent the Office of the Secretary of
Defense to discuss the Defense Health Program (DHP) and its
contributions to the health affairs of the Department. I am honored to
represent the dedicated military and civilian medical professionals in
the Military Health System (MHS), which provides direct support to our
combatant commanders and delivers health care for our 9.6 million
beneficiaries.
This hearing is occurring in advance of the formal release of the
President's FY22 full budget. My testimony will provide the
Subcommittee with information on major activities that will inform our
budget proposal for FY22 as well as issues affecting FY21 execution.
The most significant issue, looming over all of our projections, is the
national response to the COVID-19 pandemic. Our national success in
reducing the spread of the virus, and vaccinating our population, will
affect every aspect of our health care costs. For that reason, my
testimony will begin with the current state of the DoD response to
COVID-19.
covid-19 response
The past fourteen months have represented a unique and challenging
period for our Nation as we've confronted and responded to the COVID-19
pandemic. In line with the President's priorities, Secretary Austin has
made clear that the greatest proximate challenge to our Nation's
security is the threat of COVID-19. The Department has, and will
continue to, act boldly and quickly to support Federal government
efforts to defeat this disease. The MHS is providing critical health
support worldwide to our military forces, supporting other Federal and
state entities as part of a whole-of-government response to this
crisis, and continuing to meet other strategic, global mission
requirements, while sustaining high quality health services to our
military Service members and their families.
Beginning with the declaration of a global pandemic in March 2020,
the MHS provided essential crisis response services in support of
military leaders and civilian demands. Though this summary is not all-
inclusive, I will briefly mention several critical initiatives that
contributed to the national response and also generated additional
expenditures for the Department.
Surveillance and Laboratory Testing. Soon after the pandemic began,
the Secretary of Defense established the DoD Coronavirus Task Force
that included a Diagnostics and Testing Line of Effort. The Department
grew its laboratory testing capacity from 16 operational laboratories
in late March 2020 to 189 operational laboratories by March 2021, and
increased on-hand SARS-COV-2 tests from approximately 200,000 to over
1.8 million. To date, the Department has conducted well over 3 million
tests and has tests on-hand to conduct more than 100K tests per week.
Testing is a key public health intervention that has helped to limit
the spread of SARS-COV-2 within the military. Coupled with other public
health measures like social distancing and masking, military
installations have consistently lower positivity rates than their
surrounding communities.
Even as vaccination efforts continue to increase, testing will
remain a key pillar of our public health strategy to battle this
disease and maintain a ready force. Screening through antigen and PCR
testing using a variety of testing strategies in a post-vaccination
environment will continue as part of the Department's COVID-19 risk
mitigation strategy to drive cases down toward zero. The Department is
also committed to whole genome sequencing and identification of
variants of concern and interest and to understanding their prevalence
among our Service members and other beneficiaries. The Department has
already committed the resources and funding to more than double the
number of specimens the Department can sequence and analyze each week.
Clinical Support for Treatment and Therapeutics. Early in the COVID
response, the Defense Health Agency (DHA) developed and released the
first DoD COVID-19 Practice Management Guide (PMG) to provide
clinicians and Military Treatment Facilities (MTFs)--our military
clinics and hospitals--with a single document on best practices
informed by the latest evidence, and guidance across all clinical care
specialties. The PMG has been continually updated and rereleased, with
the most recent version (Version 7) published in March 2021. The DHA
also established a Joint Registry for COVID-19. Using the Joint Trauma
Registry as a foundation for this effort, the COVID Registry collects
and assesses clinical information on COVID patients, in order to inform
our military medical community on the rapidly evolving science behind
this disease. In April 2020, DHA also put forth the Health Protection
Condition (HPCON) Guidance in a COVID-19 Environment, which contained
CDC informed guidance to support MTFs in healthcare delivery in
response to COVID-19, based on the locally-determined risk level.
In June 2020, DHA began an effort to collect donated units of
plasma from patients who had fully recovered from COVID-19 to support
development of an effective treatment against the disease. Again, the
DHA relied on the COVID-19 registry to identify potential donors, as
well as capture the use of, and outcomes from, convalescent plasma on
hospitalized COVID patients. In August 2020, after receiving Emergency
Use Authorization (EUA) from FDA, COVID-19 convalescent plasma was made
available to MTFs for investigational treatment of COVID-positive
patients who met established criteria in accordance with approved
protocols.
The MHS worked closely to implement other, FDA-approved treatments
for COVID. In September 2020, shortly after Veklury (remdesivir; first
FDA-approved treatment for COVID- 19) received an expanded EUA, the
medication was rapidly pre-positioned throughout DoD to ensure
availability to hospitalized patients with suspected or laboratory-
confirmed COVID-19, irrespective of their severity of disease.
Similarly, in November 2020, after receiving an EUA from FDA for COVID-
19 monoclonal antibody treatment, DHA developed and disseminated
specialized guidance to assist MTFs and healthcare providers regarding
patient care considerations when administering this treatment for mild
and moderate cases.
Individual Medical Readiness. COVID-19 did affect medical readiness
within the military. The Department uses a concept called Individual
Medical Readiness (IMR) to measure medical readiness, which consists of
six elements. These are Dental Readiness, Immunizations, Medical
Readiness Labs, Deployment-Limiting Medical Condition (DLMC) Status,
Periodic Health Assessment (PHA), and Individual Medical Equipment. In
2015, the DoD Total Force Medically Ready (TFMR) goal was set at 85%.
Since 2015, the Total Force has consistently met or exceeded the 85%
goal. With COVID-19 pandemic beginning in the 2nd quarter of 2020, TFMR
decreased below the Department's 85% goal. As of the 4th Quarter of
Calendar Year 2020, TFMR compliance was 82.2%; Active Component IMR
compliance was 82.4% and Reserve Component IMR compliance was 81.7%.
The COVID-19 pandemic most affected Dental Readiness and
Immunizations. These IMR requirements can only be completed via in-
person clinic visits. Of note, throughout the pandemic, medical
readiness for deploying Service Members was prioritized and all
personnel are required to be fully medically ready prior to deployment.
Capabilities such as virtual and telephonic medical appointments
allowed MTFs to continue to provide access to medical readiness support
services. We expect IMR rates to quickly recover and return to pre-
COVID levels as our vaccination campaign proceeds through spring and
summer 2021.
Healthcare Delivery and Deferred Medical Care. In both the direct
care system and the TRICARE network, the Department has worked to
ensure beneficiaries receive medically necessary and readiness-related
care throughout the pandemic and we are currently working to address
delayed or deferred care. In addition to guidance for MTFs on standard
processes to provide medically necessary care that could not be
delayed, the Department significantly expanded the use of Virtual
Health (VH) to meet beneficiary demand while minimizing unnecessary
risks for patients and staff.
MTFs and Markets are increasing the number of available
appointments to meet patient demand for care and schedule previously
delayed care. Despite additional workload associated with COVID-related
deployments and vaccinations, MTF appointment availability is
approaching pre-pandemic levels and access to appointments for routine
and follow-up care averages 4.8 days, which is better than the standard
of 7.0 days or fewer. Likewise, specialty referrals are up from spring
2020 levels and are approaching pre-pandemic rates. While direct care
performance on cancer and other preventive screening is lagging
compared to strong pre-pandemic performance, MTF staff members are
actively reaching out to beneficiaries to encourage and facilitate
screening appointments.
For network care, DHA worked with the managed care support
contractors to develop strategies to ensure our beneficiaries' ability
to access care in the network, ensured resources were monitored to
confirm provider availability, expanded availability of VH and eased
beneficiary access to providers by extending referral and authorization
limits and adjusting rules impacting beneficiary cost shares.
Public Health Planning. The COVID-19 pandemic has highlighted the
importance of integrated DoD and interagency public health planning,
which includes conducting realistic exercises with federal, state and
local public health partners. However, the MHS pivoted quickly and
effectively in responding to the pandemic across a wide range of
requirements, both internal to DoD and across the public health
universe. In the process, we learned lessons and developed associated
recommendations that can have an immediate and sustained impact on the
ability of the MHS to support the ongoing pandemic and to prepare for
future major public health emergencies. Chief among these actions is
developing even tighter integrated coordination with interagency
partners such as the National Institute of Health, the Centers for
Disease Control and Prevention, the Federal Emergency Management Agency
and other organizations regarding global medical surveillance of cases
and variants of concern. As a primary partner in the interagency
scientific community, DoD shares genetic sequencing, seroprevalence
information and other relevant surveillance data with interagency
partners.
Medical Education & Training. The collaborative leadership efforts
of the Medical Enlisted Training Campus and the Services resulted in
minimal disruptions in training by maximizing the interoperability and
capabilities of alternative learning modalities and technology
adoption. The MHS kept graduation rates on target, and the end-strength
of enlisted medical career fields healthy and ready to support
Combatant Commanders. Additionally, the MHS expanded support for
continuing education credits (CE) for 16 healthcare specialties and
awarded over 90 thousand continuing education/medical credits.
Continuing education credits are required for health professional
licensure and certifications. The Defense Medical Modeling and
Simulation Office recognized an opportunity to provide immediate
support in meeting COVID-19 related simulation training gaps/needs of
the transitioned Markets and associated Military Medical Treatment
Facilities.
COVID-19 Vaccine and Immunization Implementation. Since December
2020, the Department introduced a global immunization campaign to
deliver expanding supplies of vaccines approved for use under an EUA.
In December 2020, DHA issued a DHA Interim Procedures Memorandum to
implement instructions, assign responsibilities, and prescribe
procedures for the COVID-19 Vaccination Program. DHA continues to issue
updates on the coordinated strategy for prioritizing, distributing, and
administering the COVID-19 vaccine, with the most recent DoD
Vaccination Plan modification (MOD-12) released in April 2021.
As of April 16, 2021, the Department had administered over 2.5
million doses of the three vaccines authorized by the FDA under an EUA.
However, on April 14th, DoD implemented the CDC and FDA recommendation
to pause administration of the Johnson & Johnson vaccine until federal
health experts conclude their review of the rare, severe adverse events
that have occurred in a small number of individuals. Although DoD was
distributing all of its Johnson & Johnson vaccine to overseas
locations, the Moderna vaccine still represented the majority of our
overseas allocation. If this pause extends beyond several weeks, DoD
will consider adjusting its current allocations to accommodate our
overseas requirements.
Adapted from the CDC tiered framework for prioritizing individuals
for vaccination, the DoD population schema includes persons in critical
national security positions and deploying forces in the Tier 1
priorities. Vaccinations are being administered at 350 DoD sites around
the world, in addition to access to civilian sources for our
beneficiaries. On April 19, 2021, the Department fully opened vaccine
appointments to all eligible individuals, consistent with the
President's direction to all jurisdictions.
The vaccine remains voluntary for all eligible persons to include
active duty Service members. The Department has implemented a
comprehensive outreach and communications effort to encourage all
eligible persons seek out these highly safe and effective vaccines. We
are encouraged by the trends in vaccine acceptance, and are confident
that all individuals over the age of 15 who want the vaccine will be
fully vaccinated by mid-Summer.
Defense Support to Civilian Authorities. In addition to the
comprehensive response in support of the military mission, the Defense
Department has provided significant expertise, logistics support, and
personnel to civilian communities. Early in the pandemic, the DHA
coordinated the delivery of critical inventory from existing strategic
reserves to the Department of Health and Human Services for
redistribution to civilian communities. This support included delivery
of five million N-95 masks and over two thousand ventilators. The US
Navy deployed the USNS Comfort and USNS Mercy to civilian ports on the
east and west coasts to provide hospital bed surge capacity for cities
in crisis. Throughout 2020, Army, Navy and Air Force personnel deployed
as units to civilian hospitals around the country to augment local
staff. Military medical personnel took on key positions with Operation
Warp Speed, and infectious disease experts and medical researchers from
DoD medical research and development offices collaborated closely with
the broader American medical research community.
COVID-19 After Action Review (AAR). The MHS is a learning
organization, and we are committed to continuously improving our
performance--whether in battlefield medicine, health care quality and
safety, or our COVID response efforts. Consistent with the FY21 NDAA,
Section 731, the MHS established a rigorous AAR process, led by the
Uniformed Services University of the Health Sciences. This AAR builds
on the MHS interim AAR process and report established by the ASD(HA) in
May 2020 and completed in January 2021. The Department will submit a
substantive, interim report to Congress under Section 731 by 1 June,
and submit a final report by the close of 2021.
Effects on the FY21 Budget. We remain deeply appreciative of the
FY20 supplemental appropriation of $2.2 billion, as part of the CARES
Act, that covered the significant costs incurred during our initial
response.
In FY21, however, costs attributable to the pandemic response
continue to accumulate. As of March 31, 2021, our mid-year review of
the Defense Health Program (DHP) identified likely shortfalls as part
of the ongoing pandemic response, which we are working with the
Department to resolve. In addition, the financial impact of our
military support to the Federal Emergency Management Agency (FEMA)
missions, which remain ongoing, continue to be assessed. The most
significant cost drivers include higher than projected Private Sector
Care costs; additional laboratory testing; personal protective
equipment (PPE) expenditures; and numerous other requirements from
public health surveillance to antiseptic cleaning of medical
facilities.
While there are opportunities to realign funds to meet the
operational imperative of the pandemic response, actions will still
create additional risk and financial liability at a later date.
mhs reforms and transition
The FY 2017 National Defense Authorization Act (NDAA) enacted
sweeping reforms to the organization and management of military
medicine. The over-arching direction from Congress was to centralize
and standardize many military health care functions in a way that
better integrates readiness and health delivery throughout the
Department. Included among these reforms: the expanded authority and
responsibility of the DHA to manage MTFs worldwide; and the authority
to adjust medical infrastructure in the MHS to maintain readiness and
core competencies of health care providers.
Following a strategic pause in transition activities due to the
initial COVID-19 pandemic response, which was directed and then lifted
by the Secretary of Defense in April and November 2020 respectively,
the MHS has continued executing the transition of Military Medical
Treatment Facilities (MTF) to DHA management in accordance with the
Department's approved, conditions-based execution plan that meets the
intent of Section 702 of the FY17 NDAA.
In the coming weeks, we expect to certify all Wave 1 Market Offices
(i.e, San Antonio, Tidewater, Colorado, Puget Sound, and Hawaii). These
critical markets account for 34 percent of the MHS' dispositions, 48
percent of the MHS's direct care expenditures, and 11 percent of the
MHS's purchased care expenditures--providing tremendous opportunities
for continued standardization and optimization. Wave 2 Market
Establishment planning is underway, and we plan to institute an
intermediate headquarters to manage the remainder of our small
hospitals and clinics in early June. There are still outstanding
personnel transfer issues to resolve, however, that place at risk our
ability to complete this transition by the congressionally established
deadline of September 30, 2021.
Section 703 of the FY2016 NDAA directed the Secretary of Defense to
submit to the congressional defense committees an implementation plan
to restructure or realign military medical treatment facilities. This
report was transmitted to Congress on February 19, 2020. The report
articulated the DoD's decisions to align MTFs to increase the readiness
of our operational and medical forces and achieve a proper balance
between meeting readiness requirements and managing the total cost of
health care in the direct and purchased care systems.
All restructuring efforts were paused on April 2, 2020 as a result
of the resources required to respond to the COVID-19 pandemic. The
Department is revalidating the assumptions made regarding its readiness
requirements prior to the pandemic, as well as the assessment of
network capacity to absorb additional patients where we intend to
proceed with right-sizing plans. The DHA will take a conditions-based
approach to any transition of medical services. In other words,
transition will only occur when we are certain that local TRICARE
networks can provide timely and quality access to health care. If they
cannot, we will revise our plans.
mhs genesis implementation
The Department continues to proceed with the multi-year
implementation of its new, Electronic Health Record (EHR), MHS GENESIS.
Although we paused a number of specific, in-person activities during
the COVID-19 response, we still delivered the two Waves scheduled for
completion in 2020, two currently in 2021, and remain on schedule for
enterprise completion in 2023. As of today, MHS GENESIS supports the
delivery of safe, high-quality data to patients and providers across 20
MTFs.
The value of MHS GENESIS has become even more apparent during the
COVID-19 response. We were able to implement COVID-specific
configuration changes in MHS GENESIS within hours on several occasions
that provided senior military and civilian leaders with timely
information on COVID laboratory testing results and the health of our
force and our beneficiaries; the same changes in our legacy systems
took nearly four weeks to implement.
MHS GENESIS' mass vaccination capabilities have produced a
significant improved workflow that allows the Military Departments to
assess the status of service member inoculations in order to ensure
readiness. For example, medical personnel at Twentynine Palms,
California successfully screened 700 active duty Marine records within
days of going live with MHS GENESIS in September. The process was so
successful that Cerner made the solution part of its baseline product
for commercial use.
DoD and VA continue to closely collaborate on a fully integrated
EHR with the oversight of the Federal Electronic Health Record
Modernization (FEHRM) office. The Departments collaborated with the
FEHRM to launch the joint health information exchange (joint HIE) in
April 2020, creating a single common gateway through which DOD and VA
providers can send data to and retrieve data from participating private
sector partners. With the FEHRM's leadership, the Departments support a
Federal Enclave providing a single, common record with high
cybersecurity standards, joint configuration boards to ensure
standardized workflows, and shared risks, schedules and lessons
learned.
tricare 5th generation contracts (t-5)
The Department continues to manage the TRICARE Program in a manner
that seeks to reduce the growth in health care costs while ensuring our
health benefit remains an exceptional tool for recruitment and
retention of military personnel and their families. Among the most
important strategies we pursue is the development of effective TRICARE
contracts that deliver high-value, patient-centric care designed to
seamlessly integrate military and private sector care in support of
readiness and health outcomes.
The T-5 contracts represent the next generation of contracts that
provide DHA with the flexibility to adjust network requirements,
improve professional services support, and adapt care delivery models
in support of evolving mission requirements and changes in American
health care delivery. After an extensive, multi-year engagement with
Department leaders, industry, and other stakeholders, as well as three
draft Requests for Proposal (RFPs) shared with industry, the Department
issued the T-5 RFP on April 9, 2021. The goals of this procurement
support (1) military medical readiness and the readiness of the medical
force; (2) beneficiary choice; (3) high value care; and the adoption of
Industry Business Standards.
The Department looks forward to healthy competition from industry
and the inclusion of new health care delivery models in the coming
proposals. As part of the T-5 process, the Department will conduct
``Competitive Demonstrations'' during the contract's period of
performance. Twenty-one potential markets are identified in geographic
areas where MTFs may rightsize, downsize or where DHA provides TRICARE
Prime but no MTF exists. The RFP also specifies three innovations:
Virtual Value Networks, Advanced Primary Care, and Care Collaboration
Tools that will start with T-5 initiation and up to seven other
demonstrations are planned during the life of the contract. DHA
anticipates receipt of offeror proposals no later than August 13, 2021.
The new contracts are planned to begin health care delivery in Calendar
Year 2024.
medical research and development
The Department is grateful for the long-term advocacy and support
for its military medical research program. The DHP research,
development, test, and evaluation (RDT&E) focus is to advance the state
of medical science in those areas of most pressing need and relevance
to today's emerging threats, which includes the COVID-19 pandemic.
We seek to discover and explore innovative approaches to protect
and support the readiness, health, and welfare of military personnel;
to accelerate the transition of medical technologies to development and
acquisition; and to accelerate the translation of advances in knowledge
into new standards of care and treatment that can be applied in the
field or in military medical treatment facilities.
In the coming years, we hope to leverage new technologies to
include artificial intelligence and machine learning, biotechnology,
and autonomous systems. The goal is to accelerate the transition of
medical technologies to development and acquisition programs, and to
further the translation of new standards of care to support and
treatment that can be applied in the field or in military medical
treatment facilities. We will seek to mitigate deployment-limiting
medical conditions for service members by focusing on injury prevention
and rehabilitation.
The MHS continue to employ and strengthen our enterprise-wide
performance management systems that provide stakeholders--both medical
and line leadership--at all levels of the military with visibility into
how we are performing on key metrics. These dashboards show
longitudinal performance in measures of readiness, health, access,
quality, safety and cost. We monitor critical indicators of quality and
safety--that point us toward high reliability as a system of care.
Access to primary care and specialty care are measured along with
patient satisfaction to ensure we are meeting patient expectations. We
have provided Department leadership, MTF commanders and staff with
visibility into COVID-19 specific measures that include, but are not
limited to operational hospital bed capacity and surge capabilities,
timely laboratory test results, PPE inventories, COVID-19 vaccine
target population and vaccine administration data, as well as important
private sector care data.
Our dashboards can be viewed at an enterprise level, by Service, by
market, and by individual hospital or clinic. We will continue to adapt
this management system as the MTF transition progresses. Commanders can
assess their performance against expected benchmarks, against peer
institutions, and--where possible--against civilian sector performance
as well. These dashboards help us to both assess how we are doing in
these areas, and where we need to invest resources, training, or
management attention in order to achieve further improvement.
other significant health initiatives
There are several other health initiatives that merit comment--
chief among these is access to timely, high quality mental health
services and related activities to reduce the incidence of suicide
among our service members, their families, and all beneficiaries. The
Department is committed to the health, welfare and safety of our
service members and families and we have undertaken a broad-based
campaign encouraging service members to seek mental health treatment
when signs or symptoms occur, help service members and their families
to identify those signs and symptoms, and to de-stigmatize mental
health care overall.
The DoD has invested in a number of programs to increase access to
mental health care for Service members who are experiencing symptoms of
a psychological health condition. Service members are eligible to
receive free, comprehensive behavioral health care (including clinical
assessment, psychotherapy, and psychiatric treatment) at their local
military medical treatment facilities. We also have programs that embed
psychological health providers in operational units to assist Service
members in their everyday work environments. The primary care medical
homes provide follow-up when Service members disclose psychological
health concerns to their primary care provider. Military OneSource is
our 24/7 resource to connect Service members to information about their
psychological health, non-medical counseling for stress management, and
referrals to healthcare providers.
We have witnessed significant improvements in destigmatization and
increased use of behavioral health services. Nonetheless, suicide rates
remain unacceptably high. Suicide is a very complex issue with many
biological, social, and psychological factors that contribute to
suicide. In recognition of this complexity, the DoD implements a
comprehensive public health approach to suicide prevention and
intervention. The DoD is focused on using every available resource to
support our Service members.
For example Service members are screened for symptoms of
psychological health conditions throughout their service. All Service
members who are deployed in connection with a contingency operation
receive a series of deployment health screenings designed to identify
psychological health concerns, including posttraumatic stress disorder
(PTSD) that may require referral for additional care and treatment.
Additionally, all Service members, regardless of deployment status,
receive a mental health assessment upon separation from military
service to ensure documentation of any psychological health conditions
and arrange for appropriate follow-up.
Currently the DoD and VA are working together in the development of
a single Separation Health Assessment that will include a Mental Health
Assessment. This effort will make the separation process more efficient
and improve the mental health care of our Service members. Clinical
Practice Guidelines have been formulated for all major clinical
conditions in mental health, and Joint VA/DoD Clinical Practice
Guidelines (CPGs) for mental health care facilitate delivery of
evidence-based mental health care practices and strengthen the ability
to maintain mental health readiness.
Beyond individual approaches, the public health approach also
includes broader efforts, such as those targeted for our populations of
greatest concern (young and enlisted Service members) and developing
initiatives to support military families. For example, current efforts
include interactive educational pilot programs to teach foundational
skills to effectively deal with life stressors and to address help-
seeking concerns and encourage use of support resources.
The Department continues to promote initiatives that increase
awareness of risk factors for suicide, safe storage of lethal means
(e.g., firearms and medications), and communicate how to intervene in a
crisis. For example, DoD trained more than 2,000 non-medical military
providers to provide Counseling on Access to Lethal Means (CALM) to
Service members and families to increase awareness of risk factors for
suicide, safe storage of lethal means (e.g., firearms, medications, and
other lethal means), and how to intervene in a crisis. DoD is expanding
on this pilot program for other influencers, such as spouses.
overall fy22 budget
The soon-to-be released budget will prioritize our resource
requirements to address the COVID-19 pandemic and also address health
care delivery challenges caused by the pandemic.
The Defense Health Program funding level that will be proposed by
the Department in the FY 2022 President's Budget re-baselines health
care program resources based on FY 2020 execution prior to the onset of
COVID. Some residual risks remain, such as the COVID-related effects of
previously delayed care that may return, potentially deleterious
impacts on beneficiaries' health due to delaying or forgoing care,
unrecognized impacts of COVID-19 among asymptomatic or long-term,
persistent disease, and the inherent uncertainty in predicting
healthcare costs.
The MHS is not unique in the variability associated with predicting
health care costs as all health insurers face these same challenges
when forecasting their health expenditures for a given year. Changes in
medical practice, demand for services, and new procedures and drugs are
hard to predict. COVID has only exacerbated these challenges.
It is important to consider the FY22 budget request in the context
of MHS cost control for the last ten years. Over the period of FY 2012
to FY 2018, both private health insurance premiums and National Health
Expenditures per capita rose 25% (or 3.7% annually). However, the
Department, working with Congress, instituted a series of initiatives
that reduced DoD costs well below the rate of civilian growth. A
combination of benefit changes, payment savings initiatives, contract
changes, and population reductions masked underlying increases in
health care costs. Starting in FY 2019, cost patterns returned to
normal growth until the COVID pandemic significantly reduced the
utilization of health care services beginning in March 2020.
The Department continues to pursue efforts focused on internal
business process improvements and structural changes to find greater
efficiencies, such as further integrating and standardizing the
operation of hospitals and clinics; continuing the deployment of MHS
GENESIS; modernizing clinical and business processes; and, streamlining
internal operations. The Department is not requesting any additional
changes to beneficiary cost-sharing in the FY22 budget.
The Department remains vigilant about variation in year-to-year
expenditures, and we are appreciative that Congress continues to grant
the Department carryover authority each year. Carryover authority
allows DoD to maintain better funding flows to minimize disruption of
health care services to our beneficiaries. We are committed to making
our health care cost projections even more transparent in the year of
execution, providing regular updates to the committee, and providing
full visibility to Congress on potential plans for reprogramming funds
within the fiscal year should that possibility unfold. Furthermore, we
will ensure that available funding is directed toward unfunded medical
readiness and health care delivery requirements. Carryover authority is
an invaluable tool that provides the Department with needed flexibility
to manage issues that emerge during the year of budget execution.
When released, our FY22 budget will present a balanced,
comprehensive strategy that aligns with the Secretary's priorities, to
include the ongoing response to the COVID-19 pandemic, and continues to
fulfill our requirements associated with our congressionally directed
transition. We look forward to working with you over the coming months
to further refine and articulate our objectives in a manner that
improves value for everyone--our warfighters, our combatant commanders,
our patients, our medical force, and the American taxpayer.
Thank you for inviting me here today to speak with you about
military medicine and our response to the global pandemic, the
essential integration between readiness and health, and about our plans
to further improve our health system in support of the National Defense
Strategy and for our beneficiary population.
Senator Tester. Thank you, Dr. Adirim.
General Dingle.
STATEMENT OF LIEUTENANT GENERAL R. SCOTT DINGLE,
SURGEON GENERAL, DEPARTMENT OF THE ARMY
General Dingle. Chairman Tester, Vice Chair Shelby, and
distinguished members of the subcommittee. Thank you for your
support and for the honor to speak to you on behalf of over
83,000 active-duty Guard and Reserve Army soldier medics.
COVID-19 and unexpected challenges to our national security
attempted to attack the foundation of our Nation, but it did
not disrupt the fabric of our Constitution and its Army's
response to it.
I honor the soldiers that I am privileged to lead. As
General McConville, our 40th Chief of Staff of the Army,
states, ``People first and winning matters.'' I am proud to say
that our Army is ready to win. Within days of our Nation's
call, we collaborated with Health and Human Services, the
Department of Homeland Security, and our State governments. We
expanded critical testing capacity, inculcated retiree recalls,
deployed vaccine and medical teams in support of civilian
entities, and partnered with medical research and development
in support of the whole-of-government approach.
Soldiers deployed to three countries, 19 States, and three
territories, to include California, Illinois, North Dakota,
Washington, and Wisconsin to support and to save American
lives. You called, we were ready, we responded.
My vision for Army Medicine is clear. We will be ready,
reformed, reorganized, responsive, and relevant in this era of
unprecedented global complexity whether in support of our
National Defense Strategy and whenever our government calls.
So, when the Army deploys today and fights tonight, Army
Medicine will be right there to return our soldiers to duty
tomorrow. From the foxhole to the fixed facility, we will
conserve the health and fitness of the fighting force and
reinforce our readiness requirements through healthcare acuity
for our beneficiaries.
I will ensure that integrated medical efforts occur with
strong fiscal stewardship and partnership between Army
Medicine, the Joint Force, and the Defense Health Agency
ensuring the readiness of our soldiers. The vision and
operational focus for Army Medicine remains at building
readiness and properly manned and proficiently trained units
and modernizing to remain ready and relevant for future
conflicts and challenged. Medical reform directors will be
implemented to maximize readiness in support of the Army
mission.
Finally, we are committed to sustaining and improving our
partnerships, foreign and domestic, to elevate battlefield
interoperability, and to support our National Defense Strategy.
In closing, I thank the committee for your long-standing
support to the Army and military medicine. I look forward to
answering your questions.
[The statement follows:]
Prepared Statement of Lieutenant General R. Scott Dingle
Chairman Tester, Ranking Member Shelby, and distinguished members
of the subcommittee thank you for the opportunity to speak to you on
behalf of our Army's health professionals--Soldiers, Civilians, and
their Families, about the state of Army Medicine. As the 45th Army
Surgeon General, I want to express my gratitude for your unwavering
support.
Today, in the 20th year since 9/11, over 190,000 Soldiers are
engaged worldwide to support contingency operations, multiple
exercises, and theater security cooperation activities. Before this
novel coronavirus pandemic, Army Soldiers and Civilians had served
throughout the world as part of the Joint Force. This last year,
however, has made our work like no other in our Nation's history.
Before I begin my comments, I would like to acknowledge those
tragically taken by the virus and other violent acts. They were
mothers, fathers, first responders, healthcare providers, the elder,
and the young, too many lives sacrificed. May they rest in peace.
I would also like to honor the Soldiers, civilians, contractors,
and volunteers I am privileged to lead. As our 40th Chief of Staff of
the Army states, ``People First, Winning Matters!'' I am proud to say
that our People are ready to win. Within days of the Nation's call,
Soldiers began building hospitals and testing centers where the Nation
needed them most. Soldiers and the Federal Emergency Management Agency,
state, and local partners converted the Javits Convention Center in New
York City into an alternate care facility to meet the potential demand
for hospital beds created by COVID-19. Our researchers, project
managers, logisticians, public health officials, health facility and
operational planners, and scientists were embedded with the interagency
for the whole-of-government effort against COVID-19. Over 1,850 service
members augmented civilian hospitals or community vaccination programs.
You called. We were ready. We responded.
We marshaled our best and very talented professionals from across
the Army. Our scientists and public health officials developed
therapeutics, pandemic surveillance modeling, and testing strategies
that produced the relevant outcomes we see today. Medical research and
public health, the Army's vital asset in fighting diseases, contributed
to the national effort under the Military Infectious Diseases Research
Program and partnered with civilian, academic, and federal agency
counterparts at all echelons in the whole of government response. Army
Medicine did this while sustaining the health of our Soldiers, family
members, retirees, and civilians both at home and abroad.
Since 2019, the Army and Army Medicine have been diligent in
separating the resource requirements for the Services' readiness needs
from benefit delivery. This deliberate effort has enabled the Army to
expeditiously provide the foregoing actions to support operational and
readiness requirements.
As The Army Surgeon General, my top priority is the health,
welfare, and readiness of our Soldiers, their Families, our Civilians,
and our Soldiers-for-Life, especially after two decades of persistent
conflict across the globe. The Army and Army Medicine must consider the
policy and funding needs to keep us ready and relevant for future
challenges. This is what we must discuss today.
army medicine 2028
The Army Medicine 2028 vision operationalizes my plan to meet Army
Medicine's strategic readiness priorities along with five key
objectives--Ready, Reformed, Reorganized, Responsive, and Relevant.
--Ready.--Taking care of people, our Soldiers, and our Families, is
paramount to readiness. Their physical, cognitive, and
emotional health are the cornerstones to personal readiness. We
will build and sustain strategic readiness to ensure the
operational force can win across all domains--land, air, sea,
space, and cyber, by embracing modernization efforts through
emerging technologies, synthetic training, and partnerships.
--Reformed and Reorganized.--Our Army remains committed to medical
reform initiatives. Similarly, Army Medicine must effectively
reorganize in accordance with reform requirements and Army
Senior Leader directives to remain nested with the Army
Campaign Plan and the Army Modernization Strategy.
--Responsive.--Army Medicine will tailor our expeditionary force to
support the new paradigm of multi-domain operations,
synchronized as part of the Joint Health Service Enterprise.
--Relevant.--Army Medicine must change at the speed of relevance.
This includes the modernization of critical capabilities,
technical innovations, and expanded alliances and partnerships
to meet the shared challenges of our time.
army medicine strategy
The strategic vision positions Army Medicine to achieve the
objectives and priorities set forth by the Army. The vision of Army
Medicine 2028 is clear: we are responsive and relevant with
expeditionary, tailored, medically ready, and ready medical forces to
support the Army mission to deploy, fight, and win in a joint, multi-
domain, high-intensity conflict.
Nested with Army vision and priorities, I lay the foundation for
evolving concepts, tactics, and requirements in five specific ways to
achieve this vision. We must synchronize and integrate the medical
effort. We must continue to build Army medicine readiness through
proper manning, organizing, training, equipping, and leadership. We do
this while continuing our modernization and medical reform efforts. We
must do this while cultivating our international alliances and
partnerships, force multipliers, and strategic assets to our national
defense.
Synchronize and Integrate the Medical Effort.
In line with the Secretary of Defense's and Army senior leaders'
guidance, Army Medicine will remain responsible and reliable for our
teammates and stakeholders. We do this through our teamwork as the
Army's medical voice regarding COVID-19 response, conserving the
force's health and fitness, and caring for our beneficiaries, active
and retired, at our treatment facilities. Our integrated efforts occur
within and across the Army, between the Army and Defense Health Agency,
and through the Joint Staff and Combatant Commands.
COVID-19 Response: The Nation called; the Army was there with the
relevant expertise, equipment, and technology to respond to this
unprecedented public health crisis. We will not rest until the virus no
longer threatens our Nation. The greatest proximate challenge to our
Nation's security is the threat of COVID-19. Army Medicine is
decisively engaged in fighting COVID-19 at all levels, supporting the
Department of Defense and interagency partners to eradicate COVID-19. I
will participate in the statutorily mandated COVID-19 medical health
system review panel in the coming months. Per fiscal year (FY) 2021
National Defense Authorization Act (NDAA) Section 732, my team will
contribute and support the Secretary of Defense's strategy for pandemic
preparedness and response plan. They are studying our response to
COVID-19 and modifications to a pilot program on civilian and military
partnerships to enhance medical interoperability and surge capability
and capacity of the National Disaster Medical System. I finally want to
express my gratitude to our Soldiers-for-Life. Last year, the Army
asked our retirees to assist the historic effort to defeat COVID-19,
and they responded. All of these men and women volunteers are true
patriots and exemplars of the unwavering dedication of the Army
Medicine team.
Research, Development, and Acquisition: Army Medicine is the Army's
medical shield defending the force against COVID-19 in this whole-of-
government approach. We responded to the Severe Acute Respiratory
Syndrome, Ebola, and Zika outbreaks in the recent past. The Army
Medical research enterprise delivered therapeutics, including
antibodies in convalescent plasma, collaborated on the study of 40
million compounds, and managed approximately 80% of the Defense
Department's investments dedicated to medical research and product
development. To date in FY21, the Medical Research and Development
Command dispersed $363 million for research, development, test, and
evaluation; $280 million for operation and maintenance; and $59 million
for procurement across myriad programs supporting the health of the
Department and our Nation. In the year since COVID-19 became a
household word, our research and development team used these needed
funds to protect the Nation from deadly viruses.
Health and Holistic Fitness (H2F): Holistic Health and Fitness, or
H2F, is now part of our doctrine per Army Field Manual 7-22. As the
Army Chief of Staff states, ``People are my #1 priority: Our Army's
people are our greatest strength and our most important weapon
system.'' To maintain our military strength, we will invest in
understanding, assessing, and improving the American Soldier's holistic
health. That means we have a comprehensive schema to enhance and
maintain the Soldier's performance by making Army medical and health
professionals part of building cohesive combat teams. In April 2020,
3.75% of the Army is currently medically non-deployable, equating to
38,400 Soldiers. Musculoskeletal injury contributed significantly to
the Army's healthcare burden, negatively impacting Soldier health and
Army readiness. To conserve the force, Army has 536 military
authorizations in the future years' defense program (FYDP) between 2022
and 2026 for physical therapists, occupational therapists, registered
dietitians, and enlisted specialists to be forward arrayed within our
combat formations to prevent or mitigate injuries and ensure faster
recovery to maintain combat power.
Army Recovery Care Program (ARCP): The Army maintains a robust
Warrior Care program for managing recovery and complex care for
wounded, ill, and injured Soldiers across all Army components. Our
program, formerly the Warrior Care and Transition Program, is a
critical enabler of Army readiness. Through the use of 14 Soldier
Recovery Units, ARCP manages the recovery of wounded, ill, and injured
Soldiers requiring complex care at Division/Corps installations and
specialty medical centers. The program also provides resources and
advocacy for Families and caregivers of Soldiers recovering in the
program. Since the program's inception in 2007, more than 84,000
Soldiers have entered the program. As of October 1, 2020, the program
completed a two-year Army-directed restructure. Its current population
of 1,752 reflects the single entry criteria for all three components
and is in line with original restructure estimates of 1600-1800 as of
December 31, 2020. The latest restructure has reduced 501
authorizations and $35 million for Program Objective Memorandum (POM)
2021, but will not decrement operations and support to the wounded
warrior.
Medical Military Construction: The construction of medical
healthcare and research facilities supporting Army and Department of
Defense personnel and missions continues. Army Medicine, the United
States Army Corps of Engineers, and the Defense
Health Agency provide collaborative leadership and management to
multiple projects. I thank you for your enduring support of the medical
military construction program. The Army will recapitalize over 78% (15
of 19) of inpatient facilities between 2005 and 2026. The military
health system continues to require future investments in military
construction to support safe, quality care for our Soldiers, Family
Members, and Soldiers for Life, as well as capital investments for
medical research and public health activities. As of this submission,
there are currently 14 active hospital, medical research, clinic, lab,
and blood program projects supporting Army equities.
Departments of Defense (DOD) and Veterans' Affair (VA) Partnership:
Caring for our Soldiers-for-Life reflects our commitment to People and
synchronizing the medical effort. In collaboration with the VA, the
Army has an integrated joint effort for providing care to our retired
population through robust healthcare resource sharing programs. Between
2018 and 2019, Army Medicine provided $138.2 million in reimbursable
care to veteran beneficiaries in our Army treatment facilities. All
Army facilities with excess capacity to provide care to the veteran
population under the healthcare resource sharing program. Our Soldiers-
for-Life are America's strategic reserve. We are obligated to care for
them.
Build Readiness.
Building and maintaining readiness is critical to my strategic
goal. Army Medicine is pivoting to proficiently trained and manned
units led by competent leaders, equipped with modern capabilities to
provide expeditionary life/limb-saving to a multi-domain operations
capable force by 2028. I acknowledge legislation regarding our force
mix options and service models, as well as legislation regarding the
military medical manning end strength. Readiness and deployability must
remain a top priority of Commanders and Soldiers.
Medical Readiness: To build combat readiness, we affirm the need to
reduce the Army's non-deployable rate to 5%, even during the pandemic.
This means that despite COVID-19, Soldiers continued to complete their
annual health assessments and dental exams. Initially, COVID-19
impacted our ability to conduct the screenings. To clear the backlog of
Soldiers who fell out of compliance during the early phase of the
pandemic, we began to use video or telephonic health assessments. At
the end of calendar year 2020, only 3.75% of Soldiers were medically
non-deployable.
Individual and Collective Training: The Army is committed to the
readiness for large-scale combat operations. I will provide the combat
force high-quality medical care across the full continuum of combat
casualty operations by reforming our medical training processes and
seeking innovative partnerships and solutions to providing a ready
medical force. Army Medicine is using various initiatives to build
deployment readiness:
--Army Graduate Medical Education.--Five to seven years of training
after medical school is required to produce a board-eligible
surgeon. The graduate program generates 96% of critical wartime
specialty surgeons.
--Military-Civilian Partnerships.--Army Medicine has entered into
medical training agreements with civilian trauma centers and
medical centers around the country. Pursuant to recent
legislation, Army Medicine has placed doctors, nurses, and
medics into facilities across the Nation, where, for example,
members from forward surgical teams maximize their exposure to
a high volume of patients with critical injuries. This cost-
efficient initiative provides skills sustainment opportunities
alongside our civilian counterparts in premier trauma centers
and hospitals.
Support Modernization of the Medical Force.
Army Medicine's modernization efforts include developing medical
concepts parallel with Army efforts. These expeditionary medical
capabilities leverage emerging technologies, design the future medical
force, ensure interoperability, and invest in synthetic training
environments to provide the ``sets and reps'' required to be
battlefield-ready. We must consider leveraging technology and updating
our strategies to meet the realities of the landscape.
Recruiting and Retention of Health Professional Officers (HPOs)
(Talent Management): Our Army's philosophy is People First, and our
attitude is Winning Matters. The Army is about People. I want to thank
our legislators for acknowledging the need to increase special pay
incentive programs and rate caps. The increase in health professional
compensation assisted with medical accession bonuses, health
professional scholarships, Financial Assistance Program, loan
repayment, professional training and education programs and incentives,
allows us to recruit and retain health professional officers as they
make the tough decision to serve the Nation or answer the lucrative
opportunities in the private sector. Per section 757 of the Fiscal Year
2021 NDAA, at the direction of the Department of Defense, we will
participate in the congressionally-mandated review of our force mix
options and the service models to enhance our medical force's
readiness.
Virtual Health: As we sustain and modernize Army Medicine's talent
management systems and organization, our hardware and software must
match the dynamic threat landscape of the 21st century. In this regard,
the legislation directs a review of our use of virtual health services
across the Army. Leveraging this capability during the pandemic was
critical in delivering medical treatment and timely access to care.
During the year of COVID-19, when many dreaded entering medical
treatment facilities, telehealth provided direct care to our patients.
In FY15, there were over 40,000 virtual health encounters in Army
Medicine. About 80% of these encounters were related to behavioral
health. From March 2020 to January 2021, we had an extraordinary 4.2
million virtual health encounters. Virtual health improves patient
satisfaction, continuity of care, readiness, and access-all components
for efficient and effective medical care.
Medical Simulation/Synthetic Training: The Department of Simulation
at the Medical Center of Excellence is the lead agency for Army medical
modeling and simulation policy and strategy. Working with the Army's
Program Executive Office Simulation, Training and Instrumentation, and
in collaboration with Army Futures Command, our simulation efforts will
improve medical skill training through synthetic cross-functional
training. The artificial environment will provide the realistic
repetitions necessary to train and sustain combat lifesavers and
medical personnel for Multi-Domain Operations. Other examples of our
technological needs include:
--Integrated Visual Augmentation System (IVAS).--This system enhanced
casualty care through a combination of technologies and
augmented reality delivered in the form of a Head-Up Display
device. The system will include a casualty response function
enabling the Close Combat Force to exercise squad-level
response to taking casualties in tactical training scenarios.
--Tactical Combat Casualty Care (TC3) Simulation.--A first-person
game that allows a Soldier to play a combat medic's role during
an infantry squad mission in an urban environment.
--Vertical Lift.--The next-generation medical vertical lift, such as
the medical variant of the Future Long-Range Assault Aircraft,
will give Army Medicine an aircraft with increased speed,
range, survivability, and maneuverability to allow the Army to
evacuate the injured from the battlefield to the point of care.
We must make investments to develop further and purchase the
required hardware and software to create the Synthetic Training
Environment Medical training platforms and next generation of vertical
lift.
Medical Reform.
The Medical Reform initiative aims to ensure the highest Soldier
and provider medical readiness while reducing administrative
requirements associated with military treatment facilities (MTFs)
health and business processes, procedures, and practices to deliver
more effective and efficient beneficiary care at less cost. The
Department of the Army and Army Medicine are committed to this
initiative as we diligently evaluate the Medial Department's structure,
ensuring its coherence to the needs of Title 10 and our operational
demands.
Medical and Dental Treatment Facility Transition: Due to the novel
coronavirus response, the military health systems reform efforts were
paused in the last year. The Defense Health Agency will assume
authority, direction, and control for all United States- based MTFs by
September 30, 2021. The Army will transfer 126 Medical and 60 Dental
Treatment Facilities to the Defense Health Agency. The Army retained
statutory Title 10 responsibility for training, readiness, and
oversight of Soldiers at the Medical Treatment Facilities, Dental
Treatment Facilities, Public Health establishments, and Veterinary
Treatment Facilities.
Defense Health Program Funds Transfer: The FY21 appropriations
drafted by this committee provided more than $1.1 billion from the
Defense Health Program to the Army Operation and Maintenance account
consisting of over 15 service-centric medical readiness programs--over
$655 million within Army Medicine and over $445 million across Army
Major Commands. We understand that we need to further evaluate our
readiness requirements in subsequent years as the medical health
systems reform and transition progress. We acknowledge this committee's
recommendations on the need for precise details and justification for
Army's Medical readiness programs. Finally, we are also working with
the Defense Health Agency to ensure that those medical readiness
services within the Defense Health Agency purview (about $895 million)
are meeting the Army's requirement for comprehensive readiness for our
Soldiers and their family members.
Strengthen Alliances and Partnerships.
Finally, our allies and partners are collaborators and force
multipliers with whom we engage through various multilateral and
bilateral affiliations, security cooperation programs, and global
health engagement opportunities. From the early 1800s, to today, and
into the future, the Army has a long-standing history responding to
international public global health issues as a result of our
responsibility to protect the health of our forces and to ensure that
they are ready to deploy for missions anywhere in the world at a
moment's notice. One component of global health engagements involves
building, sustaining, and improving partner capacity so that nations
can mature into competent combat health service support providers for
their forces and coalitions in which they will operate. Among other
capabilities, my goal in the Army Medicine strategy is to create a
global network of military medical capabilities that will provide niche
and system medical services to ensure ready, relevant, responsive, and
excellent health service support both in the field and in the
institutional setting.
Funding for global health activities, partnership activities, and
global health engagements has always been a challenge. As we have seen
in the last year, our scientists' international work is a crucial
funding concern. Allocated appropriations from Defense Health Program
funds provided by our partner nations do not yield impactful results.
Partner nation, Combatant Command, and Army Service Component Command
prioritization toward combat and combat support capabilities are
frequently below the cut line, underfunding global health engagements
and medical security cooperation.
To achieve global health objectives, medical forces would benefit
from funding investment to continue and capitalize on our critical
relationships with international ministries of defense, health,
interior, academia, non-governmental, and private sector organizations.
As required by statute, we will work with the Department to assess the
feasibility of establishing medical security partnership with Taiwan
(FY21 NDAA, Section 1260B) and the grant program to collaborate with
Israel on post-traumatic stress disorder research.
Medical Research and Development Command laboratories in Thailand,
Philippines, Nepal, Cambodia, Kenya, Nigeria, Tanzania, Uganda, and the
Republic of Georgia conduct essential surveillance of biological
threats and groundbreaking research on infectious diseases and diseases
of military and public health significance. Through regional and
functional health commands, the Army's global presence also serves as a
force for good, offering humanitarian assistance and disaster relief
when requested.
The Army Medical Center of Excellence provides officer and enlisted
medical leadership training to approximately 200 soldiers from partner
nations. Of these, our relationship with the Israel Defense Force
medical services, based on the 1978 United States-Israel Data Exchange
Agreement on Military Medicine, or ``Shoresh,'' sustained our
relationship through their International Medical Programs office and
the Army's Medical Strategic Leadership Program. Similarly, our
relationship with Taiwan (one which Army Medicine looks forward to
expanding) was sustained through our educational programs, which had 25
participants in recent years.
Army Medicine will build on our experience from multinational staff
hospitals in Iraq and Afghanistan as the opportunity affords. We do
this while leveraging current experiences in Europe with our allies and
partner nations to strengthen our many long-lasting international
relationships with the North Atlantic Treaty Organization and the
American-British-Canadian-Australian-and New Zealand alliances. When
matured, these relationships will enhance the readiness of future US
military operations in that region. The corporate and national response
to the global pandemic, ongoing research and development of freeze-
dried plasma, advancements in prosthetics and rehabilitation, and more
effective treatments for post-traumatic stress disorder and other
combat stress-related injuries have made Army Medicine a proven and
formidable partner in global health and military medicine.
conclusion
In closing, I want to thank the committee for your long-standing
support to the Army and Military Medicine. I remain committed to
working with our defense, interagency, intergovernmental,
multinational, and civilian partners to improve Army readiness. At the
same time, our healthcare professionals continue to care for our
Soldiers, Civilians, and their Families.
From the foxhole to the fixed facility--Army Medicine will be
ready, reformed, reorganized, responsive, and relevant. My vision will
ensure that we sustain mutual trusted relationships within the Army,
the Joint Force, and the Nation. When a Soldier calls for a medic, Army
Medicine will be ready and responsive with expertly trained Soldiers
capable of healing injuries to the body. Medical units should be
adequately manned and equipped with the best equipment and technology.
It is not about fighting the last war. We must have the People,
cutting-edge tools, medical concepts, doctrine, capabilities, and the
training for the next conflict. I appreciate the subcommittee's work
and your continued support to our Soldiers, Army Medicine, and our
Army.
Senator Tester. Thank you, General Dingle.
General Hogg.
STATEMENT OF LIEUTENANT GENERAL DOROTHY A. HOGG,
SURGEON GENERAL, DEPARTMENT OF THE AIR
FORCE
General Hogg. Chairman Tester, Vice Chairman Shelby, and
distinguished members of the subcommittee, thank you for the
opportunity to testify on behalf of more than 55,900 total
force airmen who comprise the Air Force Medical Service. Your
sustained confidence and support enables us to remain mission-
focused, excellence-driven, and ready to fight tonight.
Over the past year, our airmen have been involved in every
aspect of the COVID-19 response. From the early days of initial
public health emergency response to supporting the whole-of-
government vaccine administration efforts, Air Force medics
showed their ability to innovate.
When COVID-19 epicenters in New York, California, Texas,
and North Dakota were facing critical staffing shortages, we
acted quickly, embedding critical care strike teams directly
into civilian facilities.
Today we have 1,000 Air Force medics deployed to 11 FEMA
vaccination sites in 10 States to administer COVID-19 vaccines,
and we expect them to surpass the 1 million mark this week.
A year before the first COVID-19 case hit the U.S., we
established our newest C-STARS training program at the
University of Nebraska in Omaha. This Center for the
Sustainment of Trauma and Readiness Skills focuses on disease
containment.
Our infectious disease specialists worked alongside
civilian counterparts to treat some of the very first COVID-19
patients using the university's biocontainment unit.
We took our air medical evacuation capabilities into new
territory when we were tasked to transport COVID-19 patients.
Early in the pandemic, the rapid rise of cases drove the need
to move more patients at once while mitigating the spread of
COVID-19 to our aircrew members.
We partnered with teams across the Department of Defense
and the civilian industry to develop a new infectious disease
transport system called the Negatively Pressurized Conex. This
Conex can safely transport up to three times as many patients
as the previous isolation system, and as of 19 April, we have
completed 96 missions and moved 366 COVID-19 patients safely.
While battling the pandemic, we also remained dedicated to
the MHS (Military Health System) transformation efforts. We
have worked side by side with the Defense Health Agency to
identify all necessary processes needed to mature their
functional capabilities. We also implemented a new medical
reform model to improve our airmen's and guardians' readiness
and deployability.
We reorganized our medical treatment facilities into two
squadrons. The first squadron focuses on the health of our
airmen and our guardians, and the second squadron focuses on
the health of our beneficiaries. This new model has been
implemented at 66 bases, and early analysis has already shown
the model enhances force readiness and lethality.
This pandemic brought unprecedented challenges, but it also
provided opportunities to accelerate, change, or lose, to
become more agile, resilient, and capable to face the unknown.
This is what we train for. We remain ready for the right. This
mentality must remain in focus as we evolve to face the next
major threat.
It has been an honor to serve as the Air and Space Force
Surgeon General alongside extraordinary medical professionals
on the joint team. This is my final time to appear before this
subcommittee, as I will be retiring this summer.
Thank you for your continued support and for the
opportunity to address you today, and I look forward to
answering your questions.
[The statement follows:]
Prepared Statement of Lieutenant General Dorothy A. Hogg
Chairman Tester, Ranking Member Shelby, and distinguished members
of the Subcommittee, thank you for the opportunity to testify on behalf
of the 55,945 active duty, reserve, national guard, and civilian Airmen
who comprise the Air Force Medical Service. It is an honor to serve
with these Airmen who demonstrate their ongoing dedication to the
mission resulting in the success of the Department of the Air Force.
Your sustained confidence and support in our efforts enables us to
remain mission-focused, excellence-driven and ready to fight tonight.
The Air Force Medical Service supports the Department of the Air
Force's mission to fly, fight and win, and defend American interests in
air, space, and cyberspace. Our strength resides in our resilience and
on our willingness to succeed in austere, dynamic, and challenging
environments. Our readiness focuses on delivering lifesaving care,
whether on the battlefield or within our own communities. We train to
successfully operate in field hospitals with limited supplies, pushing
the limits of our capabilities to stretch our problem solving
abilities. The Air Force Medical Service can successfully function, in
fact, excel, on any cargo aircraft available to move our service
members to higher levels of care. Air Force medics ensure combatant
commanders have a medically ready and fit force. With the launch of our
newest military branch, the U.S. Space Force, Air Force medics are also
responsible for maintaining the readiness for Guardians operating the
nation's space capabilities. We embrace these unique physical and
psychological demands of Space mission sets and are planning for the
future demands of space medicine requirements.
My responsibility to provide the best prepared medical force has
not been dampened by the challenges of the ongoing pandemic, in fact,
it has proved the resilience and flexibility of our Airmen. This
pandemic tested our capabilities; we faced many challenges, but at the
core of our success was our medics. Their training, commitment, and
dedication to service provided a resource our nation depends upon.
air force medical service covid-19 response
Over this past year, our medics have been put on the front lines
like never before, to combat a new enemy, one that struck in our own
backyards and bases around the globe. The pandemic brought military
medical capacity and capability to the tip of the spear in our nation's
response in combating COVID. Our medical Airmen from nearly every
specialty and position have been working tirelessly alongside our
sister services and civilian partners to conquer this disease. We have
deployed to the hardest hit areas of our country to support overrun
civilian hospitals. In the midst of these challenges, our Airmen have
continued to innovate and respond to my call for disruptive innovation.
One example is the Negatively Pressurized Containment unit. During the
2014 Ebola epidemic, it became clear the Department of Defense needed a
way to safely transport multiple patients within the same airframe who
were suffering from a highly infectious disease. Four months from when
the need was identified, the transport isolation system was introduced
and ready for patient movement. It is easily transported on existing
cargo aircraft, including the C-130 and the C-17 and provides a
contained area for medics to care for these patients. While we trained
to execute this system, it never saw an operational mission until the
COVID-19 pandemic. The first operational mission for this isolation
system took place on April 10, 2020, when three COVID-19 positive
patients were transported from Afghanistan to Ramstein Air Base,
Germany.
While the mission was a success, the rapid rise of COVID-19 case
numbers required us to move larger numbers of patients at one time.
This was a challenge, but our Airmen partnered with teams across the
Air Force, Department of Defense, and civilian industry, under the
direction of the Program Executive Office for Agile Combat Support, to
develop and procure an innovative solution. In less than 100 days, a
new isolation system, the Negatively Pressurized Conex, was launched.
This innovation rapidly went from an idea to a solution, and on July 1,
2020, Airmen successfully transported 12 COVID-19 patients on a C-17.
As of February 25, 2021, we have completed 39 missions and moved 216
COVID-19 patients in this system.
Our Air Force medics also provided the nation with innovative
solutions to solve bed space and personnel shortages. When COVID-19
epicenters in New York, California, North Dakota, and Texas were
experiencing bed space shortages, our team went to work developing
solutions and designed four COVID Theater Hospitals, consisting of more
than 200 beds, to provide the support the communities were desperately
seeking. As cases surged, it soon became apparent that these solutions
would not accomplish the immediate needs of our civilian partners, so
we quickly tailored a better solution. We broke our theater hospitals
into smaller critical care strike teams and embedded them directly into
civilian facilities to augment their capabilities. Nearly 800 Air Force
medics were deployed into civilian facilities to work alongside their
civilian counterparts. Most recently, we deployed an additional 1,000
Air Force medics to 11 vaccination sites in 10 states to administer
COVID-19 vaccines. As of April 6, 2021, we have successfully
administered more than 678,162 vaccines.
delivering care to our warfighters
While the nation's attention shifted to combating COVID-19, the Air
Force Medical Service never took the eye off of the ball in supporting
the operational demands of the Air and Space Force missions. Our medics
hold the sacred responsibility for treating service members so they can
complete the mission and return home safely. We have continued to
bolster our existing capabilities.
Currently, we are halfway through a five-year rollout of a new
initiative to embed base Operational Support Teams at all Department of
the Air Force installations. The Operational Support Teams consist of a
clinical psychologist, social worker, physical therapist, exercise
physiologist, and a team leader who are all focused on improving
operational performance of our Airmen. The team will provide direct
unit-level medical engagement outside of Air Force military treatment
facilities. This is accomplished by enhancing both physical and
psychological resiliency, as well as employing military occupational
injury prevention techniques. These teams will temporarily embed into
high-risk squadrons and begin to build and foster trusting
relationships, conduct unit-focused needs assessments, provide
interventions, and conduct consultations. The overall goal of this
initiative is to address unit-specific health concerns before they have
a chance to negatively impact Airmen, Guardians, or the mission.
keeping medical airmen ready to deliver care
The readiness of my medics is my number one priority. The primary
readiness platform for medical skills are our military treatment
facilities. However, some of our treatment facilities do not have the
patient volume, diversity, and acuity Air Force medics require to have
a current skill set. To address this gap, I have developed several
partnerships and training agreements with civilian organizations. In
the past year, we continued to grow these opportunities with our most
recent partnership--the University of Nebraska Medical Center. In 2019,
we started our newest C-STARS-Omaha program with a primary focus on
disease containment. This site focuses on the care of highly infectious
disease patients. Our Air Force medics, working alongside their
civilian counterparts, were able to treat some of the first COVID-19
patients utilizing the university's biocontainment unit. On March 1st
of this year, we launched the inaugural course on principles of
biocontainment care, covering topics on recognition, diagnosis and
management of highly-infectious disease, infection prevention and
control principles, and safe donning and doffing personal protective
equipment. This course will pay huge dividends for future pandemic
events.
In addition to establishing civilian partnerships to maintain
currency, we are also developing an internal training program called
Medic-X. This program is designed to expand medical support skills in
mass casualty scenarios where patient load overwhelms medical
capabilities. This approach fundamentally changes what defines an ``Air
Force Medic,'' extending response capabilities to all Air Force Medical
Service skillsets and ranks, including non-clinical careers such as,
pharmacists, lab officers, medical administrators, and medical
logisticians. We have identified 58 specific skills aimed at equipping
non-clinical Airmen with the ability to respond in the event of a mass-
casualty event. A beta test of non-clinical personnel was conducted in
May 2020 at 10 different locations with a 96.5% success rate of
comprehension, retention and execution of these skills. We plan on
rolling out the Medic-X program in phases with the goal of full
integration into all of our bases by 2025.
commitment to military health system transition and transformation
Despite challenges posed by implementing the changes outlined in
section 702 of the 2017 National Defense Authorization Act and COVID-
19, we remain dedicated to the smooth transition of the delivery of the
health benefit, and associated functions and personnel to the Defense
Health Agency, so I can focus on my responsibility of delivering
medically-ready Airmen and Guardians and ready medical Airmen. The Air
Force Medical Service has been engaged with the Defense Health Agency
to help them formalize processes, mitigate risks, and address
challenges. We have provided a detailed framework that identified all
functions and personnel required to stand up DHA's functional
capabilities. We also worked with DHA to identify ways to standardize
these services across all military treatment facilities. Despite a
temporary pause in transition activities due to COVID-19, the Air Force
Medical Service continues to provide the necessary transition support,
providing requested resources and manpower needed to maintain specific
functional capabilities at military treatment facilities. This direct
support is expected to end on October 1, 2021.
As our Air Force Military Treatment Facilities continue to
transition to the authority, direction, and control of the Defense
Health Agency, we also implemented an Air Force Medical Reform Model to
align with the Air Force's Strategic Plan to enhance readiness,
increase lethality, and utilize cost-effective modernization. Resource-
neutral changes in structure were applied to focus and improve the
deployability of the forces. Under this new model, we reconfigured and
launched two new squadrons with distinct missions. The first squadron,
the Operational Medical Readiness Squadron, focuses on the health of
Airmen and Guardians, and the second squadron, the Healthcare
Operations Squadron, focuses on delivering care to all other
beneficiaries. Analysis to date, has shown a decrease in the duration
of Mobility Restriction by 6.6 days, an increase in Individual Medical
Readiness by 1.1% and a decrease in Non-Deployable, All Reasons status
by 2.3%.
new frontiers and new domains
Our readiness posture has equipped us to swiftly and effectively
respond to COVID-19 while maintaining the demands of our mission. We
now need to be ready for a more dynamic and demanding battlefield,
forcing us to push the boundaries of our capabilities even further Our
future ground medical forces and equipment must be more agile, lighter,
leaner, and more autonomous when considering logistical support may be
limited. Wherever our Airmen and Guardians go, Air Force medics must
follow.
As mentioned earlier, the U.S. Space Force is now a year old. Space
Force medical support focuses on addressing the occupational challenges
that emerge while operating unmanned satellites. As the demands of the
Space Force increase, so will the necessary medical support to keep
those members fit for duty.
The Arctic region's increasingly strategic importance, along with
the Department of Defense's significant regional investment, requires a
deliberate and forward-thinking approach to ensuring the U.S. can
compete and protect the nation's interests in the region. This means
leading the development and establishment of the Air Force Medical
Service's capability to provide medical care in this environment. In
support of the Department of the Air Force Strategy, on my direction,
the Air Combat Command Surgeon, in collaboration with the Air Force
Medical Readiness Agency conducted a Capabilities-Based Assessment
focused on identifying capability gaps and requirements necessary to
operate and sustain medical operations in extreme cold environments,
called Below Zero Medicine. We convened two Below Zero Medicine
Summits, made up of diverse groups of subject matter experts, to
support the establishment of a Medical Pilot Unit and a Cold Weather
Region Center of Excellence (Medical) at Joint Base Elmendorf-
Richardson. This initiative is focused on identifying and implementing
innovative ways to bring the hospital to the patient in any
environment.
The ongoing COVID-19 pandemic has consumed much of the nation's
attention, bringing with it unprecedented and unpredictable challenges.
It forced our medics to adapt at breakneck speeds and face an unknown
enemy, and they did just that. They worked to keep themselves safe, to
protect the mission and continue to save lives. While many may see a
group of military medics working against insurmountable odds, I see
military medics putting their training into action. I see the
deployment of agile, resilient and capable medics equipped with what
they need to face the unknown. This is what we train for--we remain
ready so we can fight tonight. This mentality must remain in focus as
we evolve to face the next major threat.
I am honored to serve as the Surgeon General for both the Air Force
and Space Force and to work alongside the talented leadership in both
Services, our Army and Navy partners, and the DHA as we continue to
battle COVID-19 and transform the Military Health System. Most
importantly, I am honored to work for our medics who are at the
frontlines whenever and wherever they are needed. Thank you to the
Subcommittee for your continued support of our remarkable Air Force
medics and the health of our Airmen, Guardians, Soldiers, Sailors and
Marines.
Senator Tester. Thank you, General Hogg, and we appreciate
your support to the services and wish you well in retirement
when that time comes.
Admiral Gillingham.
STATEMENT OF REAR ADMIRAL BRUCE L. GILLINGHAM, SURGEON
GENERAL, DEPARTMENT OF THE NAVY
Admiral Gillingham. Chairman Tester, Vice Chairman Shelby,
distinguished members of the subcommittee, it is my privilege
to update you on Navy Medicine. I am grateful for your
continued leadership and support as we execute our medical
readiness mission in support of the United States Navy, United
States Marine Corps, world's premier Naval Force.
Last year has been like no other in our lifetimes as we
confronted a deadly adversary, the SARS-CoV-2 virus and the
disease it causes, COVID-19. The battle continues today.
Navy Medicine's operational tempo remains high as we
protect the readiness and health of our sailors, marines, and
their families, along with making direct contributions to the
whole-of-Nation pandemic response.
To date, we have deployed over 6,000 active and reserve
component medical personnel in support of operational COVID-19
missions. I want to assure you that despite these unprecedented
challenges, the One Navy Medicine team remains relevant, ready,
and responsive.
We continue to be guided by our strategic priorities:
people, platforms, performance, and power. Well-trained people
working as cohesive teams on optimized platforms, demonstrating
high-value, high-velocity performance that will project medical
power in support of naval superiority.
With the earliest identification of the SARS-CoV-2 virus,
it was evident that we were battling an adversary whose
behavior is highly unpredictable, particularly with respect to
its asymptomatic transmission. While all of us in military
medicine are trained to respond to medical emergencies, we
quickly recognized that protecting our personnel in this public
health crisis along with maintaining operational effectiveness
would be our primary mission.
Actions and intervention by experts across Navy Medicine
during early stages directly impacted our ability to better
understand the virus, mitigate and contain its spread,
effectively support ongoing fleet operations, and preserve Navy
and Marine Corps readiness out forward.
We rapidly applied lessons learned from the early outbreaks
on board USS Theodore Roosevelt and USS Kidd and continually
incorporated the latest critical information from the Centers
for Disease Control and Prevention as well as Navy Medicine,
public health, and R&D experts.
Navy leadership quickly operationalized this guidance for
the fleet in the form of standard operational guidance, and
this is currently in its fourth update. This direction
incorporates the most up-to-date scientific and public health
information, to include testing, restriction of movement,
isolation, quarantine, physical distancing, face coverings,
contact tracing, and now vaccinations. Importantly, our sailors
and marines have demonstrated tremendous personal
responsibility, resilience, and adaptability in responding to
the pandemic.
Their work in concert with strong commitment from our
operational leaders has been instrumental in allowing our ships
and personnel to stay mission capable, despite the pandemic.
Our highest priority remains ensuring that all Department
of Navy personnel have access to the vaccine in order to
protect themselves, their shipmates, their families, and their
community. As the Navy Surgeon General, I have been clear in my
guidance that these vaccines are for the most effective
protection against this deadly virus.
The bottom line is that we are getting shots in arms and
providing our personnel with what I refer to as ``biological
body armor.'' To date, Navy sites have administrated over
three-quarters of a million vaccines, and over 50 percent of
our sailors and marines have now received at least one vaccine
dose.
Navy Medicine continues to answer the call to help our
Nation. Navy and Marine Corps personnel are now currently
deployed around the country to assist with vaccine
administration in community vaccination centers.
I recently had an opportunity to see firsthand the
significant impact they are making in the lives of our fellow
citizens affected by the virus.
Navy Medicine's COVID-19 response is marked by grit,
resolve, and an unbreakable spirit. While battling the pandemic
remains a primary line of effort, we remain fully engaged in
all aspects of our mission of improving readiness and enhancing
operational capabilities to increase warfighters'
survivability.
My written testimony provides you details on many of these
important initiatives that directly support physical and mental
well-being of our sailors, marines, and their families.
In summary, the Nation depends upon our unique
expeditionary medical expertise to support our Naval Forces.
The Navy Medicine team, some 63,000-strong, is privileged to be
entrusted with these responsibilities.
Again, thank you for your leadership, and I look forward to
your questions.
[The statement follows:]
Prepared Statement of Rear Admiral Bruce L. Gillingham
Chairman Tester, Vice Chairman Shelby, distinguished Members of the
Subcommittee, it is my privilege to update you on Navy Medicine. The
last year has been like no other in our lifetimes as we confronted a
deadly adversary, the SARS-CoV-2 virus and the disease it causes,
COVID-19. The battle continues today. Throughout this global pandemic,
the operational tempo of Navy Medicine remains high, as we protect the
readiness and health of our Sailors, Marines and their families, along
with making direct contributions to the whole of Nation response to
help our fellow citizens in need. I want to assure you that despite
these unprecedented challenges, the One Navy Medicine team remains
relevant, ready and responsive. I am grateful for your continued
leadership, support, and confidence as we execute our medical readiness
mission in support of the United States Navy and United States Marine
Corps, the world's premier Naval Force.
aligning strategy, priorities and resources
Foundational to Navy Medicine's mission effectiveness is full
synchronization with the strategic direction articulated by the Chief
of Naval Operations and Commandant of the Marine Corps in their seminal
documents CNO Navigation Plan 2021 and the Commandant's Planning
Guidance 2019, respectively. This guidance, along with the Tri-Service
Maritime Strategy (2020), details the way forward in meeting current
and future challenges posed by a dramatically changing international
security environment. We in Navy Medicine recognize that our lines of
effort must be vectored to support these strategic imperatives. Our
four priorities--People, Platforms, Performance and Power--ensure
important readiness linkages to our Marines and Sailors: Well-trained
People, working as cohesive teams on optimized Platforms, demonstrating
high value Performance that will project medical Power in support of
Naval Superiority.
To help ensure that we execute these critical priorities, I have
added additional analytical rigor and alignment to our strategic
planning process through a series of directive-type memoranda for our
key program investments. Each must align with one or more of the Navy
Medicine priorities. This process is critical as we shape our decision
making; including, guiding our resource allocations, assessing
organizational capacity and capability, and assessing performance.
Overall, I am encouraged that these priorities are taking hold at all
levels within Navy Medicine. Our personnel recognize that Navy Medicine
is a team sport; and as such, everyone, collectively and individually,
is performing an impactful role in contributing to mission success.
In FY2021, additional Defense Health Program (DHP) resources were
realigned to the Department of the Navy (DON) to support medical
readiness activities which occur outside of military medical treatment
facilities (MTFs). These resources are important to DON's efforts to
execute non-MTF responsibilities in direct support of medical
readiness. We are grateful for the financial resources provided in the
FY2021 Defense Appropriations Act, as well as the supplemental funding
that was provided last year in response to the COVID-19 pandemic. I
want to assure you that inherent in our business practices is the
application of sound fiscal stewardship of to the resources entrusted
to us.
responding to the covid-19 pandemic
With the earliest identification of the SARS-CoV-2 virus, it was
evident that we were battling an adversary whose behavior was highly
unpredictable. While all of us in military medicine are trained to
respond to medical emergencies and crises, we quickly recognized that
protecting our personnel in this public health emergency, along with
maintaining operational effectiveness, would be our primary mission.
Actions and interventions by experts from the Navy Medicine Public
Health and Research and Development enterprises during the early
stages, directly impacted Navy Medicine's ability to better understand
the virus's behavior, mitigate/contain the virus spread, effectively
support ongoing Fleet operations, and preserve Navy and Marine Corps
readiness. To illustrate, using state-of-the-art technologies and
research-use only assays for COVID-19, personnel from the Navy Medical
Research Center deployed to USS THEODORE ROOSEVELT (CVN-71) providing
the first COVID-19 detection onboard a Navy ship, and filling a
critical gap in COVID-19 in the Fleet prior to the Food and Drug
Administration (FDA) issuing Emergency Use Authorization (EUA) for
COVID-19 diagnostic devices available onboard ships.
This work continued as we learned how to deal with the virus from
the early outbreaks on THEORDORE ROOSEVELT and USS KIDD (DD-661),
particularly regarding its asymptomatic transmission. Rapidly applying
lessons learned from these ships and continually incorporating the
latest critical information from the Centers for Disease Control and
Prevention (CDC) and Navy Medicine experts, Navy leadership quickly
operationalized this guidance for the Fleet in the Standardized
Operational Guidance (SOG), currently in its fourth update. SOG
incorporates the most current scientific and public health information
to include testing, restriction of movement, insolation/quarantine,
physical distancing, face coverings, contact tracing, and vaccinations.
This direction is critical for both individual and unit health
protection and is impactful in preserving operational readiness while
protecting shipmates, installation and communities from COVID-19
transmission. Our Sailors have demonstrated tremendous personal
responsibility, resilience and adaptability in responding to the
pandemic. More than a year from the onset of the initial outbreak, the
SOG, along with other key lines of efforts throughout the Navy, have
been instrumental in allowing our ships and personnel to stay mission
capable despite the pandemic.
In an effort to gain more insight into SARS-CoV-2 virus, Navy
Medicine conducted two important studies, both of which were published
in the New England Journal of Medicine on November 11, 2020: (1) An
Outbreak of COVID-19 on an Aircraft Carrier analyzed epidemiological
data from the outbreak of SARS-Cov-2 onboard THEORDORE ROOSEVELT in
order to understand the transmission and impact of SARS-CoV-2 on the
crew. This work provides a better understanding of the behavior of the
virus shipboard and supports the development of updated guidance for
the Fleet to mitigate future outbreaks. (2) SARS-CoV-2 Transmission
among Marine Recruits during Quarantine reports on the COVID-19 Health
Action Response for Marines (CHARM) which took place at Marine Corps
Recruit Depot Parris Island and examined asymptomatic and symptomatic
transmission in a young adult population. A follow-on study with the
initial Marine volunteers, CHARM 2.0, is currently underway. This
research is important for Naval Forces but also reaffirms our
commitment to widely contribute to further the understanding of the
SARS-CoV-2 virus both nationally and internationally.
An important epicenter for actionable information is our Navy
Medicine Scientific Panel, comprised of Navy Medicine scientists,
clinicians and public health experts. They advise leadership and work
directly with operational medical personnel to facilitate rapid
consultation and enable high velocity learning with respect to COVID-
19. In addition, their work is reflected in the widely disseminated
Navy Medicine Weekly COVID-19 Public Health Report that provides
current and timely scientific, clinical and surveillance updates.
In addition to Navy Medicine's work efforts in support of Navy and
Marine Corps unique requirements, collaboration with the DoD COVID-19
Task Force, the Joint Staff, the Defense Logistics Agency, the DHA, the
other Services, Uniformed Services University of the Health Sciences
(USUHS), interagency partners, and many others have been important to
the pandemic response. This work provides the needed coordination,
standardization, and unity of effort in critical areas impacting all
the Services including diagnostics and testing, therapeutics, contact
tracing, personal protective equipment, COVID-19 convalescent plasma,
vaccinations, logistics, technology and other key areas. Within the
Military Health System (MHS), a compelling example of the synergy that
comes from this collaboration across our clinical communities is
reflected in the development and publication of the DoD COVID-19
Practice Management Guide (version 7), an excellent resource that
contains practice guidelines and studies for our providers.
We also recognize the tremendous work by General Gustave Perna,
United States Army, who led the federal response for accelerated
development, manufacturing and distribution of vaccines. These efforts
have resulted in the FDA issuing EUAs for three vaccines, and likely
more to follow. Currently, our highest priority remains ensuring that
all Sailors, Marines, and all DON personnel have access to the vaccine
in order to protect themselves, their shipmates, their families and the
community, consistent with the DoD prioritization schema. As the Navy
Surgeon General, I have been clear in my guidance that inoculation with
these vaccines, which is currently voluntary, is the most effective
protection against this deadly virus.
Navy Medicine continues to answer the call to help our fellow
citizens through medical surge support and vaccination support. In the
early stages of this public health emergency, at the request of the
Federal Emergency Management Agency (FEMA), Navy deployed both hospital
ships, USNS MERCY (TA-H 19) and USNS COMFORT (TA-H 20), as well as
personnel assigned to our expeditionary medical facilities, to support
overwhelmed civilian hospitals, clinics and skilled nursing facilities
in several states. Applying lessons learned, Navy Medicine quickly
developed new adaptive capabilities with smaller acute care teams and
rapid rural response teams, which proved effective in augmenting staff
at smaller hospitals in medically underserved locations including
Texas, New Mexico, and Arizona. Navy and Marine Corps personnel are now
currently deployed to assist with vaccinations as part of the DoD
Community Vaccination support. These personnel are administering
vaccinations to fellow citizens in state-run, federally-funded
community vaccination centers around the country. I had an opportunity
to visit several of these teams and see firsthand the impact they are
making in the lives of our fellow citizens most affected by the virus.
To date, Navy Medicine has deployed over 6,000 active and reserve
component personnel in support of operational COVID-19 missions.
projecting medical power
Navy Medicine's COVID-19 response continues to project medical
power. It is marked by grit, resolve and an unbreakable spirit. While
battling the pandemic remains our primary line of effort, we remain
fully engaged in all aspects of our mission; directly focused on
improving our readiness and enhancing capabilities to increase
survivability. These efforts include leveraging all dimensions of
people, platforms, performance, and, power.
People: Recognizing that our dedicated and diverse workforce is our
greatest strength, Navy Medicine published its Human Capital Strategy
(2020--2025). This strategic framework provides a pathway to help
ensure that our Force, active and reserve component personnel and Navy
civilians, is structured to meet the requirements of evolving
operational demands. It also requires us to optimize and align our
talent management efforts placing right people in the right place with
the right training at the right time.
Overall manning in each of active and reserve component officer
Corps (Medical, Dental, Medical Service and Nurse) remains good;
however, we continue to focus on shortfalls in critical wartime and
readiness specialties to ensure we can meet our operational
requirements in support of the National Defense Strategy. This emphasis
is important given the need to assess and realign our uniformed
personnel requirements and platforms to better support medical
capabilities of the Naval Forces with the transition to Distributed
Maritime Operations (DMO) and Expeditionary Advanced Base Operations
(EABO). We are also prioritizing the need to increase mental health
specialists assigned to the Fleet and Fleet Marine Force, and to
quickly provide full spectrum force health protection in response to
public health emergencies.
We must invest in recruiting, training and retaining our personnel.
Continued accession and retention incentives are critical to the
success of these efforts. Student accession programs are vital,
considering Navy relies on USUHS and the Health Professions Scholarship
Program for the vast majority of new Medical Corps accessions each
year. Thank you for your continued assistance in this area, including
the authorities contained in the FY2021 National Defense Authorization
Act (NDAA) for increased special and incentive pays for officers in the
health professionals.
For the Hospital Corps, manning for active and reserve component is
at 99 percent and 95 percent, respectively. Similarly, efforts are
targeted to shortfalls in critical wartime specialty Navy Enlisted
Classifications (NECs), including Independent Duty Corpsmen (surface,
submarine, dive and Fleet Marine Force reconnaissance). These highly
trained independent providers are vital to delivering expeditionary
medical support to Naval Forces operating forward. To this end, we
launched a campaign to highlight the professionally rewarding
opportunities in these challenging NECs and expanded the eligibility
pool for qualified candidates. We also increased retention bonuses. In
addition, USUHS approved the Independent Duty Corpsmen curricula for
incorporation in their College of Allied Health Sciences which will
allow these Sailors to earn college credits.
Navy Medicine civilians, a highly skilled workforce of
approximately 11,500 professionals, are essential to our mission. They
can be found throughout our world-wide enterprise delivering essential
health care services--clinical care, research and development, public
health and disease surveillance, logistics, and administration and much
more. In addition to providing mentorship and training to our military
personnel, they also provide much needed continuity in our facilities.
We recognize that we face formidable competition with the private
sector in attracting talented, highly qualified candidates, and we must
work to recruit and expeditiously onboard these personnel. Expanded
direct hire authorities provided in 2020 increased the number of
specialties from nine to 27. Currently almost 55 percent of our
civilian workforce is covered under these authorities which allows use
of additional flexibilities for hard-to-fill health care positions.
Again, we appreciate your support in helping us recruit the best and
brightest. To date, Navy Medicine has transferred 40 Navy civilians to
the DHA under transfer of function provision. We anticipate 150
additional employees will transition later this year.
Our priority is to have ready and confident personnel, with the
knowledge, skills and abilities gained by experience and high velocity
learning. The Navy Medicine Training and Education enterprise is
critical to preparing our personnel for their warfighting mission. In
spite of challenges posed by the SARS-CoV-2 virus, Navy Medicine
maintained these capabilities and developed innovative solutions to
mitigate interruptions, delays, and cancellations. Training commands,
staff education and training departments, and operational training
sites maximized use of virtual learning platforms, medical modeling and
simulation, partnerships, cross-training, and blended learning to
sustain ready medical forces. In 2020, we graduated 2,905 Hospital
Corpsmen from basic ``A'' school and 1,235 students from advanced ``C''
schools, while 1,252 Hospital Corpsmen completed Field Medical
Battalion Training. Directly supporting our maritime readiness, experts
from the Navy Medical Modeling and Simulation Training program
developed a mock shipboard training environment onboard the Medical
Education Training Campus (METC). To date, over, 2,075 students have
been trained in shipboard medical emergencies and mass casualty
exercises utilizing this realistic operational training environment.
In addition, our nationally recognized graduate medical and health
education programs are critical to Navy Medicine. I refer to this
robust training as Navy Medicine's ``industrial base'' since they are
foundational to sustaining our pipelines to generate a proficient and
combat credible medical force.
Our partnerships with leading trauma and academic medical centers
are essential in helping our providers get the trauma volume,
complexity and experience to maintain competencies to save lives at sea
and on the battlefield. We continue to leverage our existing
collaborative agreements with the James H. Stroger Jr. Hospital in
Chicago, Illinois; the University of Florida Health Shands Hospital in
Jacksonville, Florida; and the University Hospital Cleveland in
Cleveland, Ohio. Earlier this year, we established a new partnership
with WakeMed Hospital, a Level I trauma center in Raleigh, North
Carolina, while continuing to support a relationship with the Cleveland
Clinic to provide skills sustainment specifically for Independent Duty
Corpsmen. Pre-deployment training for our teams continues at the Navy
Trauma Training Center at Los Angeles County + University of Southern
California. In addition, we are working closely with the University of
Pennsylvania Health System in establishing a military-civilian
partnership for trauma skills sustainment.
Inclusion and diversity are important components to a mission-ready
Navy. Diverse, high performing teams provide us power, advantage and
unity. We are a stronger Navy because of our differences as we draw on
the diverse culture, skills and perspectives of our shipmates. All of
us recognize that we have more to do. These efforts must be
consistently demonstrated through our behaviors and a commitment to
achieving a Culture of Excellence grounded in our Navy Core Values of
Honor, Courage and Commitment.
Platforms: Navy Medical personnel remain forward deployed with the
Fleet and Fleet Marine Force. They are engaged in all warfare domains
with the focus of keeping our Sailors and Marines ready and healthy to
perform their demanding missions. To be effective, they must have
optimized platforms and capabilities to deliver the full range of
medical support, including combat casualty care at sea, rapid public
health response, humanitarian assistance/disaster response, as well as
Defense Support of Civilian Authorities missions.
To meet the demands of sustained operations at sea, Navy continues
to develop new medical capabilities as well as to re-shape current
capabilities to operate throughout the range of military operations. We
recognize that Naval Expeditionary Health Service Support in the DMO
environment requires modular and scalable capabilities able to provide
theater hospitalization and forward resuscitative care, ashore and
afloat. Additionally, we are focused on improved patient movement and
enroute care capabilities, along with more dispersed holding
capabilities to maximize survivability. An important priority currently
in development is fielding a Role 2 Enhanced medical payload for the
Expeditionary Fast Transport (T-EPF) Flight II, hull 14 currently under
construction. Progress continues in support of our overarching
deployable medical systems strategy with the direction and resource
sponsorship of the Navy's Medical Systems Integration and Combat
Survivability Office and in close collaboration with the United States
Marine Corps.
It is also important to note that MTFs serve as important readiness
training platforms. Within the MTFs, as well as through other
partnerships, our providers get needed readiness-centric medical cases
to keep their skills sharp and stay ready to deploy. Accordingly, our
Navy Medicine Readiness and Training Commands (NMRTCs) provide the
critical command and control for Navy Medicine personnel and ensure,
through the Readiness Performance Plans, that our men and women have
the clinical and operational currency and competency to support
operational platforms such as hospital ships and expeditionary medical
facilities. We work to ensure that we man, train and equip our
personnel for current and future operations. These efforts continue to
be impactful during the deployments of personnel from the MTFs in
support of the COVID-19 medical and vaccine response. Furthermore, our
overseas facilities function not only as vehicles for health care
delivery, but more importantly as in-theatre pre-positioned medical
capabilities that are critical components of Combatant Commanders'
operational plans.
Performance: Navy Medicine's success is measured by those we serve,
our Sailors and Marines. All of us recognize that it is necessary to
ensure we provide well-trained personnel serving on agile platforms
with the proper equipment sets; however, we also recognize that it is
not sufficient. We must complement these efforts with relentless
pursuit of applying the principles of a high reliability organization
in all our actions, particularly in the operational forces. High
velocity learning, rapid cycle feedback, and applying lessons learned
are the underpinnings of our collaborative work to improve clinical
outcomes and patient safety. Drawing on our high reliability successes
in MTFs, we are rapidly moving to fully operationalize these tenets to
improve warfighter readiness and increase survivability including the
establishment of six operationally-focused clinical communities: female
force readiness; psychological health; neuromusculoskeletal;
operational medicine; trauma; and, dental services. This priority is
also clearly evident in the whole of Navy Medicine response to the
pandemic as led by our network of chief medical officers and others to
rapidly assimilate and disseminate relevant clinical and scientific
information and best practices throughout the enterprise.
It is critically important that our Sailors and Marines have access
to mental health services, where and when they need them. Navy Medicine
maintains a ``no wrong door'' approach to deliver prevention, early
identification and evidence-based mental health treatment. Services are
available world-wide in mental health specialty clinics, within primary
care, at Navy and Marine Corps installation counseling centers, on the
waterfront, and embedded within the Fleet and Fleet Marine Force to
decrease stigma and ensure access to care for our Sailors, Marines, and
their families. In 2020, embedded mental health (EMH) continued to
expand with 35 percent active component mental health providers and 30
percent of behavioral health technicians assigned to EMH billets. MH
providers are permanently assigned to support aircraft carriers,
submarine forces, amphibious assault and surface combatant ships, Naval
Expeditionary Combat Command units, Marine Corps Ground Combat and
Logistics Element units, and Navy and Marine Corps Special Operations.
Navy Medicine supports operations and readiness, collaborating with
stakeholders on enterprise-wide strategies to address EMH manning,
laydown, and practices, Disaster Mental Health, resiliency, suicide
prevention efforts, and expansion of Operational Virtual Mental Health.
Navy Medicine adeptly responded to new challenges presented by the
pandemic through proactive mental health guidance, surveillance, and
outreach, as well as rapid transition to virtual mental health
modalities in MTFs and EMH. Mental health assets deployed across the
Fleet to support COVID-19 related missions and increased operational
tempo. This support included deploying a Special Psychiatric Response
Intervention Team (SPRINT) to THEODORE ROOSEVELT during the COVID-19
outbreak. Navy Medicine continues to execute and expand the Caregiver
Occupational Stress Control program to support psychological health and
prevent burnout in Navy Medicine personnel, which may be particularly
relevant during COVID-19.
We remain acutely aware of the impact of traumatic brain injury
(TBI) on our Sailors and Marines. Services are provided through a
network of TBI clinics with a range of care levels, including Intrepid
Spirit Centers at both Camp Lejeune and Camp Pendleton, and larger
programs at Naval Medical Centers Portsmouth and San Diego providing
scalable, multidisciplinary, evidenced-based TBI care with a high
return to duty rate. Programs at Camp Lejeune and Naval Medical Center
Portsmouth offer TBI evaluation and treatment tracks specifically
targeted at tip-of-the-spear warfighters who are at greater risk for
sustaining TBI.
Supporting a medical ready force requires that we work diligently
to improve the deployability of Sailors and Marines each and every day.
Navy Medicine emphasizes the importance of completing a deployability
assessment at every provider-based encounter. We also have made
significant improvements to the management of our personnel on limited
duty to include changing the assignment of limited duty from a fixed,
prescriptive duration (180 days) to one that allows for the recommended
recovery period to be determined by the specific medical condition for
the service member. Navy Medicine is also refining algorithms within
our information systems to better identify potential deployment
limiting and temporary non-deployable conditions. All of us know that
warfighting is inherently demanding and we need to do everything we can
to support full recovery when a Sailor or Marine is injured or ill.
Recognizing the unique health care needs of our female Sailors and
Marines, we developed our comprehensive Navy Medicine Female Force
Readiness Strategy. The focus is to organize and coordinate efforts to
increase medical readiness, resiliency, and retention in the female
force and to improve comprehensive care delivery. We are prioritizing
efforts to increase patient education, improve access to care and
striving to ensure front-line provider proficiencies specific to
women's health. To this end, we launched a pilot program to embed a
women's health provider within care settings closer to operational
units to increase service women's ability to resolve health concerns
and minimize time away from duty. The pilot is in place at two Fleet
sites, Naval Station Norfolk and Naval Station Mayport, and both are
yielding promising results. We also published the Deployment Readiness
Education for Service Women Handbook, a digital women's health
education resource for active duty Marines and Sailors.
DON does not tolerate sexual assault. As part of Navy's Culture of
Excellence, we continue to focus on developing and implementing
prevention efforts while maintaining victim support and resiliency.
Navy Medicine remains ready to respond to sexual assault by ensuring
the availability of sexual assault medical forensic exams, ashore and
afloat. We continue to provide responsive medical forensic care during
the pandemic. Collaboratively, the Services sustained ongoing training
by creating a virtual training platform for Sexual Assault Medical
Forensic Examiner students to meet the requirements of the 80 hour
multi-disciplinary course. These efforts helped ensure that we had the
personnel trained to provide sexual assault care in both MTFs and
operational settings. Despite COVID-19 restrictions, we trained 83 new
medical forensic providers for total inventory of 167 serving across
Navy Medicine platforms.
Navy Medicine continues to support the fielding of MHS GENESIS,
DoD's modernized electronic health record. This effort is essential to
our work to drive standardization, improve patient safety and foster
high reliability within the MHS. From 2017 through March 2021, MHS
GENESIS has been deployed to nine Naval facilities in Washington and
California. Lessons learned from the earlier MHS GENESIS deployments
have been applied to current sites and we are seeing substantive
improvements in both training and implementation. We are fully engaged
in joint implementation and optimization efforts in the fielding of MHS
GENESIS and will continue to work collaboratively with DHA and the
other Services. Despite challenges due to the COVID-19 pandemic,
significant progress has been made with implementation and the MHS
remains on track to complete MHS GENESIS deployment by 2024.
Power: Navy Medicine's capability to project medical power is
critical to increasing the survivability of Naval Forces, at sea and on
the battlefield. Our contributions include providing the best combat
casualty care along with rapidly addressing the threats that contribute
to disease non-battle injuries. The global pandemic has demonstrated
that we must be prepared to employ the full strength of our One Navy
Medicine capabilities to protect the health of Sailors and Marines.
Our Navy Medicine Research and Development enterprise continues to
demonstrate that it is responsive to operational requirements and is
capable of providing rapid solutions for the warfighter. Collectively,
their expertise in unique Naval environments provide high-value, high-
impact knowledge and materiel products as evidenced by the significant
contributions in battling the SARS-CoV-2 virus, including diagnostic
testing, genome sequencing of potential viral variants and
countermeasures development.
In addition, we conduct a range of research from basic research,
applied research, advanced development, to testing and evaluation. Navy
Medicine is engaged in work that directly supports Sailors and Marines,
including advancing treatments of decompression sickness among diving
and submarine personnel, providing research response to unexplained
physiological events in tactical aircraft, and studying the impact of
blast exposures on personnel. Due to the strategic location of labs,
many projects involve infectious disease surveillance and international
outbreak response enabling better understanding of global emerging
health threats to military readiness.
Our partnerships with nations on six continents, U.S. academia,
non-profit organizations and the private sector, along with access to a
global network of scientists, allow for research focused on keeping
service members healthy and ready.
Similarly, the Navy Marine Corps Public Health Center (NMCPHC) and
its field activities continue to be on the vanguard of Navy's public
health efforts in response to the COVID-19 pandemic. Their impactful
contributions are reflected in all aspects of our strategy of
prevention, mitigation, and recovery. Contributions include deploying
public health and preventive medicine expertise on COVID-19-related
missions to developing science-driven and evidence-based publications
such as the ``Playbook for Managing Coronavirus Disease 2019 in a
Shipboard Operational Setting'' which details management of SARS-CoV-2
outbreak with platform specific recommendations for sanitation,
prevention and treatment. Their portfolio is broad and includes
laboratory operations, environmental health, population health as well
as preventive medicine. NMCPHC brings the unique and vast expertise
that is sought after, and, more importantly, is valued by Navy and
Marine Corps operational leaders.
Global Health Engagement (GHE) remains a critical element of global
stability and national security, particularly in support of security
cooperation by strengthening strategic partnership and alliances. Given
its importance, GHE represents another important line of effort in
support of projecting medical power. Our health security cooperation
officers and global health specialists are working in support of
Combatant Commanders, Navy Component Commanders as well as interagency
and international partners. In addition, Navy GHE improves readiness,
builds resiliency and provides competencies of our Navy Medicine
personnel and prepares them to address an increasingly complex and
interconnected world where health threats do not respect borders.
Given that our Naval Forces are operating forward around the world,
we must continue to leverage the inherent power of Naval Virtual
Health, applying technology to provide care and clinical consultations,
without the constraints of time and distance. Our response to the
COVID-19 pandemic served to accelerate our efforts as Navy Medicine
used virtual health services, both operationally and in-garrison, to
continue to support the operational readiness of Sailors and Marines
during a time when access to face-to-face care diminished, and movement
limitations impacted our personnel. We saw significant increases in
virtual health visits in many areas, but most notably in mental health.
This trend is very encouraging and signals that we are able to maintain
important access to care for our patients, particularly given the
stressors brought about by the pandemic. We are also working to expand
virtual health reach in important readiness areas including periodic
health assessments, deployment-related assessments, suitability
screening and others. A key complement to our virtual health priorities
is Navy Medicine's enterprise-level efforts to advance and integrate
data and data analytics throughout our decision making processes
through capabilities such as machine learning, robotic process
automation and metrics dashboards.
moving forward
We continue the important work of MHS transformation. While the
COVID-19 response necessitated an extended pause for many of these
efforts, we have returned to planning and implementing the relevant
Congressionally-directed reforms. Military Medicine's response to the
pandemic provides us a meaningful organizational stress test to assess
our capabilities and progress, essentially identifying what's working
well, along with highlighting areas that need attention. Critical self-
assessment and applying lessons learned derived from rapid cycle
feedback are important as we build a high reliability organization.
Within the DON, our leadership recognizes the tremendous
opportunity we have to refocus our efforts on medical readiness while
transitioning health care benefit administration and management to the
DHA, including direction and control of the MTFs. Properly executed,
this construct will provide important opportunities to increase
standardization, eliminate redundancies and favorably impact safety,
quality and access within the MHS. In addition, it affords the DON
capacity to focus exclusively on medical readiness and its unique
responsibilities to provide a trained and ready medical force capable
of operating in the maritime domain to meet their missions of Naval and
Joint Forces.
To this end, our work continues to address the smooth transition of
MTFs to the DHA as well as the key mission and functions of our NMRTCs
in providing critical command and control structures for Navy Medicine
personnel to meet Navy and Marine Corps missions. NMRTCs, at the local
MTF level, will facilitate and reinforce the mutually supportive
relationship between Navy Medicine and the DHA. Our goal remains to
build an integrated system of readiness and health. While there is much
work ahead, I see tremendous potential for military medicine to be a
national model for health care high reliability and integration.
All of us in Navy Medicine understand the important
responsibilities placed on us by the Nation to care for our Sailors and
Marines who go in harm's way. Again, thank you for your support.
Senator Tester. Thank you, Admiral, and thank you all for
your testimony.
We are going to start with 5-minute rounds of questions.
Dr. Adirim, in your testimony, you talked about a $1.8
billion shortfall, $1 billion with TRICARE, $800 million with
military shortfall. Do these shortfalls impact the delivery of
service of care to our servicemembers, retirees, or their
families?
Dr. Adirim. Senator, our first priority is our healthcare
to our troops and to their family members. That will never
suffer any decrement whatsoever. That is our first priority.
And those numbers that I cited are projections that we are
making. Currently, we have about $673 million in costs that
were not expected due to the COVID response, but we project
that it will be over $1.8 billion.
Senator Tester. Okay. And so what are your plans to address
these shortfalls? Does Congress need to step up?
Dr. Adirim. The Department is not planning to ask for a
supplemental. We are looking to other programs within the DHP
(Defense Health Program), such as sustainment, modernization
funding. We will have to postpone facilities maintenance. We
are looking for things like that, and we will likely have to
look to the Department as well to fill these shortfalls.
Senator Tester. So you are going to fill these shortfalls
with transfers within the Department of Defense?
Dr. Adirim. We are currently now looking at how we can
mitigate the shortfalls in any way that we can. It is a
challenge.
Senator Tester. Okay. I may come back to another question
on that in a bit.
I want to talk about TRICARE. I am going to stay with you,
Dr. Adirim. Can you tell me what impact the recent
implementation of enrollment fees for TRICARE Select is having
on the number of beneficiaries enrolled?
Dr. Adirim. Sure. I am not aware that there has been an
impact due to any historical increase in fees. I can get you
more precise information for the record if that is what you
want, but I am not aware that there has been a decrement in our
enrollment due to the fees.
Senator Tester. So you are not seeing a decline in
enrollment in TRICARE?
Dr. Adirim. Senator, I think I would like to take that for
the record so we can get you a more precise answer.
[The information follows:]
effect of new enrollment fees on tricare participation
The overall decrease in TRICARE Select enrollments from December,
2018 to April, 2021 for Retirees and their family members who are not
Medicare eligible and the corresponding increase in the number not
enrolled in a TRICARE plan may be attributable to the statutory
requirement that most Group A Retirees and family members pay TRICARE
Select enrollment fees beginning January 1, 2021 and the availability
of other health insurance (OHI) options to some of these beneficiaries.
There is certainly a correlation between implementation of
enrollment fees and changes in the number of enrolled beneficiaries but
an exact causation is more difficult to predict. If fees were not paid
by early February, 2021, their existing TRICARE Select coverage was
terminated for failure to pay enrollment fees, as required by statute.
About 139,000 (15.9 percent) remaining Group A retirees and family
members have until June 30, 2021 to request reinstatement of their
TRICARE Select coverage if they desire to stay in TRICARE for the 2021
calendar year.
--Select Enrollment for Retiree & their family members who are not
Medicare eligible fell by about 160,000 (18 percent) between
December 2020 and March 2021, then went up by 10,000 in the
April 2021 data. It is inferred that the increase in the April
2021 data was a result of beneficiaries paying fees and
enrolling following the failure to pay notifications.
--Aside from the differences between the Select and Prime
populations, one could conclude that other insurance options
are available and there may be other reasons for enrollments
(i.e. Medicare eligibility, change of address) to change over
time. As an example, Prime Enrollment for Retiree and their
family members who are not Medicare eligible dropped 18,000 (1
percent) between December 2020 and March 2021, then decreased
another 3,500 from March to April.
Senator Tester. Okay. That would be good.
In 2018, when the Military Health System was first
beginning to implement reforms, we saw increases in TRICARE
copays for specialty care, and this includes physical therapy
and mental health, two treatments that are very common in
military and veteran communities. Can you speak to the impact
these increased copays have had on utilization of physical
therapy and mental healthcare treatments under TRICARE?
Dr. Adirim. Sure. And again, Senator, I am not aware that
there has been an impact on utilization of those services due
to the copays, and I am happy to take that back too and get you
a more precise answer. We can compare years for you.
[The information follows:]
effect of higher copays on demand and accessibility of mental health
services
With our data, we cannot estimate the impact that copay
modifications had on the utilization of these therapies, as there are
many factors which modify utilization rates.
For all behavioral health we saw increases in utilization in all
years 2018-2020 for all beneficiary categories, though the rise in
utilization was smaller for Retirees than Active Duty Family Members.
For physical therapy, there were increases in utilization for ADFMs
in 2018-2019. In 2020 we saw increases in Prime ADFMs, but a slight
decrease in Select ADFMs. In 2018 there were decreases in Retiree
utilization, a similar increase in 2019, and a small decrease in 2020.
However, the data show that utilization of physical therapy for
Prime Retirees fluctuated throughout 2011-2020, and not just the time
period after implementation of NDAA 2017.
Senator Tester. That would be good. I think it is
critically important we know this. This is information that we
need to know, and I will tell you why, because I am hearing
about it on the ground in Montana. And if I am hearing about
it, I am sure a lot of other Senators and Representatives are
too.
Dr. Adirim. Sure, Senator. I am happy to bring that back.
Senator Tester. Okay. So considering the reforms that have
taken place, not to beat this mule anymore, but considering all
the reforms that have taken place for TRICARE beneficiaries
over the last 3 years, do you believe this benefit has retained
the same level of historical value?
Dr. Adirim. Absolutely. I think it is a very rich benefit,
especially when you compare it to the civilian sector. It is a
uniform benefit. So all beneficiaries have access to the same
benefit and menu of services that TRICARE offers.
I believe that with the new T5 Request for Proposal coming
out and that new contract, that we will see even more benefits
for beneficiaries.
Senator Tester. Okay. I want to go back to the shortfall,
the $1.8 billion, and this is for the other folks who are here,
the Surgeon Generals. Do you have any concerns about whether we
are risking a shortfall? I mean, with this shortfall, that it
is going to impact care to your troops?
Go ahead, General Dingle. We will just go down the line
here.
General Dingle. I will start it off, Chairman Tester.
So, as the Army looks at the operational force, what we do
in conjunction with the Defense Health Agency and the Defense
Health Agency and OCD (Office of Civilian Defense) Health
Affairs, we identify our readiness requirements up front.
Right now, we do not have a shortfall, as we have worked
through our readiness requirements as we identify those, but we
will have to assess that as the fiscal year continues on.
Senator Tester. But the answer right now is no?
General Dingle. Correct. Yes, sir.
Senator Tester. Okay. General Hogg?
General Hogg. Yes. So, along the same lines, Chairman,
medical readiness of our force is paramount and number one, and
so everything that we do will be directed toward that. At this
point, yes, no shortfall.
I do, however, have a concern that as we move forward, if
there is a shortfall, how that is going to get covered.
Senator Tester. Yep, I gotcha.
Admiral Gillingham.
Admiral Gillingham. Yes. Thank you, sir.
Like my colleagues, I think this is something that we will
watch carefully and continue to work internally. At present, I
do not see a threat to our medical readiness, and as always, we
will make sure that we provide most effective and high-quality
care we can to our beneficiaries.
Senator Tester. Appreciate that.
Senator Shelby.
Senator Shelby. Thank you, Mr. Chairman.
Dr. Adirim and General Dingle, I will direct the first
questions to you, both of you. As I noted in my statement, this
committee continues to invest in medical research without
regard to other similar Federal investments, it seems to me, at
NIH, and maybe NIH is doing things you are doing better. I do
not know that.
Can you answer the question that I posed in my opening
remarks, which is this?: What specifically are Defense medical
research dollars doing that NIH funding cannot or is not doing?
I think that is an important question.
Dr. Adirim. Senator Shelby, I will start with this
question, and I think that is a very good question.
We focus our research priorities within the Department on
the warfighter and on the needs of the Joint Force and on those
conditions which may greatly impact our troops.
We work very closely with the NIH and other agencies,
coordinate very closely on research so that----
Senator Shelby. What do you mean by working closely? Is
that collaborative working together----
Dr. Adirim. Yes. Yes, we do.
Senator Shelby [continuing]. On specific things? Name some
of them.
Dr. Adirim. Sure. So, for example, for something like
suicide and mental health, there is collaborative research that
we work with NINDS (National Institute of Neurological
Disorders and Stroke), have annual meetings on the research
that comes out of both departments. The work groups work
together to ensure that the research that is being done and
sponsored by each department or together, because sometimes
these research proposals come out of both departments are
aligned to the requirements of our force.
Senator Shelby. Ma'am, I realize, and I think we all do,
that the military has certain needs that the general population
does not need, but the military at the same time probably needs
all of the needs and all the things that the general population
in addition to the military specific things. Is that a fair
statement?
Dr. Adirim. Sure. Yes, sir.
Senator Shelby. So name your top three research areas that
you are doing through the military research.
Dr. Adirim. Sure. I am going to turn it over to my
colleague, General Dingle.
Senator Shelby. Okay. General.
General Dingle. Vice Chair Shelby, one of the things, to
tag on to what Dr. Adirim was saying, the thing that the
military also brings, as it takes the National Defense
Strategy, the DOD guidance, and our service guidances, the
focus is on the survivability of the soldiers.
Senator Shelby. Absolutely.
General Dingle. So prolonged real care in combat
operations, trauma care, the latest technologies that we get
from the civilian sector or in NIH, but taking those civilian
technologies, medical technologies, it takes that military
service research and development to incorporate it into
tomorrow's battlefield on how it is going to be incorporated in
a multidomain environment. And I think that is one of the key
things that we bring from the military as we couple with the
civilian sector, academia, and the industry.
Senator Shelby. Okay. In the area that we all see a lot of,
that is, improvised explosive devices dealing with our military
that is a traumatic thing. We see it with our soldiers and
everywhere. Is there any connection between our efforts to
detect and prevent that and the treatment of the victims, our
soldiers, after they have sustained huge blasts?
General Dingle. Yes, sir. And that is one of the beauties
of what the Chief of Staff of the Army set up with our Army
Futures Command, because it takes that prevention mode and the
detection to get ahead of that blast, but then even if that
blast happens, occurs, that is when the medical research and
development piece comes in and we are studying those blast
injuries and how to conserve and save lives.
So the short answer, yes, we are doing those preventive
measures. It is all being done under Army Futures Command in
which medical is incorporated across all of the cross-
functional teams.
Senator Shelby. Is there any correlation in research
dealing with, say, trauma medicine, emergency medicine,
domestically, civilian, and what the soldiers--you know, the
soldiers are shot at. They are shelled. They step on mines.
They do this, a lot of the civilians are shot at too much in
the country, but I guess, the treatment of wounds, is there
correlated research there, Doctor?
Dr. Adirim. Yes. And I am an emergency physician, and there
is a number of research that has come out of the military that
has----
Senator Shelby. Absolutely.
Dr. Adirim [continuing]. Greatly benefited the civilian
sector. I mean, I can name the REBOA, which is a device that is
used in trauma. There is fresh frozen plasma, which is
currently being used for battlefield, which will have civilian
applicability. So, yes, you are exactly right. A lot of what we
do within the Department of Defense, especially around trauma
research, is applicable to the civilian sector.
Senator Shelby. In the area of warfighter, our soldiers,
sailors, and marines, Air Force readiness and their health, is
there research going on between the military research and the
NIH research regarding with the health of our people, the
health of our soldiers? Of course, the soldiers are probably--
not probably--are exposed to a lot different environments than
the average American is.
Dr. Adirim. Well, Senator, as you alluded to, there are
multiple domains of research that we do in coordination and
collaboration with the NIH and a lot of which has applicability
to the civilian sector and to the American people at large.
Senator Shelby. Admiral Gillingham, I want to shift to the
ambulance ship, transport ship.
The Navy recently issued a $235 million contract
modification to construct a multipurpose Expeditionary Fast
Transport ship. Can you talk about Navy Medicine adapting to
Distributed Maritime Operations and specifically how the
Expeditionary Fast Transport ship and ambulance ship will add
value to those operations?
Admiral Gillingham. Yes, sir. Thank you for this
opportunity.
We are enormously excited about what is known as the EPF
Flight II, which is the vessel that was previously known as the
Joint High Speed Vessel, designed initially as a logistics
ship.
In reviewing medical concept of operations for the
Distributed Maritime Operations and Expeditionary Advanced Base
Operations in support of the Marine Corps, recognized that we
had a gap in the ability to respond quickly and much more
quickly than we can with our Role 3 platform, the T-AH, or the
hospital ship.
So the ambulance ship, as envisioned, will allow us to
respond to ships in distress, ships that may have been damaged
in combat, be able to assist in personnel recovery.
Senator Shelby. It also gives you a lot of mobility on the
water, does it not?
Admiral Gillingham. Yes, sir. The speed is--it is a
catamaran, bi-hull catamaran. It moves very quickly. It will
allow an Osprey aircraft to land for medevac purposes. It will
allow us--as envisioned and as being built and adapted with
that additional funding, it will have an operating room that
will accommodating two operating room tables, a room for 18 ICU
beds, a medical-enhanced Role 3 medical staff of about 100
personnel.
We see this as filling a critical gap in the DMO (Defense
MilPay Office) environment.
Senator Shelby. Would you say this--fairly say this is a
high priority for Naval Medicine?
Admiral Gillingham. Yes, sir. It very much is.
Senator Shelby. Thank you.
Thank you, Mr. Chairman.
Senator Tester. Thank you, Senator Shelby.
We have Senator Baldwin virtually.
Senator Baldwin. Thank you. Thank you, Mr. Chairman.
Dr. Adirim, how many cases of COVID-19 has the military
seen this year and in 2020? And I also would like to hear the
breakdown of the number of military personnel who have been
hospitalized or who have passed away from COVID-19 since we
first identified that threat.
Dr. Adirim. Sure. Thank you for that question. I do not
have the precise numbers, and we can get those to you. But what
I can say is having looked at our percent positivity and
following the hospitalizations, it is much less than in the
civilian sector, which is what you would expect for a younger,
healthier population.
Currently, right now, we are seeing a test positivity rate
of about 4.4 percent, and it is 6 percent out in--nationally.
So we have a lower case rate than we see out in the civilian
sector, and we have lower hospitalization rates as well.
But I will get you those precise numbers for the record.
[The information follows:]
statistics on covid-19 infections/hospitalizations/deaths within the
tricare population
----------------------------------------------------------------------------------------------------------------
All beneficiaries Active duty
-----------------------------------------------------------------------------
Private Private
Direct Care Sector Care Total Direct Care Sector Care Total
----------------------------------------------------------------------------------------------------------------
All COVID+........................ 220,377 257,464 477,841 133,866 33,370 171,807
Hospital admissions............... 5,171 37,941 43,112 948 750 1,698
Deceased.......................... 262 10,018 10,280 7 37 44
----------------------------------------------------------------------------------------------------------------
Senator Baldwin. I will appreciate that.
How many anthrax cases has the military seen over the same
period of time?
Dr. Adirim. Ma'am, I am not aware of anthrax cases.
Senator Baldwin. Okay. Are you aware of potential anthrax
exposure incidents that the military has experienced in the
last year or the last 5 or 10 years?
Dr. Adirim. Ma'am, I would not have that information. I can
ask one of my Surgeon General colleagues if they might know the
answer to that.
Senator Baldwin. Does anyone have any information about
anthrax exposure or cases in the last decade?
General Dingle. Senator, This is Lieutenant General Dingle.
We do not have that information on us. However, we do have
a very detailed Environmental Health Surveillance Registry,
which that information is documented in. We would have to take
that for record to come back to you to provide you those
details.
[The information follows:]
statistics on anthrax infections/hospitalizations/deaths within the
tricare population
The military has not had any cases of anthrax this year and in
2020. There were a number of laboratory-based exposures in 2015 where
individuals were treated with antibiotics and vaccinations. While there
have been limited cases of potential anthrax exposure due to naturally
occurring disease or laboratory incidents, the DoD maintains the
requirement for anthrax vaccination in our personnel to counter the
threat of the use of anthrax as warfare agent, to include use in
bioterrorism. The advancement of biotechnology only increases this
risk, and this is a validated threat for both DoD and the larger U.S.
Government.
Senator Baldwin. Okay. Does the Department of Defense plan
to continue procuring anthrax vaccines moving forward, and if
so, how many?
Dr. Adirim. Senator, the anthrax is still considered a
threat to our forces. Other governmental agencies as well has
determined that anthrax is a threat. So to answer your
question, it is yes. We do plan to protect our forces from
those threats.
Senator Baldwin. Okay. I think you can get a sense of the
point that I am trying to make. There has been a lot of concern
over vaccine declination rates for COVID-19 vaccines. There has
also been a long history of concern over compulsory
vaccinations, including for anthrax, beginning in the--towards
the end of the 1990s. I would like to hear details on how the
DOD has increased voluntary participation in vaccines in the
past, and how does the Department approach making decisions
about whether vaccinations should be compulsory for our
servicemembers?
Dr. Adirim. Right. Thank you for that question.
And I can talk about COVID because we are doing a lot with
regard to helping our servicemembers make their decisions about
taking the vaccine.
As you know, under EUA (Emergency Use Authorization), the
vaccine is voluntary, and we are using every avenue possible to
provide information, social media, and town halls. We have MTF
physicians available to answer questions. We do Facebook live
sessions. We put information on websites in order to provide
accurate information about the vaccine, and as you alluded to,
we do not have a perfect acceptance rate.
We do not know what the declination rate is, really,
because we only just yesterday opened up vaccination to all
eligible beneficiaries. But we do track this, and we are very
interested in helping our servicemembers and other
beneficiaries make the decision to get vaccinated.
Senator Baldwin. Dr. Adirim, you stated in your testimony
that the greatest proximate challenge to our Nation's security
is the threat of COVID-19, and I asked about anthrax because I
am concerned that our spending priorities are not aligned with
both current and emerging threats.
We have known that a pandemic based on a novel virus, that
it would attack the respiratory system, could cripple our
country, and yet we did not purchase PPE (Personal Protective
Equipment), and we did not reassure manufacturing of critical
medical supplies or vaccines, yet 2020 saw one of the largest
purchases of anthrax vaccines, a threat that to my knowledge
has not been included in annual worldwide threat assessments or
highlighted in testimony to the Congress in many years.
And from 2015 through 2020, we spent about $1 billion on
anthrax vaccines, even though many experts, including Dr.
Fauci, have suggested that the best approach towards anthrax is
antimicrobial therapy.
I understand the continued need to monitor this thread, but
it does seem to me like we have prioritized the requirement for
this vaccine at the expense of preparing to protect our
servicemembers and families against things like global
pandemics. So I am looking forward to following up on my line
of questioning.
Thank you.
Senator Tester. Thank you, Senator Baldwin.
I only have one request, and then we will close this
hearing out. And it is for Dr. Adirim. I would like to have you
get to me and the committee, the research that is being done in
respiratory ailments as it applies to burn pits, and I would
ask that you be specific on the respiratory ailments that you
are looking at. It is a big, big, big issue that has got some
legs, this Congress, as far as providing benefits to our
veterans.
[The information follows:]
health issues associated with burn pits
The Department of Defense (DoD) and the Department of Veterans
Affairs (VA) have funded many research studies related to the possible
respiratory effects of airborne hazards in theater, including burn pit
exposure. Many studies have been published on the relationship between
exposure to airborne hazards and respiratory conditions, including:
respiratory symptoms (chronic cough, dyspnea (shortness of breath), and
wheezing); asthma; COPD (chronic obstructive pulmonary disease, that
is, chronic bronchitis and emphysema); constrictive bronchiolitis; and
several other lung diseases, such as sarcoidosis. DoD is currently
funding human health studies on the relationship between burn pit
exposure and the following conditions: respiratory symptoms; asthma;
chronic bronchitis; constrictive bronchiolitis; and several other lung
and cardiovascular diseases. VA is currently performing a long-term
mortality study of veterans of Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF), which will evaluate the death rates
due to several types of lung diseases and several types of cancer. The
National Academy of Sciences (NAS) is a nationally recognized
organization that is independent of the Federal Government. The NAS
published a comprehensive 270 page report in September 2020, entitled
``Respiratory Health Effects of Airborne Hazards Exposures in the
Southwest Asia Theater of Military Operations.'' The NAS reviewed
hundreds of health studies related to airborne hazards in theater,
including studies funded by DoD, VA, and non-Federal sources. The NAS
report evaluated the scientific evidence on 27 respiratory health
outcomes, including all the diseases mentioned previously. The NAS
report concluded there was limited evidence that there is an
association (relationship) between exposure to airborne hazards in OIF/
OEF and respiratory symptoms of chronic persistent cough, shortness of
breath, and wheezing. DoD and VA are continuing to fund multiple human
health studies to develop more definitive evidence on the relationship
of exposure to airborne hazards in theater and long-term health
effects.
ADDITIONAL COMMITTEE QUESTIONS
Senator Tester. I want to thank Senator Shelby and Senator
Baldwin for their questions today. I want to thank you for your
testimony today. The witnesses know that Senators may submit
additional written questions, and we ask you to respond to them
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 Dr. Terry Adirim
Questions Submitted by Senator Richard J. Durbin
Question. This Subcommittee has long prioritized life-saving
medical research--it improves our military edge, protects our service
members and their families, and produces real, tangible benefits for
all Americans.
As the Defense Health Agency works toward a larger role in defense
medical research, how do you plan to ensure that the effort continues
to prove its value?
Answer. DHA recognizes the long history of Research, Development
and Acquisition (RDA) accomplishments made within DoD. DHA seeks to
continue that history with support to the vital DoD research enterprise
in advancing the delivery of capabilities to the warfighter and
beneficiaries through support to elements such as the Congressionally
Directed Medical Research Program that fosters synergy with academia,
industry and other Federal agencies and continued support to CONUS and
OCONUS DoD laboratories. As DHA takes on a larger role in the defense
biomedical research enterprise, metrics will be captured that will
demonstrate the value of a consolidated enterprise medical research
organization.
Question. Over the years, DoD has leveraged civilian partnerships
to stretch limited dollars wisely and maximize research efforts, direct
care, and military readiness. For example, DoD has successfully
partnered with academic institutions on trauma training, through
engagement on various programs as well as even assigning military
medical personnel to civilian trauma centers. And in fiscal year 2019,
Congress created a new pilot program to treat members of the Armed
Forces for psychological conditions--such as PTSD--stemming from
military sexual trauma, with the idea being that DoD should partner
with civilian institutions for this effort. As we know, sexual assault
can be a significant source of trauma stress for service members and
their families. And while service members can and do receive adequate
care within the Department, it is to DoD's advantage to have outside
treatment options available to accommodate service members, where
public stigma has too long been a barrier to care. However, I have been
disappointed that in implementation of this new pilot, for which
Congress has appropriated $9 million between fiscal year 2019 and
fiscal year 2021, DoD has yet to choose a civilian academic medical
center to participate.
Please elaborate on the benefits of civilian partnerships within
the defense health program and provide some examples.
Answer. The defense health program (DHP) engages in civilian
partnerships to address emerging needs that are not able to be met by
existing government capacities. Civilian partnerships are most valuable
when they provide expertise and/or programmatic capability that the
government cannot feasibly or efficiently deliver in the timeline
needed. Several examples are noteworthy. In 2010 the DHP funded and
established the Military Suicide Research Consortium (MSRC). The MSRC
leverages civilian scientific expertise as well as DoD capabilities to
study the causes and prevention of suicide. Suicide etiology and
prevention are complex scientific fields with substantial research gaps
that cannot entirely be met by existing internal defense health program
efforts. The military's Alcohol and Substance Abuse Disorder Research
Program (ASADRP) expedites the identification of therapeutic compounds
for the treatment of alcohol and substance use disorders through the
multidisciplinary expertise of researchers from both the DoD and the
civilian sector, most notably the University of California San
Francisco and the Research Triangle Institute. The Study to Assess Risk
& Resilience in Service members Longitudinal Study (STARRS-LS) benefits
from a broad DoD/civilian partnership to address behavioral health
issues in the military. The STARRS-LS collaboration taps the diverse
skills of investigators at numerous research institutions including
Uniformed Services University of the Health Sciences, the University of
California at San Diego, Harvard Medical School, and the University of
Michigan. In addressing treatment needs associated with military sexual
assault and sexual harassment, the VA/DoD Women's Health Working group
has also engaged with civilian partners with subject matter expertise
from the School of Medicine at the University of Colorado-Denver and
the University of Washington.
DoD outreach campaigns to support transitions and reduce stigma
also significantly benefit from collaborative partnerships with
academic, industry, and civilian organizations. For example, the
inTransition program and the Real Warriors Campaign make dedicated
efforts to engage and foster collaborative partnerships with the
Elizabeth Dole Foundation, Washington Nationals Baseball, Sesame
Workshop, Give an Hour, Army Wife Network, Operation Homefront, Emory
University Healthcare Veterans Program, General Electric, George Mason
University, the University of Texas, and the American Red Cross.
If the government has the capability and expertise to complete the
mission, external partnerships may not be warranted. Internally
conducted government projects ensure that incentives are aligned with
internal needs and priorities, with minimal financial or scientific
biases. Sometimes, however, contributions from civilian partners can
add knowledge, resources, scope, and efficiencies that DoD alone cannot
offer. Ultimately, the choice whether or not to work with external
partners is determined by the availability of expertise, the maturity
of the scientific and programmatic field, and the timeline for
delivery.
Question. How has DoD used the appropriated funds for the
implementation of the MST pilot, and how do you intend to use the
fiscal year 2021 funds?
Answer:
--Healthcare Cost Impact: Actual healthcare costs are not available
due to claims lag. Based on the current participation rate (43
participants as of 4/30/21), it is projected that DoD will
execute the full amount of $174,000. The pilot ends 8/31/21
with last admission to the pilot program on 7/31/21.
--Administrative Cost Impact: The total administrative cost as
reflected in the definitization modifications of the contracts
is $200,059. The contractor's proposal costs came in lower than
the Independent Government Cost Estimate (IGCE), therefore,
lower costs were negotiated.
--Related tasks/adjustments: Based on the current participation rate,
it is not expected that there will be higher enrollment as
projected. Therefore, DoD cannot execute $297,000 for related
tasks or adjustments as indicated in previous spend plans.
Question. How does DoD plan to expand its civilian partnerships
when it comes to the MST pilot, and will there be an opportunity for
academic medical centers to participate?
Answer. Section 702 of the NDAA for fiscal year 2019, authorized a
pilot program to treat psychological sequelae associated with sexual
assault to be accomplished through partnerships with public, private,
and non-profit healthcare organizations and institutions. These
partnership institutions must provide healthcare to TRICARE eligible
members of the Armed Forces (including National Guard and Reserve). The
pilot program is focused on treatment of Service members suffering from
psychological health conditions associated with sexual assault
including PTSD, substance misuse and depression. The pilot is designed
to assess the feasibility and advisability of DoD-wide implementation
of a DoD/civilian partnership model utilizing the IOP treatment format.
All academic and private civilian intensive outpatient programs
were eligible to participate in the pilot if they met TRICARE standards
and were TRICARE certified (based on TRICARE Operations Manual chapter
6010.59-M, Chapter 18, Section 8). Despite an open call for partners
across civilian and academic medical centers, no academic medical
centers applied for TRICARE certification.
Civilian partner IOPs were selected in September 2020. To date,
five TRICARE-certified intensive outpatient programs have enrolled in
the pilot as well as two DoD intensive outpatient programs. All
civilian partner IOPs have been engaged and are in active data
collection.
Enrollment numbers are in line with expectations overall, but the
Humana sites have lower enrollment (Humana = 2, Healthnet = 41, DoD =
133). PHCoE has engaged in several efforts to increase enrollment in
civilian sites. PHCoE met with THP and Humana clinics to review
implementation procedures and problem solve, DHA Communications was
engaged to increase awareness of pilot among end users, and Humana has
plans to pivot to 100 percent telehealth in an effort to mitigate
travel concerns.
Civilian Partner IOP programs include:
--Oceans at Waco, TX
--Oceans at Biloxi, MS
--Help for Heroes at Denver Springs, CO
--Strong Hope at Salt Lake Behavioral Health
--Aurora Behavioral Health at San Diego
Due to data collection being underway at all DoD sites and civilian
partner sites, no additional sites are projected to be added to the
pilot prior to its completion in August 2021.
Question. I am pleased that the Defense Health Agency (DHA) chose
the Army's Civilian Human Resources Agency (CHRA) as its provider of
human resource support. I worked to ensure that CHRA, based at Rock
Island Arsenal, was the primary office responsible for supporting DHA's
human resource needs. I recognize that COVID placed a hold on hiring of
many positions within the Department of Defense and, to date, only
about 50 positions have been filled at Rock Island in support of the
DHA contract.
Can you detail for me when you expect the freeze on civilian
hiring to be lifted?
Answer. There has not been a freeze on civilian positions in the
DHA. The DHA leverages all available human resource authorities to fill
positions above the MTF level that include: Transfer of Functions,
Management Directed Reassignments and competitive hiring since CHRA
became the Human Resource Service Provider to the DHA.
Question. Further, can you detail how many additional positions you
expect CHRA to hire in order to support DHA requirements?
Answer. The DHA has in excess of 450 civilian positions being
actively recruited through CHRA. There are over 310 additional vacant
positions available to the DHA for recruitment.
Question. I understand the importance of the on-demand blood
program and it's potential benefit to readiness and addressing critical
supply challenges.
Can you elaborate on the anticipated funding for the program this
current fiscal year as well as into the FYDP?
Answer. The total funding for this program is $110 million over 5
years. To date the program has received $15 million (fiscal year 2019;
Year 1) and another $12 million (fiscal year 2021, Year 2; pending
award) this year for a total of $27 million.
Question. Can we expect future budget requests to seek making this
program a program of record within the Department of Defense? Why or
why not?
Answer. Currently the On-Demand Blood (ODB) program and its host,
the USU-4D Bio3 Center for Biotechnology, are not Programs of Record
and rely on annual budget funding prioritization. The ability to
manufacture clean blood products near the point-of-need, even austere
environments, could mitigate blood supply vulnerabilities not only for
our warfighters deployed overseas but also for our Nation as reported
in the 2020 HHS Report to Congress: Adequacy of the National Blood
Supply (attachment). This report highlighted multiple challenges with
sustaining the National Blood Supply that are particularly problematic
during national emergencies such as the current COVID-19 Pandemic. With
this program, we hope to mitigate the various National Blood Supply
vulnerabilities by creating an alternate source of clean blood to
traditional blood donation, not only for our Warfighters but also for
the Nation and Global Health Community.
Question. Has DoD done enough with interagency partners and the
scientific community to address concerns? What type of interagency
collaboration is occurring with this project?
Answer. The USU-4D Bio3 ODB program consists of collaborations with
the FDA, Harvard/Massachusetts General Hospital, as well as three
industry partners. The program is also in partnership discussions with
other Federal agencies, to include National Institutes of Health (NIH),
Armed Service Blood Program (ASBP), Assistant Secretary for
Preparedness Response (ASPR), Biomedical Advanced Research and
Development Authority (BARDA), Federal Emergency Management Agency
(FEMA), National Institute of Standards and Technology (NIST), National
Aeronautics and Space Administration (NASA), and the UK Ministry of
Defense and Innovate UK.
Question. Does the Department of Defense have plans to develop a
demonstration of on-demand blood in a real world training scenario like
any of the major training exercises in the Pacific?
Answer. Yes, in conjunction with USU-4D Bio3's Fabrication in
Austere Military Environments (FAME) Program, it is our goal to conduct
demonstrations of the On-Demand Blood program's capabilities to
fabricate blood in austere environments. Currently, we are also
exploring development of autonomous means to provide blood in theater.
The team is in discussions with leadership of the ASBP and individual
COCOMS to determine a transitional training scenario for fiscal year
2022/2023 as the bioreactor technology that fabricates the blood
products will be ready for in-field testing/deployment at that time.
Question. I am concerned that there has been significant decrease
in DHP core neurosensory research especially in vision-ocular trauma
intramural funding that decreased from fiscal year 2019 $5.8 million
under the JPC-8 Army Medical Material Research Command (MMRC) in the
core vision research funding to $1,000,000 for fiscal year 2020 and
fiscal year 2021 with no further funding fiscal year 2022 to fiscal
year 2025. This leaves military trauma ophthalmologists with no
internal trauma research funding, despite wounded warrior research
remaining a priority at DoD.
Please provide the amounts that DHP has funded for core trauma
research funding for sensory injuries, including vision and hearing,
TBI, orthopedic, and spinal cord injury research for fiscal year 2021.
What is projected for fiscal year 2022 for each?
Answer.
Planned RDT&E Funding for Trauma Research
------------------------------------------------------------------------
Fiscal Year
Research Area -------------------------------
2021 ($k) 2022 ($k)
------------------------------------------------------------------------
Vision.................................. $-- $--
Hearing................................. $10,538 $7,587
TBI..................................... $105,065 $47,272
Orthopedic.............................. $19,641 $19,511
Spinal Cord............................. $4,272 $2,377
Other (non-specified)................... $71,107 $59,686
Total............................... $210,623 $136,433
------------------------------------------------------------------------
______
Questions Submitted by Senator Patty Murray
Question. As you know, the Department of Defense has a long
standing need for agents to prevent disease and death caused by plague
and botulinum toxin, with the Department of Homeland Security issuing a
Material Threat Determination in 2004 for both of these diseases.
However, funding for these two vaccines under the Joint Vaccine
Acquisition Program (JVAP) were zeroed-out as a result of the fiscal
year 2021 Defense-Wide Review despite significant previous financial
investment and completion of both Phase 1 & 2 clinical trials. Why are
these programs being cancelled without alternatives in place? Will the
Department propose other avenues to ensure servicemembers are not at
risk?
Answer. While OASD(HA) supports the Warfighter and all DoD
personnel for all health aspects, we would have to defer questions on
the development of countermeasures against manmade threats such a
plague and botulinum toxin to the Office of the Assistant Secretary of
Defense for Nuclear, Chemical and Biological Defense Programs. OASD(HA)
is a stakeholder within the Chemical and Biological Enterprise, but we
do not have control over the resourcing and developmental decisions in
this space.
______
Questions Submitted by Senator Jeanne Shaheen
Question. The Biden Administration has reported that National
Institute of Allergy and Infectious Diseases (NIAID) is examining the
durability of the immune response and that the National Institutes of
Health (NIH), Centers for Disease Control and Prevention (CDC), and
Department of Defense (DoD) are assessing whether vaccine-induced
immunity, or natural immunity from prior infection, can be effective in
combating COVID 19 emerging variants. T cell testing has been
integrated into the United Kingdom COVID immune response assessment.
What are your views on the need to measure immune response?
Answer. The Department believes it critical to understand the
immune responses to COVID vaccination (and wild-type disease) to
establish a known correlate of protection. This will help improve
diagnostics and vaccines and help drive the future efforts to combat
this disease.
Question. What role do you see for T cell mediated response being
integrated into vaccine efficacy assessments at DoD?
Answer. The Department supports further study of the T cell
compartment, as various studies have shown differing results between
the B cell and T cell compartments, to include distinct kinetics.
Although T cell tests are not routinely used clinically, they do
provide extremely valuable insight to ultimately determine efficacy of
some vaccines. We are committed to continued collaboration/partnership
of DoD with national efforts. An Uniformed Services University/
Infectious Disease Clinical Research Program protocol proposal is just
one example of that commitment.
______
Questions Submitted by Senator Susan M. Collins
Question. At the beginning of the COVID-19 pandemic last year, the
nation saw a huge spike in demand for modular negative pressure room
containment systems that can offer civilian hospitals or Military
Treatment Facilities the capability to safely assess and treat patients
with suspected COVID-19 symptoms. It is clear these commercial-off-the-
shelf systems can help ensure the readiness of the defense health
system worldwide, especially in the case of future pandemics or
biological attacks. Section 732 of the recently enacted fiscal year
2021 National Defense Authorization Act (NDAA) requires a report of the
Department's pandemic preparedness. I was pleased that the Department
has committed to ensuring that these modular negative air pressure room
containment systems are included as part of that Pandemic Preparedness
Report directed by the NDAA. Provisions unanimously approved in the
Senate's fiscal year 2021 NDAA bill also required a specific review of
these systems.
Given the use of these systems in the civilian sector and in VA
hospitals, what does the DoD believe to be the potential benefits of
these systems?
Answer. Although there is limited published literature that
provides a comparative analysis of modular negative air pressure room
systems to traditional structures, such systems have demonstrated value
in specific situations and environments. Specifically, these systems
are believed to create a negative pressure environment designed to
contain airborne infectious pathogens with minimal assembly time and
disruption to permanent facility structures. One unique system with
demonstrated success is the USTRANSCOM/Air Mobility Command developed
Negatively Pressurized CONEX and CONEX Light (NPC, NPCL), which allows
the transport of critically ill patients with highly contagious
diseases aboard pressurized, military cargo aircraft. The CDC
highlights the fact that inadvertent exposure to airborne pathogens can
result in significant morbidity and/or mortality and the American
Society of Heating, Refrigerating and Air Conditioning Engineers
(ASHRAE) has emphasized that disease outbreaks (i.e., epidemics and
pandemics) are increasing in frequency and reach.
Question. How could these types of systems be used by DoD in the
future to help mitigate the spread of future pandemics or biological
agents in the future?
Answer. Understanding that some facilities and environments may not
be conducive to construction of permanent fixtures, modular negative
air pressure room systems have the potential to serve as an alternative
solution for pathogen containment. Integration of such systems is most
applicable in situations where facilities are at risk for operating
beyond surge capacity (e.g., uniquely positioned OCONUS facilities) and
therefore emergency preparedness should be directly aligned to each
facility's risk assessment. ASHRAE supports such statements and
emphasizes that, Mitigation of infectious aerosol dissemination should
be a consideration in the design of all facilities, and in those
identified as high-risk facilities the appropriate mitigation design
should be incorporated.
Given the unique mission of the DoD, integration of innovative
solutions such as the NPC/NPCL is critical for effective emergency
preparedness with broad-scale applicability, including protection of
personnel from pathogens during humanitarian relief operations.
Decision-making regarding any emergency preparedness strategy must
consider the evolving nature of biologic threats and therefore
integrate a multi-layered systems approach in collaboration with
bioenvironmental engineering.
______
Questions Submitted by Senator Lisa Murkowski
Question. A multitude of studies indicate that those who have
served in the military are at a much greater risk of developing ALS
(ALS, or amyotrophic lateral sclerosis, is a progressive
neurodegenerative disease that affects nerve cells in the brain and the
spinal cord) and dying from the disease than those who have no history
of military service. I was pleased that $40 million in funding was
provided to the Congressionally Directed Medical Research Program
(CDMRP) for peer-reviewed ALS research for fiscal year 2021. Support
for this research has been a long-time priority of mine, and an issue
that is near and dear to my heart.
Do you believe enough research on ALS is being done through the
DoD's Peer Reviewed Medical Research Program (PRMRP)?
Answer. The annual appropriation for the Peer Reviewed Amyotrophic
Lateral Sclerosis (ALS) Research Program (ALSRP) has grown from $10
million in fiscal year 2019 to $20 million in fiscal year 2020 to $40
million in fiscal year 2021, totaling $149.4M since the program was
established in 2007. With a focus of expediting the pipeline from bench
science to new clinical therapeutics, historically, the ALSRP has
offered awards in the areas of ``Therapeutic Development'' and
``Therapeutic Ideas,'' with maximum awards up to $1 million and $500k
in fiscal year 2020 respectively. This has resulted in 84 awards made
through fiscal year 2019 and currently 19 awards made against the
fiscal year 2020 appropriation.
The Therapeutic Development award mechanism supports post-discover
validation and development of candidate therapeutic agents through the
steps required prior to FDA approval as an Investigational New Drug
(IND). The Therapeutic Idea award mechanism supports high risk/high
reward hypothesis-driven therapeutic ideas in an early stage of
development. In fiscal year 2020, a third category, ``Clinical
Development'' was introduced with a maximum award of $300k. This
category of award is designed to support leveraging of patient-based
ALS resources to define subtypes, predict therapeutic responses,
improve the value of ongoing clinical trials, and/or optimize the
components of current ALS clinical care.
Question. Do you anticipate that an increase in funding will be
needed to continue research under the new realities that the pandemic
has imposed on us?
Answer. The cost of research is always increasing due to inflation.
The ALSRP adjusts the number of awards made in order to fund
scientifically and technically appropriate research that provides the
greatest impact in support of the programmatic vision established by
the Programmatic Panel as part of the five-step process for soliciting,
reviewing, and funding research. As an example and as described in the
question above, the increase to $20 million in fiscal year 2020 enabled
a new award mechanism to be established.
______
Questions Submitted by Senator Jerry Moran
Question. Dr. Adirim states in her written testimony that Joint VA/
DoD Clinical Practice Guidelines (CPGs) have been formulated for
provider use for all major clinical conditions in mental health.
However, there are not any current CPGs available that address serious
mental illness (SMI) and conditions such as bipolar disorder and
schizophrenia. In Public Law 116-171 Sec. 304, Congress directed DoD
and the Department of Veterans Affairs to work together to develop
current CPGs that address these SMI conditions.
Can the Department please provide an update on the establishment of
the work group directed by Congress in this Act in order to begin the
development of the SMI CPGs?
Answer. The VA and DoD are collaborating on two new VA/DoD CPGs
that address serious mental disorders, one for schizophrenia and the
other for bipolar disorder. Both VA and DoD teams have secured working
group members and are awaiting on final arrangement with the VA
contractor to start the work. A new CPG usually takes anywhere from 12-
18 months to complete.
Question. Dr. Adirim, I continue to have concerns in regards to the
high rate of suicide among our service members in the 1 year period
post-transition. In your written statement, you mention that the
Department and VA are currently working together to develop a
Separation Health Assessment which will feature a Mental Health
Assessment.
Can you provide any more detail on what this Mental Health
Assessment will include?
Answer. The Mental Health Assessment (MHA) of the Separation Health
Assessment (SHA) will have five components. These components are (1)
The PC-PTSD-5, a screening instrument for PTSD; (2) The Patient Health
Questionnaire (PHQ)-2, a screening instrument for depression; (3) The
AUDIT-C, a screening instrument for alcohol use; (4) The Columbia
Suicide Severity Rating Scale (C-SSRS) Screener, a screening instrument
for suicide risk; and, (5), A 2 question screening instrument for
violence risk.
Question. Further, do you have an estimated timeline for when this
assessment will be rolled out to service members?
Answer. The Department anticipates that the SHA will be implemented
in late 2022.
Question. How will the DoD and VA share information to make certain
recently-separated individuals receive the care they require?
Answer. The DoD and VA will utilize the Electronic Health Record
(EHR) to share information to make certain recently-separated
individuals receive the care they require. Additionally the DoD's
inTransition program and the VA's Military and Veterans Crisis line
have integrated efforts to provide improved, comprehensive support for
service members. The inTransition program works closely with the MVCL
to connect callers with follow-up treatment after receiving crisis care
at a military or civilian emergency department.
Question. There is a somewhat long and complicated process for
active duty service members in allied healthcare occupation specialties
to receive approval and funding for professional credentialing
opportunities. This leaves service members unable to translate their
military training and experience into skills and qualifications
required by private sector healthcare employers. As the COVID-19
pandemic puts an increased burden on the healthcare workforce,
improving the credentialing process seems like an easy way for DoD to
assist in this space while helping thousands of service members
transition to civilian life.
Does the Department have a strategy to assist the service branches
to fund and strengthen the credentialing process, such as through DHA's
Education and Training Directorate?
Answer. This question primarily concerns enlisted service members
in the MHS, thus this answer focuses on the Medical Education and
Training Campus (METC) and the work it does to both enhance the skills
and education of our enlisted healthcare personnel while also assisting
them in obtaining credentials that translate to the civilian sector
upon separation or retirement. The METC offers 48 enlisted education
and training programs and is accredited by the Council on Occupational
Education (COE). METC's institutional accreditation qualifies
individual programs to obtain specialized or programmatic
accreditation. Both institutional and programmatic accreditation are
prerequisite to students earning a certification, or a professional
license.
The METC has 14 accredited programs and five non-accredited
programs that generate a student certification or license.
In addition to maintaining institutional and programmatic
accreditations, the METC is a branch campus of the College of Allied
Health Sciences (CAHS) under the Uniformed Services University of
Health Sciences (USU). The METC/CAHS branch campus is currently
comprised of 15 enlisted training programs, all of which have Associate
of Science in Health Sciences (ASHS) degree plans.
Students attending programs that are part of the METC/CAHS branch
campus receive a USU transcript with credit hours for successfully
completed course work. Credit hours can be applied toward the programs'
established degree plan, or transferred directly to the student's
choice of school. All 48 enlisted medical education and training
Programs have an avenue to receive college credit which can be
transferred directly to colleges or universities, or applied to a
bridge school program.
The METC also partners with colleges and universities to offer
Bridge Degree Programs. This program offers pathways to college degrees
and certifications by giving credit for military education and
articulating the credit into a career/college degree pathway.
Currently, METC has 89 Bridge Degree Partners and over 1400 degree
bridge pathways. This program saves both enlisted service members' and
veterans' time and money, and makes the possibility of earning a
college degree more attainable. Colleges and universities that wish to
become a bridge partner express interest and then navigate a
streamlined 8-step process that usually includes a campus tour,
curriculum crosswalk, a question and answer session via email or other
venues, a proposal of transfer credits, feedback from METC program
directors, and acceptance of the proposal and bridge pathway that
signifies an informal partnership. Degree bridge programs, plans, or
pathways illustrate the courses military members must complete to earn
a specific college degree after transfer credits have been authorized.
Maintenance and expansion of these partnerships and pathways are vital
to the well-being of veterans and their families and saves the DoD
millions in education related costs. This program is at no-cost to the
government and free to the service members receiving transferable
credit. The only cost occurs when the service member attends the
institution of choice to complete the remaining degree requirements as
spelled out on the degree pathway.
______
Questions Submitted by Senator John Hoeven
Question. To immunize our service members as well as the general
population, we need to produce enough vaccines. This includes having
enough domestic manufacturing capacity to effectively produce the key
components of the vaccines. As you may be aware, Aldevron is a company
based out of Fargo, North Dakota, that manufactures advanced biological
materials such as those used in the COVID-19 vaccines. They have a
history of working with Federal partners, and are uniquely fitted to
meet our future vaccine materials needs. Aldevron has been in
communication with the Defense Production Title III Office at the
Department of Defense as well as with the Biomedical Advanced Research
and Development Authority (BARDA) to discuss their manufacturing
capabilities.
Will you work with my staff to ensure that American manufacturing
companies like Aldevron, which supply key starting materials for the
production of medical countermeasures and vaccines, can be part of the
solution as we continue to respond to COVID-19 and prepare for future
pandemics?
Answer. OASD(HA) is happy to work with your staff to look at ways
to improve the readiness of our Forces, including scale up and access
to pandemic vaccines. We also have a robust relationship with Health
and Human Services including BARDA, and are happy to explore
partnerships that enable the Department to increase the protection of
our force where it is most needed.
Question. I note from your testimony the work that you are doing
with the Veterans Administration to develop a single separation health
assessment for those leaving service. You mentioned that this would
include a mental health assessment, which is an important component. In
the past, we have taken steps to support our active duty force but left
out our service members in the reserve components.
Can you confirm whether this assessment would be available to
members of the reserve component who are separating from service?
Answer. Currently this assessment would be available to members of
the Reserve Component (RC) who are separating from Service if they meet
the eligibility requirements as specified in Section 1145(d) Physical
Examinations for Certain Members of a Reserve Component, of Title 10.
Question. Would you support providing a single separation health
assessment, including a mental health assessment, to all members of the
Selected Reserve, regardless of whether or not they have served 30 days
in support of a contingency operation?
Answer. We support evidence-based screenings and examinations based
on known and potential risks experienced during military service and
the individual's medical needs. The single separation health assessment
under development includes a physical examination. For many short non-
contingency operations a DD2697, ``Report of Medical Assessment'' or
post-deployment health assessment and mental health assessment would be
more appropriate and efficient for the Service member and DoD.
______
Questions Submitted to Lieutenant General R. Scott Dingle
Questions Submitted by Senator Richard J. Durbin
Question. What are you doing on a regular basis to drive an anti-
tobacco message throughout your Service? Are we making progress?
Answer. The Army Surgeon General's role in promoting tobacco-free
living and directing tobacco-free campuses creates momentum to
transform Army culture. By providing a healthier, tobacco product- free
environment and readily accessible services to help users quit, the
Army will cultivate a resilient, effective, and battle-ready force.
Revisions to Army policy, such as AR600-63, AR40-5, AR 600-85, to
name a few, highlight and emphasize the responsibility of
installations, commanders and supervisors to create a culture that
encourages and reinforces tobacco-free living.
Tobacco use has decreased by nearly 7.0 percent since 2013. As of
2017 Army has a lower rates than the general population.
Question. What is the impact that we are seeing on service members
with the rise of tobacco alternatives such as e-cigarettes and vapes?
Answer. Tobacco product use, including e-cigarettes and vapes are a
threat to the readiness and the resilience of our Army. 7.2 percent of
Soldiers now self-report use of E-cigarettes or vape pens. Soldiers who
use e-cigarettes realize decreased performance during physical
evaluation tests compared to those who do not use. Soldiers that smoke
and vape do the poorest.
Some Soldiers view e-cigarettes and vapes as a safer alternative to
cigarettes. Army Public Health is actively engaged with the DoD tobacco
education campaign, and is continuing to educate Soldiers on the
negative effects of e-cigarettes and resources to quit.
Question. What are you doing about the impact of tobacco on
military children and family members? Are you reviewing whether these
products should be sold in military exchanges or commissaries?
Answer. My team is working with Army Installation Management
Command, in support of a great effort called Healthy Army Communities.
Healthy Army Communities is an effort to create an environment where
the healthy choice is the easy choice. The tobacco free-living part of
this initiative is to work with installation commanders to expand
tobacco free zones to where children live and play on installations,
which is aimed at raising our Army youth as non-tobacco users.
Cigarettes used to be cheaper to buy on post than off post. One
important effort with the reduction of tobacco use in our military was
the DoD Tobacco Pricing Policy. Now, tobacco products sold on post must
be the same price as off post. This is a big change for our Soldiers
and literature demonstrates that price increase discourages tobacco use
and increases quit rates.
______
Questions Submitted by Senator Susan M. Collins
Question. At the beginning of the COVID-19 pandemic, the nation saw
a huge spike in demand for modular negative pressure room containment
systems that can offer civilian hospitals or Military Treatment
Facilities the capability to safely assess and treat patients with
suspected COVID-19 symptoms.
It is clear these commercial-off-the-shelf systems can help ensure
the readiness of the defense health system worldwide, especially in the
case of future pandemics or biological attacks.
Section 732 of the recently enacted fiscal year 2021 National
Defense Authorization Act (NDAA) requires a report of the Department's
pandemic preparedness. I was pleased that the Department has committed
to ensuring that these modular negative air pressure room containment
systems are included as part of that Pandemic Preparedness Report
directed by the NDAA. Provisions unanimously approved in the Senate's
fiscal year 2021 NDAA bill also required a specific review of these
systems.
Given the use of these systems in the civilian sector and in VA
hospitals, what does the Army believe to be the potential benefits of
these systems?
Answer. In accordance with NDAA 2017 and 2019, the Defense Health
Agency assumed authority, direction, and control of DoD's CONUS medical
treatment facilities (MTF) on 25 OCT 19 with the transfer of all MTFs
and Service direct support to be complete by 30 SEP 21.
The Defense Health Agency implemented 14 modular COVID-19 screening
facilities in CONUS and another eight OCONUS. The eight units in Europe
include negative pressure rooms and HEPA filtration. The units in the
U.S. do not include negative pressure rooms.
These modular facilities are used to screen patients before they
enter the medical treatment facility. Modular, negative pressure room
containment systems were not used for the treatment of Army COVID-19
positive patients.
Hospitals used existing patient isolation capabilities and modified
rooms and HVAC systems to create isolation within their existing
footprints. Portable, self-contained HEPA filtration systems were
employed in some cases to create negative pressure in treatment spaces.
For dental clinics, DHA created Expeditionary Dental Air Infectious
Isolation Rooms (EDAIIR) for two dental chairs per clinic using
commercial-off-the-shelf HEPA whisper flow fan units and zip wall
barrier sheathing.
Question. How could these types of systems be used by Army in the
future to help mitigate the spread of future pandemics or biological
agents in the future?
Answer. From Army perspective, Military Health System can implement
a range of methods to help mitigate the spread of infectious diseases
within MTFs.
Patient isolation, personal protective equipment, frequent
cleaning, and personal hygiene all play a part.
Modular systems are one method for temporarily creating anterooms,
treatment spaces, and support spaces. These systems can be used to
physically separate visitors from patients and staff, contagious
patients from non-contagious patients, and pre-admit patients from the
admitted patient population.
Future implementation would be in DHA's decision space.
______
Questions Submitted by Senator Lisa Murkowski
Question. Over the past year, the world has grappled with COVID,
and mental health continues to be one of the least understood and most
overlooked effects of the pandemic. Stress, fear, isolation, financial
impacts and the loss of friends and family have contributed to the
increase in anxiety and depressive disorder symptoms.
Has the Department of Defense seen an increase in service member
suicides over the past year?
Answer. Army Medical Command vigorously supports Army G-1 efforts
to assess the root cause of the Army suicide cluster.
The Army is experiencing an increase of suicides coinciding with
the COVID-19 pandemic.
Preliminary analysis by Army Public Health Center indicates the
suicide cluster among Regular Army is correlated with COVID's timeline,
however causality is not currently known.
Army Medicine provides Army Senior Leaders methods to mitigate
clinical suicide risk through critical engagements with their troops
and ensures critical information is provided to Commanders to support
those with identified risk of suicide.
Question. Have you seen an increase in the utilization of mental
health and suicide prevention services that the Department offers?
Answer. Early in the pandemic, BH service engagement by Army
beneficiaries decreased.
Army Medicine's adaption to pandemic healthcare environment
beneficiaries re-engaged in virtual behavioral services with a peak
utilization of 70 percent of services being conducted virtual
environment in April of 2020.
Social distancing policies are carefully lifted, the mix of in-
person and virtual appointments are exceeding pre-pandemic levels and
roughly 10 percent more unique beneficiaries are engaging in behavioral
health services when compared to this time in 2019.
In March 2021, greater than 38K beneficiaries sought behavioral
health services, which represents 33 percent increase from the same
time in 2019.
Innovations in the virtual space developed from necessity are
affording Army Medicine increased flexibility to provide services to
patients in their home.
Army Medicine, in partnership with DHA, will continue to
aggressively pursue and capitalize upon advancements in virtual
behavioral health services as an enduring positive outcome of the
global pandemic.
______
Questions Submitted to Rear Admiral Bruce L. Gillingham
Questions Submitted by Senator Richard J. Durbin
Question. I remain a very concerned about curbing the use of
tobacco in the military. We know that smoking makes it harder for
individuals to perform the tasks we ask of them, lengthens medical
recovery, and increases illness, increases healing times and accounts
for greater health costs. In fact, the DoD indicates that tobacco use
costs the department at least $1.6 billion annually. And it continues
to trouble me that--amid all of the rigorous physical challenges and
testing they perform--so many of our service-members pick up these
habits after enlisting. We also know that there are continued concerns
about military members using tobacco alternatives such as e-cigarettes
and vapes. In addition, I was supportive of Congressional efforts to
raise the Federal minimum age of sale of tobacco products from 18 to
21. But I remain concerned that we are not adequately addressing the
youth vaping epidemic
What are you doing on a regular basis to drive an anti-tobacco
message throughout your Service? Are we making progress?
Answer. I share your concerns about tobacco use in the military.
Navy Medicine is strongly committed to ensuring Sailors and Marines are
healthy, resilient, and physically and mentally fit to perform their
demanding duties. Tobacco use impairs readiness, performance and
fitness. As the Navy Surgeon General, I continue to promote tobacco
free living. Given the stress brought about by the COVID-19 pandemic,
we have released messages highlighting the negative effects of tobacco
use and encouraging those who use tobacco to quit. We want our
personnel to know that Navy Medicine can and will assist them in these
efforts.
Our medical campuses are tobacco free compounds which reinforces
our messages of healthy living and tobacco free living. During our
medical and dental care, healthcare teams address tobacco use and
provide evidence based treatment for nicotine dependence. Navy provides
awareness and training on the dangers and harmful effects of tobacco
and also provides education during the command orientation and
indoctrination process. During recruit training and other schools,
students are tobacco free. We use social media messages, developed by
the Navy, Department of Defense (DoD) and Centers for Disease Control
and Prevention (CDC), to promote tobacco free living along with
extensive online resources to support our personnel and providers. We
have also worked closely with the other Services and the CDC's Office
of Smoking and Health to develop a 2020 media tobacco toolkit ``Tips
From Former Smokers Military Service Members & Veterans Media Outreach
Kit'' for use and to partner with local and state organizations to
promote tobacco free military communities.
We are making progress with reducing tobacco use in the Navy and
Marine Corps. The encouraging news is that our tobacco use rates have
declined over the past decade. Data from the Navy and Marine Corps
Public Health Center's Health Risk Assessment show a reduction with
smoking cigarettes and the use of smokeless tobacco in the Navy and
Marine Corps within the past 2 years. These current trends as positive.
We also anticipate that the Tobacco 21 law will contribute to a decline
in tobacco use rates. It should be notes, however, vaping in the Marine
Corps increased during this time period similar to the national trends
of e-cigarette use.
Question. What is the impact that we are seeing on soldiers with
the rise of tobacco alternatives such as e-cigarettes and vapes?
Answer. We are concerned about the use of e-cigarettes, vaping and
other new and alternative tobacco products in the Navy and Marine
Corps. Over the past few years, there has been increased use of e-
cigarette use and vaping in this country among youth and adults. We
know that they are addicting, harmful and not a proven smoking
cessation strategy. E-cigarettes also contain cancer causing chemicals
and cause lung and cardiovascular disease. At this time we don't know
the full extent of and all the negative long term effects of vaping
which is being studied and researched.
E-cigarette use is not safe. The use of these products have caused
fires, explosions and injuries to our sailors and marines. As a result,
Navy Fleet Forces Command and Pacific Fleet have suspended the use,
storage and charging of any electronic nicotine delivery system device
aboard all ships, submarines, aircraft, boats, crafts, vehicles and
heavy equipment to ensure the safety of our forces. The new Secretary
of the Navy instruction (SECNAVINST 5100.13F Navy and Marine Corps
Tobacco Policy--2 December 2020) also bans e-cigarette, vaping and
other alternative tobacco product use within military workspaces and
facilities. We believe this approach helps protect the health and
safety of our Naval Forces.
Question. What are you doing about the impact of tobacco on
military children and family members? Are you reviewing whether these
products should be sold in military exchanges or commissaries?
Answer. We want our military children, teenagers and families to be
healthy and tobacco free. We address tobacco use during wellness and
medical visits for children, adolescents and family members. Navy
Medicine and the Defense Health Agency use the U.S. Public Health
Service Treating Tobacco Use and Dependence Clinical Practice
Guidelines to screen for and address tobacco use, encourage tobacco
free living and provide resources, support and counseling. We encourage
parents to quit using and not to use tobacco in their homes and around
their children and families. Our medical team offers no cost, evidence-
based tobacco cessation treatment for all beneficiaries. The Secretary
of the Navy instruction protects children and families by banning
tobacco use where children live, play and learn--at playgrounds and
athletic fields, pools and schools.
Navy Medicine bans tobacco use on all medical property. Tobacco
products are prohibited for sale in any exchanges and stores that are
within hospitals, clinics or any other medical facilities. Sale of
tobacco products at other exchanges are under the purview of the Navy
Exchange and Marine Corps Exchange.
______
Questions Submitted by Senator Susan M. Collins
Question. At the beginning of the COVID-19 pandemic last year, the
nation saw a huge spike in demand for modular negative pressure room
containment systems that can offer civilian hospitals or Military
Treatment Facilities the capability to safely assess and treat patients
with suspected COVID-19 symptoms. It is clear these commercial-off-the-
shelf systems can help ensure the readiness of the defense health
system worldwide, especially in the case of future pandemics or
biological attacks. Section 732 of the recently enacted fiscal year
2021 National Defense Authorization Act (NDAA) requires a report of the
Department's pandemic preparedness. I was pleased that the Department
has committed to ensuring that these modular negative air pressure room
containment systems are included as part of that Pandemic Preparedness
Report directed by the NDAA. Provisions unanimously approved in the
Senate's fiscal year 2021 NDAA bill also required a specific review of
these systems.
Given the use of these systems in the civilian sector and in VA
hospitals, what does the Navy believe to be the potential benefits of
these systems? How could these types of systems be used by Navy in the
future to help mitigate the spread of future pandemics or biological
agents in the future?
Answer. Senator Collins, thank you for your question. As reflected
in my written testimony, Navy Medicine continues to work
collaboratively with the DoD COVID-19 Task Force, the Joint Staff, the
Defense Logistics Agency, the Defense Health Agency, the other
Services, Uniformed Services University of the Health Sciences,
interagency partners, and many others on the pandemic response.
There has always been a need for negative pressure capabilities in
our medical treatment facilities to meet the needs of our patients and
staff. Negative pressure systems, whether built-in or modular, can
assist patients and protect healthcare staff from certain diseases and
agents.
Navy Medicine has addressed these requirements on a permanent and
temporary basis to meet the ongoing demands of the pandemic. In
addition, both of Navy's hospital ships, USNS COMFORT and USNS MERCY,
have negative pressure capabilities.
As directed by the fiscal year 2017 National Defense Authorization
Act, the Defense Health Agency (DHA) has assumed authority, direction
and control of military medical treatment facilities. In this role, the
DHA has primary responsibility for medical systems and their clinical
application in these facilities. Given these responsibilities, the
integration and value of portable negative pressure capabilities is
most appropriately addressed by the DHA to ensure a coordinated and
comprehensive response within the Military Health System.
______
Questions Submitted to Lieutenant General Dorothy A. Hogg
Questions Submitted by Senator Richard J. Durbin
Question. I remain very concerned about curbing the use of tobacco
in the military. We know that smoking makes it harder for individuals
to perform the tasks we ask of them, lengthens medical recovery, and
increases illness, increases healing times and accounts for greater
health costs. In fact, DoD indicates that tobacco use costs the
department at least $1.6 billion annually. And it continues to trouble
me that--amid all of the rigorous physical challenges and testing they
perform--so many of our service-members pick up these habits after
enlisting. We also know that there are continued concerns about
military members using tobacco alternatives such as e-cigarettes and
vapes. In addition, I was supportive of Congressional efforts to raise
the Federal minimum age of sale of tobacco products from 18 to 21. But
I remain concerned that we are not adequately addressing the youth
vaping epidemic.
What are you doing on a regular basis to drive an anti-tobacco
message throughout your Service? Are we making progress?
Answer. The Department of the Air Force continues to discourage the
use of all tobacco products. The DAF military treatment facilities
support enrolled beneficiaries who require tobacco cessation support,
which included access to medications, in-person counseling, and quit
line counseling.
Yes, we are making progress. Since early 2020, Active Duty
cigarette and smokeless tobacco use continues to decline, and E-
cigarette use rates have remained steady.
Question. What is the impact that we are seeing on service members
with the rise of tobacco alternatives such as e-cigarettes and vapes?
Answer. We have not seen a significant negative impact in reported
cases of pulmonary distress due to use of tobacco alternatives.
Retrospective study analysis illustrate individuals using vaping oils
have the highest likelihood of experiencing pulmonary distress,
particular because vaping oils are not regulated. Active military
members who use tobacco and its alternatives are provided educational
information about the dangers and available resources if they wish to
quit.
Reference: Rice SJ, Hyland V, Behera M, Ramalingam SS, Bunn P,
Belani CP. Guidance on the Clinical Management of Electronic Cigarette
or Vaping-Associated Lung Injury. J Thorac Oncol. 2020 Nov;15(11):1727-
1737. PMID: 32866653.
Question. What are you doing about the impact of tobacco on
military children and family members? Are you reviewing whether these
products should be sold in military exchanges or commissaries?
Answer. The sales of tobacco products is prohibited in all Air
Force Services Activity (AFSVA) facilities (e.g., Clubs, Force Support
Morale, Welfare, and Recreation facilities, golf course). Note: The
military exchange and commissary are not AFSVA facilities and therefore
cannot provide further comment about their anti-tobacco policies or
initiatives.
______
Questions Submitted by Senator Susan M. Collins
Question. At the beginning of the COVID-19 pandemic last year, the
nation saw a huge spike in demand for modular negative pressure room
containment systems that can offer civilian hospitals or Military
Treatment Facilities the capability to safely assess and treat patients
with suspected COVID-19 symptoms. It is clear these commercial-off-the-
shelf systems can help ensure the readiness of the defense health
system worldwide, especially in the case of future pandemics or
biological attacks. Section 732 of the recently enacted fiscal year
2021 National Defense Authorization Act (NDAA) requires a report of the
Department's pandemic preparedness. I was pleased that the Department
has committed to ensuring that these modular negative air pressure room
containment systems are included as part of that Pandemic Preparedness
Report directed by the NDAA. Provisions unanimously approved in the
Senate's fiscal year 2021 NDAA bill also required a specific review of
these systems.
Given the use of these systems in the civilian sector and in VA
hospitals, what does the Air Force believe to be the potential benefits
of these systems?
Answer. The primary benefit is the minimal assembly time required
and subsequently, limiting the disruption of operations in the military
treatment facilities (e.g., fixed facility operations).
Question. How could these types of systems be used by Air Force in
the future to help mitigate the spread of future pandemics or
biological agents in the future?
Answer. Modular containment systems can be used in the future to
help mitigate the spread of future pandemics or biological agents by:
--Providing a temporary, alternative solution when a permanent
facility is at risk of operating beyond its surge capacity
--Mitigating the difficulties in establishing facilities in austere
environments
______
Questions Submitted by Senator Lisa Murkowski
Question. I appreciate Lt Gen Hogg's recognition of the ever
growing importance of the Arctic. I would like to hear more about the
Below Zero Medicine Program.
What challenges does extreme cold place on medical service?
Answer. The major challenges include, but not limited to, a lack of
reliable extreme cold weather functioning medical and non-medical
equipment, no suitable expeditionary medical facility, and the need to
develop standard operating procedures/clinical practice guidelines.
Question. What has the outcome been from the Below Zero Medicine
summits?
Answer. First, we developed the Cold Region Expeditionary Medical
Operations concept. Second, we increased collaboration in extreme cold
weather medicine research and facilitated joint service exercise
participation. Finally, we are pursuing the development of recurring
medical educational materials and a training curriculum proposal for
military personnel.
Question. Will the fiscal year 2022 request contain any Arctic-
centric medical requests?
Answer. There are no budget requests planned for fiscal year 2022.
Question. In October of 2018, administration and management of the
Military Treatment Facilities (MTFs) began to transfer from each
Military Department to the Defense Health Agency (DHA). This transition
also came with significant cuts to active duty medical personnel, the
fiscal year 2021 plan reduces the medical force by 9.6 percent (7,422
personnel). Additionally, the transition includes restructuring the
mission and scope of each MTF which must be completed by the end of
fiscal year 2021.
Given these significant changes and cuts to medical personnel, have
medical readiness rates increased for our total force?
Answer. No, the Military Health System changes have not
significantly affected the medical readiness rates over the last 2
years.
Question. If so, have the standards for tracking medical readiness
also changed?
Answer. The standards for tracking medical readiness have not
changed.
Question. It was mentioned that COVID-19 has affected medical
readiness within the military.
Specifically Dental Readiness, how far behind has the DoD fallen
with regard to providing dental care to service members and what is
your plan to eliminate this backlog?
Answer. AF/SG has worked closely with the military treatment
facilities to develop a leveling strategy to expand scope and capacity
of dental care and to target any backlog of pending dental readiness
examinations. Pre-pandemic dental readiness in February 2020 was 93.8
percent. Currently, dental readiness is 92.7 percent and continues to
increase as we move past the pandemic. Overall, meeting dental
readiness requirements has not slowed down the ability to support the
warfighting mission.
______
Questions Submitted by Senator John Hoeven
Question. In your testimony, you mention the ongoing rollout of a
new initiative that embeds Operational Support Teams (OSTs) at Air
Force installations around the country. Minot Air Force Base was one of
four locations to participate in the Task Force True North beta test,
where the OST initiative began. In 2020, RAND Corporation evaluated the
beta test and its initiatives. Four of five initiatives, including
OSTs, were well received by leadership, providers, and airmen and the
data supports a broad expansion of those initiatives across the Air
Force. I want to express my support for new programs like Task Force
True North and its initiatives that can improve the resilience and
well-being of our airmen and their families.
What were the key takeaways from the Task Force True North beta
test?
Answer. The key takeaways are:
--Embedded medical programs are very popular with Airmen and
Guardians. In particular, they like the accessibility, and
ability to build a relationship with the assigned medic.
--Embedded medical programs increase help-seeking, not only for their
services but for the military treatment facilities as well
(i.e. Mental Health Clinic increased 25 percent)
--Training civilian embedded professionals takes significant time, to
ensure their cultural competence and ability to synchronize
with the military treatment facility.
Question. How do you see these types of initiatives being rolled
out across the entire Air Force?
Answer. Embedded initiatives should be rolled out based on risk and
need because of the practical limitations of how many providers/
specialists the Department of the Air Force can retain or recruit
(i.e., impossible to embed personnel in every unit).
Additionally, supporting these types of initiatives requires
balancing the access demands placed on our military treatment
facilities demands.
SUBCOMMITTEE RECESS
Senator Tester. The Defense Subcommittee will reconvene on
Tuesday, April 27, at 10:00 a.m. for a closed hearing on the
Missile Defense Agency.
This committee stands in recess.
[Whereupon, at 10:13 a.m., Tuesday, April 20, the
subcommittee was recessed, to reconvene at 10:00 a.m., Tuesday,
April 27.]