[Senate Hearing 117-]
[From the U.S. Government Publishing Office]


 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2023

                              ----------                              


                        TUESDAY, MARCH 29, 2022

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10 a.m. in room SD-192, Dirksen 
Senate Office Building, Hon. Jon Tester (chairman) presiding.
    Present: Senators Tester, Baldwin, Shelby, Collins, and 
Moran.

                         DEPARTMENT OF DEFENSE

                         Defense Health Program

STATEMENT OF DR. DAVID J. SMITH, PERFORMING THE DUTIES 
            OF ASSISTANT SECRETARY OF DEFENSE FOR 
            HEALTH AFFAIRS


                opening statement of senator jon tester


    Senator Tester. I call this hearing to order. I want to 
welcome Dr. Smith, General Place, General Dingle, General 
Miller, and Admiral Gillingham to the hearing here today. I 
want to thank you for your testimony you are about to give, and 
I want to thank you especially for your service to this 
country.
    Nearly 9.5 million Americans, from private to general, from 
service member to spouse, from recruit to retiree, depend upon 
you for the healthcare services that you oversee. Your job is 
difficult because so many people are depending on you to have 
the right medical professionals and the right treatments at the 
right time because their lives, literally, depend on it.
    Over the past 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, the 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 
the service members and their families at home and abroad. This 
challenge is even more important as we begin to move past this 
global pandemic.
    I would like to know more about how the DoD is moving into 
the next phase of caring for the physical and mental health of 
our military members and their families, with a particular 
focus on mental health and suicide prevention. I would also 
like to hear your views on whether the military healthcare 
system is adequately funded for the issues that you must 
address.
    Thank you again for your service, and thank you for your 
work to better the lives of 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. Thank you, Mr. Chairman. And I 
also want to take a moment to thank our witnesses for being 
here today.
    As we move past year two of the COVID-19 pandemic I would 
like to recognize each of you for your commitment to our 
service members, and the nation as we continue to recover, and 
hopefully move forward. We have expended a significant amount 
of resources on technological innovation in the delivery of 
medical services since the start of COVID-19.
    Today I would like to just hear how our dollars, since this 
is the Appropriation Committee, our dollars have been invested 
and the lessons that you have learned while combating the 
virus. I would also like to hear how you intend to apply that 
knowledge to prevent, if possible, and fight future biological 
threats.
    Through medical research, innovation, education and 
training the U.S. Military Health System remains a global 
leader in healthcare delivery on and off the battlefield. 
Maintaining this level of effort, however, will only get more 
expensive as the competition for scarce resources becomes more 
acute.
    To ensure continued excellence, we need to allocate our 
limited defense dollars only to those efforts, I believe, that 
directly support and impact our war-fighting capabilities. Our 
Military's Health System conducts medical research on a wide 
variety of topics, such as cancer, infectious diseases, 
traumatic brain injury, and burn research, among many others. 
Defense funding for these important research efforts has grown 
significantly over the years, notwithstanding the billions of 
dollars that this committee, the whole committee, provides 
annually to NIH (National Institutes of Health) to conduct 
research in many of the same areas.
    In the 2022 Omnibus Appropriation Act, Congress funded an 
Advanced Research Project Agency within HHS (Health and Human 
Services) for $1 billion, in this year's budget the President 
has requested an additional $5 billion for this effort. And 
while the U.S. Medical Force and its mission will continue to 
be a high priority for the members of this subcommittee, the 
full committee must also ensure that medical research dollars 
are allocated appropriately across the spectrum.
    With that in mind, I look forward to reviewing the 2023 
Defense Health Budget and to hearing your testimony today. I 
thank you for your service again. Thank you, Mr. Chairman.
    Senator Tester. Thank you Senator Shelby. We will start 
with you Dr. Smith, for your testimony. You may proceed.


                summary statement of dr. david j. smith


    Dr. Smith. 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, and its contributions to the health and 
medical readiness of the Department.
    I am speaking today just after the formal release of the 
President's proposed fiscal year 2023 budget, but prior to the 
release of the detailed J Books, but I will outline the major 
activities unfolding in the Military Health System that will 
inform our budget proposal for 2023, as well as briefly discuss 
issues affecting the 2022 execution.
    In the past year we have witnessed significant advances in 
our response to the COVID-19 pandemic, both within the 
Department as well as the Department's support of civilian 
authorities. Lieutenant General Place, the director of the 
Defense Health Agency, will provide further details on our 
COVID response and preparedness for the future.
    Now the National Defense Authorization Act for fiscal year 
2017, enacted sweeping reforms to the organization and 
management of Military Medicine and we have made significant 
progress in implementing these reforms. And today, the Defense 
Health Agency exercises authority, direction, and control over 
all MTFs (Military Treatment Facilities) worldwide. The same 
law directed DoD to restructure or realign MTFs as necessary 
and appropriate to support the Department's readiness 
requirements.
    Those restructuring efforts were paused on April 2 of 2020 
as a result of resources required to respond to the COVID-19 
pandemic, but we clearly plan to restart implementation 
beginning in the first quarter of fiscal year 2023, with a 
targeted completion in September of 2026.
    The Department's mission requirements in supporting our 
national COVID response, however, have adversely affected the 
Defense Health Program budget in fiscal year 2022. Private 
sector care costs have increased as military medical staff were 
deployed to support the civilian missions, and other military 
medical personnel vacancies increased in our MTFs, our mid-year 
review is underway and it will provide a more detailed look at 
the spending trends we have experienced in the first quarter.
    At this point in the fiscal year DHP (Defense Health 
Program) purchased sector care projections are still somewhat 
uncertain, as you might expect, both due to the trajectory of 
the COVID-19 costs, and the uncertainty regarding return of 
suppressed non-COVID care requirements. Despite these short-
term budgetary challenges the MHS (Military Health System) 
continues its sustained decade-long track record of responsibly 
managing healthcare costs, which remain below the national 
health expenditures per capita rate, and the Department 
continues to pursue opportunities for greater effectiveness and 
efficiency by fully integrating the operation of our medical 
services, and streamlining internal operations.
    The Department is grateful for the long-term advocacy and 
support from this committee for our Military Medical Research 
Program in those areas of most pressing need and relevance of 
today's emerging threats, which include the COVID-19 pandemic.
    And in order to sustain this momentum and prepare for 
future pandemics, our future budget will support pandemic 
readiness and response in the MHS by enhancing our capabilities 
to conduct rapid research and medical countermeasure 
development, such as diagnostics, treatments, and vaccines, 
while strengthening the capability of the Department to quickly 
identify and characterize new variants and other emerging 
biologic threats.
    Our fiscal year 2023 budget will present a balanced, 
comprehensive strategy that aligns with the Secretary's 
priorities, to include ongoing response to the COVID-19 
pandemic, and we look forward to working with you over the 
coming months to further refine and articulate our 
requirements.
    So thank you for inviting me here today to speak with you 
about the vital role of military medicine in supporting our 
national security. And I look forward to answering your 
questions today. Thank you.
    Senator Tester. Thank you Dr. Smith. And there will be 
questions. Next, we will go to General Place.
STATEMENT OF LIEUTENANT GENERAL RONALD J. PLACE, 
            DIRECTOR OF THE DEFENSE HEALTH AGENCY
    General Place. Chairman Tester, Vice Chairman Shelby, 
distinguished members of the subcommittee, thanks for inviting 
me today to join Dr. Smith and the Services' Surgeon Generals 
to discuss the Defense Health Program.
    I will add to Dr. Smith's remarks by briefly focusing on 
some of the critical responsibilities of the Defense Health 
Agency in support of the military departments and combatant 
commands.
    The response to the COVID-19 pandemic was one of our top 
priorities, vital to the medical readiness of our forces, and 
the health and wellbeing of all Americans. The Department 
expanded its COVID-19 testing capability and capacity. We 
currently have 140 operational laboratories for COVID-19 
testing, having conducted over 6.2 million tests worldwide.
    In February of this year we also allowed military medical 
treatment facilities to distribute over-the-counter antigen 
tests for eligible beneficiaries, at no cost, providing the 
Department of Defense with the opportunity to diagnose COVID-19 
earlier, and allowing our clinical team to deliver treatment in 
a more timely manner for those who test positive.
    The Defense Health Agency is regularly updating our COVID-
19 practice management guidelines, currently on version number 
eight, to provide military clinicians and military medical 
treatment facilities, worldwide, with a single document on best 
practices, and the latest evidence and guidance across all 
clinical care specialties.
    The DHA led a comprehensive campaign to administer COVID-19 
vaccines. As of March 23rd of this year, the Military Health 
System had administered over 7.9 million doses of COVID-19 
vaccines, and more than 1.6 million military personnel have 
been fully vaccinated.
    Throughout the pandemic the DoD provided extensive support 
to FEMA for COVID-19 response that included both mass 
vaccination, and healthcare delivery augmentation, and 
communities needing additional personnel resources. We also 
delivered medical support to the Department of State and 
Homeland Security for assisting evacuees from Afghanistan. Our 
medical teams were proud to contribute to this whole-of-
government response to both events.
    In non-COVID activities the Department continues to proceed 
with the multi-year implementation of our new electronic health 
record, or EHR, that we call MHS GENESIS; today, MHS GENESIS 
has been deployed at 66 medical treatment facilities, and at 
more than 1,300 individual locations, with more than 93,000 
active DoD users of that system. We will complete the 
deployment by the end of calendar year 2023, on schedule.
    The DHA manages the TRICARE Program, and among the most 
important strategies we pursue is the development of effective 
TRICARE contracts that deliver high value, patient-centric care 
that integrates military and private sector care. The T5 
contracts represent the next generation of these contracts 
after an extensive multi-year engagement with industry and 
other stakeholders the DHA issued the T5 request for proposals 
in 2021, and is now in the process of evaluating the proposals 
with our intention to announce award by the end of this fiscal 
year.
    Dr. Smith noted our current budgetary status and future 
plans. I will add that the Military Health System is not unique 
in the year-to-year variability associated with predicting 
health care costs. COVID-19 has only exacerbated these known 
challenges. Nonetheless, we remain vigilant about our medical 
expenditures, and we appreciate that Congress continues to 
grant the Department carry-over authority, allowing the DoD to 
maintain better funding flows to minimize disruption of health 
care services to our beneficiaries.
    I am grateful for the opportunity to represent the men and 
women of the Defense Health Agency. I thank you for inviting me 
here today. I look forward to your questions.
    [The statement follows:]
               Prepared Statement of Dr. David Smith and 
                   Lieutenant General Ronald J. Place
    Chairman Tester, Vice Chairman Shelby, distinguished Members of the 
Subcommittee, we are 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. We are honored 
to represent the dedicated military and civilian medical professionals 
in the Military Health System (MHS), providing direct support to our 
combatant commanders and delivering or arranging healthcare for our 9.6 
million beneficiaries.
    This hearing is occurring shortly after the formal release of the 
President's proposed fiscal year (FY) 2023 budget, and after the 
enactment of the fiscal year 2022 budget. This testimony provides the 
Committee with information on major activities that will inform our 
budget proposal for fiscal year 2023 as well as issues affecting fiscal 
year 2022 execution. Once again, the past year witnessed significant 
advances in our response to the COVID-19 pandemic, both within the 
Department and the Department's support to civilian authorities. We 
will begin this testimony with the current state of COVID-19-related 
efforts in the Department.
                           covid-19 response
    On his first day in the Pentagon, Secretary Austin made clear that 
the greatest proximate challenge to our Nation's security is the threat 
of COVID-19, and that the Department will act boldly and quickly to 
support U.S. Government efforts to defeat this disease. Throughout this 
pandemic, the MHS has provided 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 and sustain high quality 
health services to our military population. We will briefly mention 
several critical elements of our response along with our ongoing 
operational demands.
    COVID-19 Testing. Testing remains a key pillar of our public health 
strategy--and our objective to maintain a medically ready force. The 
Department continued to sustain and expand its COVID-19 testing of the 
force, as well as testing for suspected cases in our beneficiary 
population. The Department currently maintains 140 operational 
laboratories for COVID-19 testing, and has conducted over 6.1 million 
tests worldwide since the declaration of the pandemic.
    In February 2022, the MHS also issued guidance allowing military 
medical treatment facilities (MTFs) to distribute over-the-counter 
antigen tests to eligible beneficiaries at no cost. This policy 
provides DoD with the opportunity to diagnose COVID-19 at an earlier 
date, potentially reduces the requirement for more expensive in-house 
laboratory testing, and allows our clinical team to deliver treatment 
in a more timely manner for those who test positive.
    Clinical Support for Treatment and Therapuetics. Early in the 
COVID-19 response, the Defense Health Agency (DHA) developed and 
released the DoD COVID-19 Practice Management Guide (PMG) to provide 
clinicians and MTFs with a single document on best practices, the 
latest evidence, and guidance across all clinical care specialties. The 
PMG has been continually updated and rereleased, with the most recent 
version (Version 8) published on January 31, 2022.
    The DHA continues to develop and disseminate specialized guidance 
to assist MTFs and healthcare providers regarding patient care 
considerations when administering emerging new therapies to treat 
COVID-19. Over the last several months, a number of new therapies have 
received emergency use authorization from the Food and Drug 
Administration (FDA), to include therapies authorized for use in 
outpatient settings. While these new therapies represent additional 
costs, they also are cost-saving approaches that help avoid 
hospitalization or more severe cases of COVID-19 requiring more 
intensive treatment.
    Health Care Delivery and Deferred Medical Care. In both the direct 
care system and the TRICARE network, the Department has worked to 
ensure beneficiaries receive timely medically necessary and readiness-
related care throughout the pandemic. In addition, we are focused on 
educating beneficiaries to return to MTFs for care that was deferred 
due to the pandemic. 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 to meet beneficiary demand while minimizing unnecessary risks 
for patients and staff.
    In fiscal year 2022, MTFs and Markets increased available 
appointments to meet patient demand for care and schedule previously 
delayed care. Despite the additional workload associated with COVID-19-
related deployments and vaccinations, MTF appointment availability is 
approximating pre-pandemic levels, and access to appointments is 
exceeding standards. Direct care services for cancer and other 
preventive screening, however, are lagging compared to strong pre-
pandemic performance, and MTF staff members are actively reaching out 
to beneficiaries to encourage and facilitate screening appointments.
    In a similar vein, for network care, the DHA works with TRICARE 
contractors to ensure our beneficiaries have timely access to care in 
the network; we have expanded availability of telemedicine coverage, 
and eased beneficiary access to providers by extending referral and 
authorization limits and adjusting rules impacting beneficiary cost 
shares. In fiscal year 2017, DHA formally amended the TRICARE Policy 
manual that included many enhancements that supported the use of 
telemedicine including reimbursing for care at the same rate as ``in 
person care'' and covering medically necessary remote monitoring of 
weight, blood pressure, pulse oximetry, and respiratory flow rate for 
patients with acute and chronic conditions in support of improved 
health outcomes. Finally, DHA added coverage for audio-only telephone 
visits, which remain the most popular type of telemedicine visit, 
through an interim final rule. DHA plans to continue these telemedicine 
enhancements and include them in the next iteration of the TRICARE 
Contracts, known as ``T5'', which DHA expects to begin implementing in 
fiscal year 2023.
    COVID-19 Vaccine and Immunization Implementation. Since December 
2020, the Department has managed a comprehensive campaign to administer 
COVID-19 vaccines to Service members and other eligible beneficiaries 
and personnel. Upon the first COVID-19 vaccine receiving FDA licensure, 
Secretary Austin directed mandatory vaccination of all members of the 
Armed Forces under DoD authority on active duty or in the Ready 
Reserve, including the National Guard. As of March 23, 2022, the MHS 
has administered over 7.9 million doses of COVID-19 vaccines to Service 
members, DoD civilian employees, contractor personnel, and other 
eligible beneficiaries. More than 1.6 million military personnel 
(Active/Reserve/National Guard) have been fully vaccinated, and an 
additional 342,078 have received at least one dose. Additionally, 
335,384 military personnel have received a COVID-19 booster dose.
    Defense Support of Civilian Authorities. In fiscal year 2022, the 
DHP provided timely support to the Federal Emergency Management Agency 
(FEMA) for COVID-19 response that included both mass vaccination 
efforts as well as healthcare delivery in communities needing 
supplementary medical teams; and supported the Departments of State and 
Homeland Security for evacuees from Afghanistan.
    Since the beginning of COVID-19 response, the Department has 
received 578 FEMA mission assignments and 72 requests for assistance 
from other Federal departments and agencies in response to the COVID-19 
pandemic.
    Since January 27, 2021, more than 1,800 of the Department's medical 
professionals deployed to 29 States and one Indian Nation, many times 
to multiple locations within a State. Army, Navy, and Air Force medical 
teams provided surge medical support in civilian hospitals. More than 
4,600 DoD personnel have supported the national vaccination effort in 
California, Colorado, Florida, Georgia, Illinois, Indiana, Kentucky, 
Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New 
Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, 
Tennessee, Texas, Virginia, Washington, Wisconsin, Guam, the U.S. 
Virgin Islands, and the Commonwealth of Northern Mariana Islands. Since 
the pandemic began, National Guard Soldiers and Airmen have vaccinated 
more than 13 million civilians while activated in support of COVID-19-
reponse operations.
    Effects on the fiscal year 2022 Budget. In both fiscal year 2021 
and fiscal year 2022, the Department did not seek supplemental funding 
for the DHP despite substantial outlays to support the pandemic 
response. In fiscal year 2022, there were sustained MILPERS vacancies 
within MTFs that affected private sector care (PSC) costs, along with 
significant deployments for DSCA missions already discussed. 
Additionally, the MHS had limited carryover budget for fiscal year 2022 
as compared to prior years due to the shortfall in fiscal year 2021 
caused by COVID-19. In fiscal year 2021, the Department also used 
Restoration and Modernization funds to cover that year's PSC 
shortfall--creating project backlogs at MTFs.
    At this point in the fiscal year, DHP PSC projections are still 
uncertain, especially due to the trajectory of COVID-19 costs and the 
uncertainty regarding return of suppressed non-COVID-19 care. However, 
costs attributable to the pandemic response continue to accumulate.
                       mhs reforms and transition
    The National Defense Authorization Act (NDAA) for fiscal year 2017 
enacted sweeping reforms to the organization and management of military 
medicine. These statutory requirements centralized and standardized 
many military healthcare functions in a way that better integrates 
readiness and health delivery throughout the Department. Included among 
these reforms were 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 healthcare providers. Today, DHA exercises authority, direction, and 
control over all MTFs worldwide.
    Section 703 of the NDAA for fiscal year 2017 directed the Secretary 
of Defense to submit to the congressional defense committees an 
implementation plan to restructure or realign MTFs as necessary and 
appropriate to support the Department's readiness requirements.
    All restructuring efforts were paused on April 2, 2020, as a result 
of the resources required to respond to the COVID-19 pandemic. During 
this pause, there were changes to local health systems capacities and 
capabilities. Consequently, the Department undertook efforts to 
revalidate the assumptions made regarding MTF and local capacity and 
preparedness. That work was completed in December 2020. The MHS is 
currently refreshing enterprise and local MTF planning efforts 
regarding this transition, and we plan to re-start implementation 
beginning in the 1st Quarter of fiscal year 2023 with targeted 
completion by September 2026.
                       mhs genesis implementation
    The Department continues to proceed with the multi-year 
implementation of its new, Electronic Health Record (EHR), MHS GENESIS. 
The value of MHS GENESIS has become even more apparent during the 
COVID-19 response. On several occasions, we were able to implement 
COVID-19-specific configuration changes in MHS GENESIS within hours 
that provided senior military and civilian leaders with timely 
information on COVID-19 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.
    Since April 2018, DoD has applied bi-annual commercial upgrades to 
MHS GENESIS from the EHR's vendors, taking advantage of industry best 
practices in healthcare information technology. In addition, DoD has 
rolled-out capability improvements such as Cerner's HealtheIntent 
Platform for secondary data use, MHS Video Connect, as well as multiple 
Cerner Millennium modules to improve the end user experience.
    Today, MHS GENESIS has been deployed at 53 MTFs and at more than 
1,300 individual locations, with more than 77 thousand active DoD 
users. The deployment of MHS GENESIS is currently on track to be 
completed by the end of calendar year 2023.
                tricare 5th generation contracts (t-5).
    The Department continues to manage the TRICARE Program in a manner 
that seeks to reduce the growth in healthcare costs while ensuring our 
health benefit remains exceptional, serving as an important 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 
healthcare delivery. After an extensive, multi-year engagement with 
Department leaders, industry, and other stakeholders, as well as three 
draft Requests for Proposal shared with industry, the Department issued 
the T-5 Request for Proposals on April 9, 2021. The goals of this 
procurement are to support (1) military medical readiness and the 
readiness of the medical force; (2) beneficiary choice; (3) high value 
care; and (4) the adoption of Industry Business Standards.
    The Department is now in the process of evaluating the proposals 
submitted by industry, and intends to announce awards by the end of 
fiscal year 2022. The new contracts are planned to begin healthcare 
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 include 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 MTFs.
    The fiscal year 2022 DHP budget request for RDT&E was $631 million; 
the fiscal year 2022 appropriation was $2.633B. The additional funds 
were Congressional Special Interest items that included investments in 
various areas such as neurological and psychological health, combat 
readiness research, chronic pain management, hearing restoration, 
spinal cord injury, infectious diseases, cancer, and Alzheimer's 
disease.
    Since the start of the pandemic, the Department has used its 
decades' worth of experience studying infectious diseases of military 
importance, including HIV/AIDS, Ebola, and coronaviruses such as Middle 
East Respiratory Syndrome, at the Department's laboratories to help 
defeat the COVID-19 pandemic. In January 2020, the Department began 
research and development on diagnostics, therapeutics, and vaccines for 
SARS-CoV-2, the strain of coronavirus that causes COVID-19. The Defense 
Health Program Medical research and development funds provided the 
initial infusion required to support early COVID-19 research efforts.
    As part of the President's reignited Cancer Moonshot, DoD is 
expanding a signature clinical research program to all DoD hospitals. 
As part of the Cancer Moonshot in 2016, DoD launched the Applied 
Proteogenomics OrganizationaL Learning and Outcomes (APOLLO) network as 
a collaboration between NCI, DoD and the Department of Veterans Affairs 
(VA). The goal of this collaboration is to incorporate proteogenomics 
into patient care as a way of looking beyond the genome, to the 
activity and expression of the proteins that the genome encodes. To 
date, this network includes thirteen DoD and VA hospitals which started 
with eight cancer-specific programs, including studies in lung, breast, 
prostate, ovarian, pancreatic, testicular, and brain cancers, and is 
now expanding to all cancer types. DoD, as part of the reignited Cancer 
Moonshot, will now ensure that the APOLLO trial network expands to 
include every DoD hospital.
    In order to sustain the momentum in the COVID-19 fight, continue to 
defend the force against further evolutions of the virus, and to 
prepare for future pandemics, our future budget will support pandemic 
readiness and response in the MHS by enhancing capabilities to conduct 
rapid research and medical countermeasure development such as 
diagnostics, treatments, and vaccines, while strengthening the 
capability of the Department to quickly identify and characterize new 
variants and other emerging biological threats.
                         management of the dhp
    The MHS continues to employ enterprise-wide performance management 
systems that provide stakeholders at all levels of the military with 
visibility into how we are preforming on key metrics. These dashboards 
show longitudinal performance in measures of readiness, health, access, 
quality, safety and cost. We provide leadership, MTF directors, 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, personal protective 
equipment 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 Military 
Department, by Market, and by individual hospital or clinic. We will 
continue to adapt this management system as the MTF transition 
progresses. Directors 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.
                    overall fiscal year 2023 budget
    The fiscal year 2023 budget will prioritize our resource 
requirements to address urgent military medical readiness requirements 
to include ensuring military medical resources are prepared to support 
contingencies around the world; demands placed on the MHS from the 
COVID-19 pandemic; and increased PSC costs that are driven by a number 
of factors.
    The MHS is not unique in the variability associated with predicting 
healthcare 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 foresee. COVID-19 has only exacerbated these challenges.
    Despite these short-term budgetary challenges, the MHS continues 
its sustained decade-long track record in responsibly managing 
healthcare costs cost control. Our costs remain below the National 
Health Expenditures per capita rate. The Department continues to pursue 
efforts focused on internal business process improvements and 
structural changes to find greater efficiencies that may result from 
fully integrating the operation of hospitals and clinics; continuing 
the deployment of MHS GENESIS; modernizing clinical and business 
processes; and, streamlining internal operations.
    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 healthcare services to our beneficiaries. We are 
committed to providing regular updates to the committee, and providing 
full visibility to Congress on plans for reprogramming funds should 
that need arise. Furthermore, we will ensure that available funding is 
directed toward unfunded medical readiness and healthcare 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.
    Our fiscal year 2023 budget will present a balanced, comprehensive 
strategy that aligns with the Secretary's priorities--Defend the 
Nation; Take Care of our People; Succeed Through Teamwork--and that 
explicitly included DoD's role in the ongoing response to the COVID-19 
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 us 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, General Place. General Dingle.
STATEMENT OF LIEUTENANT GENERAL R. SCOTT DINGLE, 
            SURGEON GENERAL OF THE ARMY
    General Dingle. Chairman Tester, Vice Chairman Shelby, and 
distinguished members of the subcommittee, thank you for the 
opportunity to speak to you on behalf of the Army's soldiers, 
civilians, and their families about the Defense Health Program.
    As the 45th Army Surgeon General my promise to you, our 
soldiers, and family members is that we will remain good 
stewards of the DHP, and will always be ready to answer our 
Nation's call. Today our Army's Medical Force is ready to 
deploy today, fight tonight, and return them to duty tomorrow 
as we provide world-class health care to over 146,000 forward-
deployed U.S. Army soldiers around the globe.
    The Army's ready medical force will provide evolving 
healthcare to meet the demands of the warfighter in any 
operational environment. My strategy to provide a trained and 
ready medical force, while remaining a good steward of the DHP, 
consists of five objectives: We will synchronize and integrate 
the medical effort within the Department of the Army, the 
Defense Health Agency, the Joint Staff, and combatant commands 
to ensure responsive and relevancy as we execute the National 
Defense Strategy.
    We will build readiness through investments in our human 
capital. People first. Our healthcare professionals have 
demonstrated their dedication and readiness in response to the 
global pandemic for the last 2 years. We must be innovative and 
judicious to remain competitive with national healthcare 
industries to recruit and retain our best medical 
professionals.
    We must monitor the impacts of the prolonged pandemic 
response on our healthcare workforce, our soldiers, and our 
families. Suicide and stress harms our most valuable resource, 
our people. One suicide is too many, and we will continue to 
combat it at every level to get ahead. We will modernize the 
medical force, modernization is occurring in near-term as Army 
aviation expands future vertical lift, and future long-range 
assault aircraft. In parallel, we are developing a medical 
variant.
    Army Medicine will not be left behind, we will medically 
reform. We are transforming in accordance with legislation and 
the Department guidelines. The Army has completed or programmed 
resource transfers, transfers of more than $22 billion of the 
DHP, and over 32,000 civilians to the DHA (Defense Health 
Agency). Focused on readiness, our regional health commands 
will reflag to medical readiness commands this fall.
    Finally, we will strengthen alliances and partnerships. I 
have reestablished liaison roles in support of our NATO (North 
Atlantic Treaty Organization) and partner medical groups. The 
cohesion ensures combined forces medical readiness in a 
globally integrated environment.
    In closing, I want to thank the subcommittee for your long-
standing support to the Army and Army Medicine. Our trained and 
ready medical force depends on timely, adequate, predictable, 
and sustainable funding with your continued support, Army 
Medicine from the foxhole to the fixed facility will, in fact, 
remain trained and ready.
    Army Medicine is Army strong. I look forward to the 
subcommittee's questions. Thank you.
    [The statement follows:]
        Prepared Statement of Lieutenant General R. Scott Dingle
    Chairman Tester, Vice Chairman 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.
    The Army and Army Medicine is ready to deploy on a moment's notice 
in support of the Nation.
    Today, America's oldest and largest service has more than 146,000 
Soldiers assigned or allocated to Combatant Commanders supporting named 
contingency operations, various exercises, and theater security 
cooperation activities. With them are our doctors, nurses, and all 
specialties in all ranks who make up Army Medicine. They represent an 
expeditionary workforce focused on high-intensity conflict in any 
environment.
    In the third year of the global coronavirus pandemic, Army Medicine 
has been at the forefront of responding to the national emergency. 
Working with our sister Services and interagency partners to deliver 
support where the Nation needs us, we have consistently answered the 
call. For the development and distribution of the COVID-19 vaccine, 
America turned to an Army logistician to lead operations. Our National 
Guard and Reserve units across America supported both their neighbors 
and the Nation in an unprecedented level of mobilization, not only for 
COVID support, but also in response to civil unrest, hurricanes, and 
wildfires, all while continuing to train for wartime missions. Soldiers 
have served across our Nation, going into hospitals when cumulative 
virus cases threatened America's communities. The Nation called and we 
responded. As the 45th Army Surgeon General, my promise to you is that 
we will continue to answer the call.
    In order to meet the Army Medicine vision, we continued to build on 
our current state of readiness for operational deployments. Our vision 
focused on interoperability with combat units. To achieve this, we 
worked to modernize our training, doctrine, equipment and formations to 
keep pace with a complex and rapidly evolving world.
    Army Medicine remains synchronized with Army Commands and the Joint 
Force in preparation for all contingencies. We engage with our allies 
and partners. Most of all, Army Medicine is committed to maximizing the 
health of the Army. Achieving this ready force requires that we have 
resilient Soldiers, Civilians, and contractors who can think 
critically, accept prudent risk, and adjust rapidly--the hallmarks of 
Army Medicine.
                      the operational environment
    Army Medicine must be ready for any operational environment given 
the exponential changes around the globe. In the last year, our 
attention has moved from arid climates to the frozen Arctic landscapes. 
Global borderless challenges have required Army Medicine to be 
adaptable and prepared for any operating environment including large 
scale combat operations, natural disasters, or austere theaters 
degraded by cyberattacks. As the Army Chief of Staff stated last year, 
``America's Army remains prepared to compete globally and fight and win 
the Nation's wars as a member of the Joint Force.''
    Operational units will deploy with capable Medical Command 
(Deployment Support) mission command headquarters, trained 
expeditionary personnel to staff field hospitals and Forward 
Resuscitative Surgical Teams. We will provide tailored healthcare to 
the warfighter, against any adversary, anytime and anywhere. From 
responding to the challenges of biological, chemical, and nuclear 
threats in the Middle East and Central Asia, to contingencies in 
Europe, or in the Arctic--we train to be ready to answer the Nation's 
call.
Army Medicine 2028
    My vision to achieve a ready, reformed, reorganized, responsive, 
and relevant medical force capable of supporting the Army and the Joint 
Force consists of five overarching objectives:
    1. Synchronize and Integrate the Medical Effort--Army Medicine 
remains responsive and reliable for teammates and stakeholders.
    2. Build Readiness--Army Medicine supports the warfighter's 
readiness.
    3. Support Modernization of the Medical Effort--Army medicine 
expands expeditionary medical capabilities and ensure their 
interoperability with the Joint Force in multi-domain operations as 
part of the Joint Health Service Enterprise.
    4. Medical Reform--Army Medicine changes at the speed of relevance, 
including key capabilities, technical innovations, and expanded 
alliances and partnerships.
    5. Strengthen Alliance and Partnerships--Army Medicine maintains 
and fosters our alliances and partnerships to enhance Army readiness.
  synchronize and integrate the medical effort and building readiness
    Synchronizing and integrating with the Army strategy is 
foundational to building readiness, supporting modernization, and 
leading medical reform efforts described in the Army Medicine Strategy. 
Our operational missions reflect the achievements of a multi-year 
effort to rebuild readiness and accelerate modernization. Our ready 
medical force deserves the tools for recruiting and retention, 
training, modernization, and equipping a future expeditionary medical 
force.
    Similarly, a medically ready force involves a series of assessments 
to ensure that our uniformed service members are free of health-related 
conditions that endanger others or limit their ability to achieve their 
assigned mission. Army Medicine is integral in Soldiers making the 
health and lifestyle decisions to maintain their individual medical and 
dental readiness requirements and to report health issues that may 
affect their readiness to deploy or be retained to continue serving.
    As of March 1, 2022, the Army reached a medical readiness status of 
roughly 84.20 percent, or 5.80 percent below the 90 percent goal. The 
pandemic environment has resulted in intermittent decreased access to 
care to some medical readiness services due to pandemic mitigation 
measures. In particular, access for periodic health assessments and 
annual dental exams reduced with elevated HPCON levels. The subsequent 
backlog of medical readiness requirements takes time and resources to 
address in order to return to pre-pandemic levels of medical readiness. 
We will continue to improve, especially as the Nation emerges from the 
novel coronavirus pandemic.
    Nationwide, the healthcare profession faces personnel challenges. 
The Army must compete with the civilian sector and other public 
healthcare entities to recruit qualified healthcare providers. The 
inventory for Army healthcare specialties, particularly in the medical 
and dental corps, continues to fall significantly below authorizations; 
shortages are projected to increase over the next three to 5 years. 
Retention of certain medical specialties, especially personnel within 
Health and Holistic Fitness disciplines, has been demanding given 
limits on junior grade promotions stemming from the length of their 
medical training.
    We are grateful to Congress for increases in Health Professional 
Officer special pay caps. We must continue to make the necessary 
investments in special pay and stipends commensurate with the needs of 
the market and the fiscal environment. This is vital to recruit and 
retain the best quality healthcare professionals. We must also continue 
to explore other ways to maximize the use of scholarship and financial 
assistance programs as well as expand our pool for potential applicants 
for civilian healthcare positions.
    One of the greatest challenges that directly relates to readiness 
is the terrible impact of suicides within our ranks. To be clear, Army 
Medicine is using every tool possible to address suicides.
    Behavioral Health encounters grew from approximately 900,000 in 
fiscal year (FY) 2007 to approximately 2.05 million in fiscal year 
2020. In fiscal year 2021, despite pandemic conditions, 1.68 million 
Behavioral Health encounters were conducted. Army Medicine in 
collaboration with the Army Staff, specifically Army Office Chief of 
Chaplains, Army G-1 Resilient Directorate, and Army G-9 are integrated 
and synchronized to address suicide prevention and quality of life 
initiatives. Efforts include educating on lethal means, data collection 
and analysis, and ongoing communications about suicide-related 
behaviors. The Army, in collaboration with Army Resilient Directorate, 
providers, leaders, Soldiers and Families, is redoubling its efforts on 
how to reduce access to lethal means (both firearm and medications) and 
focusing on how to empower Soldiers to seek help. As a part of a larger 
strategy, the Army is finalizing a robust campaign to address all risk 
factors associated with self-harm.
    The Army is working diligently to solidify a culture of cohesion 
and intervention to address the invisible dangers of impulsive 
behaviors to include substance use issues, alcohol, physical, 
emotional, financial and legal stressors. These behaviors harm our most 
valuable resource, our People--Soldiers and family members. Among the 
most vulnerable population, the survivors of sexual harassment and 
assault. To ensure the integrity of the Army Sexual Harassment and 
Assault Response Program, Army Medicine vigorously supports and 
collaborates with the Defense Health Agency (DHA), the Army SHARP, 
units and organizations to ensure victims receive the necessary 
provision of care throughout the traumatic event. The path to suicide 
is not solely a mental health problem. It takes the support of many 
individuals, from Families, friends, peers, religious. Examples of this 
collaboration include: Army Medicine, in partnership with the DHA, Army 
Staff, local installation and garrison communities, provide staff 
assistance visits and when warranted, epidemiological consults to 
advise and identify risk areas. These impulsive behaviors harm unit 
cohesion. It degrades the ability of the Army to defend the American 
people. We must do all we can to support those facing physical and 
emotional challenges, so that we do not lose our Soldiers or family 
members to suicide.
    The Army's Embedded Behavioral Health program was recognized by a 
recent Department of Defense Inspector General Report for our work to 
align providers to deployable units thereby facilitating unit leader 
consultation and Soldier access to Behavioral Healthcare. Embedded 
Behavioral Health teams are currently being implemented throughout 
active duty deployable combat units to provide improved access to care 
and continuity of behavioral healthcare for Soldiers assigned to 
deployable units. Further, case managers assist Service members who are 
in active mental healthcare transitioning out of military service to 
obtain a provider and create a bridge for continuous care between the 
Department of Defense and the Veterans Health Administration.
Support Modernization of the Medical Force.
    Army Medicine, as part of the Total Force, the Joint community, and 
with our allies and partners will modernize our medical concepts, 
doctrine, and capabilities that enable prolonged care on the 
battlefield. The focus of Modernization in Army Medicine is providing 
expeditionary life- and limb-saving capabilities in a multi-domain 
operation. It begins with concepts and doctrine tailored to the future 
operating environments we see in the 21st Century.
    Our Soldiers must be properly trained and tested in realistic 
scenario-based medical simulations, validated in the most demanding 
exercises, and fielded to the operational force. Part of this 
modernization effort requires a focus on research and development that 
takes into account operational capabilities.
    The most vital modernization requirement at the point of injury is 
medical evacuation via ground or air assets in a contested battlefield. 
As we modernize several parts of the ground force, the ability to save 
the Soldier will require deliberate planning and programming for 
consistent funding of vertical lift capability to rapidly get the 
injured Soldier to the medical care he or she needs in support the 
expeditionary medical force.
Medical Reform.
    Army Medicine's pivot to readiness requires that we reform our 
organizations to improve business processes and gain efficiencies. To 
better support the Army, we have reorganized and restructured our 
headquarters. This fall, our regional health commands will reflag as 
Medical Readiness Commands. This is not a simple ``name change.'' In 
recent years, we have executed the transition of healthcare functions 
including public health to the DHA. Currently, the Army has completed 
and/or programmed resource transfers of more than $22 billion of the 
Defense Health Program and over 32,000 civilians to the DHA through 
fiscal year 2023 in accordance with a prescribed timeline and with 
negligible impact on beneficiaries. We have reorganized internal 
functions to enable the health of the Army warfighter. We have also 
reformed and improved our resource management process to increase 
transparency and management of funding and manpower to better support 
my vision for medical readiness. The change to an operational mind-set 
has become inherent in the transformation of our headquarters in the 
National Capitol Region and in our regional headquarters throughout the 
entire Army Medicine Enterprise.
    In accordance with recent legislation, Army Medicine has changed 
its structure to align medical operations to sustain the readiness of 
Soldiers and deploy a medical force trained and ready for high-
intensity conflict and any directed mission. As the Army Surgeon 
General, I am the integrator of these capabilities within the Service 
as I advocate for Army- specific medical concerns within the DHA. The 
changes, initiated by Congress will result in a more flexible, 
adaptable, effective and integrated system to manage our medical 
facilities.
Strengthen Alliances and Partnerships.
    Army Medicine is ready and responsive to global needs because we 
are also engaged with our allies and partners. The cohesion we build 
around the world ensures that no matter the mission or environment, the 
Joint Force does not fight alone.
    The Office of the Surgeon General and the Army Medical Command 
supports Combatant Commands, the DHA, Army Commands, and the 
international community by providing institutional medical training, 
collaboration on medical research and development, innovative 
approaches to global health engagement activities, and trained and 
ready medical professionals to units and individual engagement 
opportunities. This is a mission I hold especially close.
    I reestablished the U.S. Liaison Officer to the United Kingdom 
Military Medical Department in the fall of 2021 as Army Medicine has 
continued its leadership roles in several North Atlantic Treaty 
Organization Medical Standardization administrative and specialty 
groups. We support a program of engineer and scientist exchange program 
officers through the Institute of Surgical Research.
    Along with partner nation physicians and medical researchers we 
participate in projects ranging from blood and surgical research to the 
best practices in prosthetics, rehabilitation and burn treatment. The 
Medical Center of Excellence hosts a long standing exchange 
relationship with Australia while more recently an exchange instructor 
position with Germany.
    Finally, in the Middle East, Army Medicine hosted a visit with the 
Israeli Surgeon General in anticipation of the upcoming SHORESH 
conference and has maintained a rotating medical exchange program with 
the Israel Defense Force. Further, Army Medicine's contribution to the 
region includes $54 million in foreign military sales to develop a 
trauma, burn and rehabilitation medicine capability in the United Arab 
Emirates. Our contributions included a team of up to 11 medical 
professionals to be embedded in the United Arab Emirates to provide 
training, assistance, and development of an Emirati trauma system that 
will serve both the military and civilian community.
                               conclusion
    I want to thank the Committee for your steadfast support to the 
Army and Military Medicine. Army Medicine is focused on maintaining 
readiness during the pandemic. We are working with the Joint Services 
to closely align medical readiness and deployability for Commanders and 
Army Senior Leaders. Medical readiness of the Army and the preparedness 
of Army Medicine to meet operational requirements depends in large part 
on timely, adequate, predictable and sustainable funding. It also 
requires the funding to support the recruitment and retention of health 
professional Soldiers and the continued modernization of the medical 
force.
    During the global pandemic when the Nation called, Army Medicine 
was ready and we responded. Today we remain ready and responsive to the 
needs of the Nation. In closing, I appreciate the Subcommittee's work 
and continued support to our Soldiers, and our Army. Army Medicine is 
Army Strong.

    Senator Tester. Thank you General Dingle. General Miller.
STATEMENT OF LIEUTENANT GENERAL ROBERT I. MILLER, 
            SURGEON GENERAL OF THE AIR FORCE
    General Miller. Good morning Chairman Tester, Vice Chairman 
Shelby, and distinguished members of the subcommittee. It is an 
honor and a privilege to appear before you today, as the 
Surgeon General of the Air Force and Space Force, to provide an 
update on the Air Force Medical Service, and discuss my vision 
and priorities.
    I appreciate the committee's long-standing support to 
include the fiscal year 2022 Omnibus that provided much needed 
additional resources to the Department. I also want to take the 
opportunity to recognize and thank the outstanding 
professionals who chose to serve in the Air Force Medical 
Service, which we call the AFMS.
    Since its creation in 1949, the AFMS has continued to 
provide leadership in aerospace medicine developments, 
aeromedical evacuation capabilities, emerging military 
operations, and recently the U.S. COVID-19 response efforts.
    The AFMS team has, and will continue to serve the Nation as 
we fly, fight, and win. The Air and Space Forces are 
inextricably linked in defense of our Nation. The AFMS provides 
ready medics to ensure airmen and guardians are medically ready 
to defend the crucial high ground in a rapidly shifting global 
security landscape.
    Over the past year we faced unprecedented, simultaneous 
challenges, from responding to the COVID-19 pandemic, to 
finalizing the transition of Air Force military medical 
treatment facilities to the Defense Health Agency. I know my 
DHA colleagues will provide more detail on the transformation.
    I can report, however, that we continue to be an all-in 
partner with the DHA. In fact, more than 80 percent of 
uniformed AFMS medics work and train in military medical 
facilities which serve as one of our key readiness training 
platforms.
    It is critical we maintain a strong partnership with DHA to 
ensure the Military Health System continues to sustain this 
vital source for clinical training currency for the AFMS. 
Although MTFs are not our only readiness platform they are 
certainly our preferred platform in the AFMS.
    The 21st century is reaffirming the world is not a safe and 
tranquil environment, beyond the pandemic aftermath, we face 
national security challenges from the Russian Federation, the 
People's Republic of China, the vulnerabilities of proliferated 
technology and weapons, climate change, and continued conflicts 
old and new.
    The medical system, specifically the AFMS, more than ever, 
must be bold, resilient, and above all else ready for a fight 
tonight, tomorrow, and beyond. Our vision is to ensure we are 
the world's elite medical service in air and space. The reality 
we know is the future fight will not be like what we have seen 
in the past. The next fight requires us to evolve now. We need 
your support to modernize our key readiness capabilities, 
properly equip our medics, and ensure the Air Force and Space 
Force remain ready, fighting forces.
    With this in mind, I want to focus on three things: First, 
my vision and priorities; second, America's return on 
investment from your current support; and third, the need to 
create more resilient medics and training platforms while being 
an optimal steward of taxpayers' resources.
    As we know all too well, the world is not static, new 
diseases emerge unexpectedly, chemical, radiological, nuclear, 
and bioterrorism threats persist, and combat weapons are 
deadlier. In future conflicts we cannot assume we will have the 
upper hand, however, America is in an era of great scientific 
opportunity, advances in our understanding of human biology, 
digitization, communications, and artificial intelligence will 
enable Air Force medics to accelerate change and win.
    We are in a race against economic and human consequences of 
national security and disease, yet we are on the brink of 
transforming AFMS' medical readiness capability and capacity. 
Included in the testimony is the AFMS strategy map which I will 
briefly go over now. In short, my priorities are to first, 
generate high-performing airmen and guardians by prioritizing 
training, maximizing medical availability, and optimizing human 
performance.
    Second, enhance joint and combatant commander capabilities 
by increasing the agility of patient movement, improving the 
medical supply chain, and increasing global health engagements.
    And third, maximize human capital and strategic resources 
by breaking down barriers of inequity, incorporating policies 
focused on diversity and inclusion, and equipping Airmen to 
evolve for tomorrow's fight. Toward these goals AFMS is 
reimagining the design and future of our readiness 
capabilities, such as aeromedical evacuation, and critical air 
transport teams.
    We must build on past successes, but be willing to break 
the cultural norm that says: Things have always been done this 
way. We are exploring and challenging our previous decisions 
about the size and types of clinical teams, and how to best 
train and sustain their skills. We believe innovation and fresh 
ideas will enable us to be more resilient and expand these 
teams' capacities within the current AFMS end strength total.
    Future conflicts may see medics needing to hold and treat 
patients in deployed settings for longer periods than in the 
past. We are actively evaluating how our teams can remain 
agile, and leverage technology to provide trusted care anytime, 
anywhere.
    To respect the committee's time considerations, and ensure 
time for any questions, I ask to submit my remaining written 
comments into the record.
    In closing, it is an honor to have this opportunity to be 
here today. Thank you for your continued support of the Air 
Force Medical Service. Your future investments will ensure we 
remain prepared for tomorrow's fight. Thank You.
    [The statement follows:]
       Prepared Statement of Lieutenant General Robert I. Miller
    Good morning Chairman Tester, Vice Chairman Shelby, and 
distinguished members of the subcommittee. It is an honor and a 
privilege to appear before you today, as the Surgeon General of the Air 
Force and Space Force, to provide an update on the Air Force Medical 
Service and discuss my vision and priorities.
    I appreciate the Committee's longstanding support to include the 
fiscal year 2022 Omnibus that provided much needed additional resources 
to the Department. I also want to take the opportunity to recognize and 
thank the outstanding professionals who chose to serve in the Air Force 
Medical Service, which we call the ``AFMS''. Since its creation in 
1949, the AFMS has continued to provide leadership in aerospace 
medicine developments, aeromedical evacuation capabilities, emerging 
military operations, and recently the U.S. COVID-19 response efforts. 
The AFMS team has and will continue to serve the Nation as we fly, 
fight, and win.
                              introduction
    The Air and Space forces are inextricably linked in defense of our 
Nation. The AFMS provides ready medics to ensure Airmen and Guardians 
are medically ready to defend the crucial high ground in a rapidly 
shifting global security landscape. Over the past year we faced 
unprecedented, simultaneous challenges from responding to the COVID-19 
pandemic to finalizing the transition of Air Force military medical 
treatment facilities (MTFs) to the Defense Health Agency (DHA). I know 
my DHA colleagues will provide more detail on the transformation. I can 
report, however, that we continue to be an all-in and partner with the 
DHA. In fact, more than 80 percent of uniformed AFMS medics work and 
train in military medical facilities, which serve as one of our key 
readiness training platforms. It is critical we maintain a strong 
partnership with DHA, to ensure the military health system continues to 
sustain this vital source for clinical training and currency for the 
AFMS. Although MTFs are not our only readiness platform, they are 
certainly our preferred platform in the AFMS.
    The 21st Century is reaffirming the world is not a safe and 
tranquil environment. Beyond the pandemic aftermath, we face national 
security challenges from the Russian Federation, the People's Republic 
of China, the vulnerabilities of proliferated technology and weapons, 
climate change, and continued conflicts--old and new. The medical 
system, specifically the AFMS, more than ever, must be bold, resilient, 
and above else ready for a fight tonight, tomorrow, and beyond. Our 
vision is to ensure we are the world's elite medical service in air and 
space. The reality we know is the future fight will not be like what we 
have seen in the past. The next fight requires us to evolve now. We 
need your support to modernize our key readiness capabilities, properly 
equip our medics, and ensure the Air Force and Space Force remain ready 
fighting forces.
    With this in mind, I want to focus on three things; first, my 
vision and priorities; second, America's return on investment from your 
current support; and third, the need to create more resilient medics 
and training platforms, while being an optimal steward of taxpayers' 
resources.
          strategic vision and priorities: lead change and win
    As we know all too well, the world is not static. New diseases 
emerge unexpectedly; chemical, radiological, nuclear and bioterrorism 
threats persist; and combat weapons are deadlier. In future conflicts, 
we cannot assume we will have the upper hand. However, America is in an 
era of great scientific opportunity. Advances in our understanding of 
human biology, digitization, communications, and artificial 
intelligence will enable Air Force medics to accelerate, change and 
win.
    We are in a race against economic and human consequences of 
national security and disease. Yet, we are on the brink of transforming 
AFMS medical readiness capability and capacity. Included in the 
testimony is the AFMS Strategy Map, which I will briefly go over now. 
In short our priorities are to:
  --First, generate high performing Airmen and Guardians by 
        prioritizing training, maximizing medical availability, and 
        optimizing human performance;
  --Second, enhance Joint and combatant commander capabilities by 
        increasing the agility of patient movement, improving the 
        medical supply chain, and increasing global health engagements;
  --And third, maximize human capital and strategic resources by 
        breaking down barriers of inequity, incorporating policies 
        focused on diversity and inclusion, and equipping Airmen to 
        evolve for tomorrow's fight.
    Toward these goals, the AFMS is re-imagining the design and future 
of our readiness capabilities such as aeromedical evacuation and 
critical care air transport teams. We must build on past success, but 
be willing to break the cultural norms that say, ``things have always 
been done this way.'' We are exploring and challenging our previous 
decisions about the size and types of clinical teams, and how to best 
train and sustain their skills. We believe innovation and fresh ideas 
will enable us to be more resilient and expand these teams' capacity 
within the current AFMS end strength total.
    Future conflicts may see medics needing to hold and treat patients 
in deployed settings for longer periods than in the past. We are 
actively evaluating how our teams can remain agile and leverage 
technology to provide Trusted Care . . . anytime, anywhere.
    To respect the Committee's time considerations and ensure time for 
any questions, I ask to submit my remaining written comments into the 
record. In closing, it is an honor to have this opportunity to be here 
today. Thank you for your continued support of the Air Force Medical 
Service. Your future investments will ensure we remain prepared for 
tomorrow's fight. Thank You.
                     america's return on investment
Global Patient Movement
    Our Aeromedical Evacuation (AE) and Critical Care Air Transport 
Team (CCATT) are the envy of the world, having accomplished more than 
360,000 patient movements in the past 20 years. Supporting these 208 
teams makes the AFMS unique, distinct and invaluable to the Joint 
Force. Recently, we have proven how our capabilities have played a 
crucial role in supporting the demands of the Department of Defense and 
our Nation. A few illustrative examples:
  --On August 26, 2021, following, the bombing at Kabul's airport, 
        three C-17 Globemaster III aircraft with aeromedical evacuation 
        crews and critical care air transport teams launched to 
        retrieve injured troops and Afghan allies. These medics were 
        ready on a moment's notice, fully capable of using any 
        available cargo aircraft to successfully evacuate and treat 
        those in harm's way.
  --As the COVID-19 pandemic impacted much of the country, aeromedical 
        evacuation crews continued moving critically ill patients, some 
        of whom were experiencing severe respiratory distress and had 
        to rely on extracorporeal membrane oxygenation, better known as 
        ``ECMO.'' This capability is similar to a heart-lung by-pass 
        machine used in open-heart surgery. It pumps and oxygenates a 
        patient's blood outside the body, allowing the heart and lungs 
        to rest.
  --In November of 2020, a service member went into a clinic at Ali Al 
        Salem Air Base in Kuwait with abdominal discomfort. Then-Capt. 
        Faraz Ghoddusi, a physician, upon seeing the serious condition 
        of the patient, immediately conducted a more thorough 
        evaluation despite the austere environment and limited 
        resources. Because the patient had a previous COVID-19 
        infection, Ghoddusi, relying on his extensive training, knew 
        that this was much more than a routine issue. The patient was 
        quickly transferred to Landstuhl Regional Medical Center in 
        Germany via a CCAT and AE Team where the patient received life-
        saving care for multisystem inflammatory syndrome.
    Continued advancement in aerospace medicine is crucial to 
maintaining our life-saving mission. Accelerated by the COVID-19 
pandemic, we fielded an enhanced negatively pressurized contained 
capability system to more safely transport increased numbers of 
patients through the aeromedical evacuation system. This capability can 
be used to support the transportation needs of our warfighters 
afflicted with emerging infectious diseases globally. Furthermore, 
building on lessons learned from the past 2 years, the U.S. Air Force 
School of Aerospace Medicine is working to expand their infectious 
disease control training and expand our aeromedical evacuation teams' 
clinical and operational knowledge on infectious diseases.
    Leveraging technology to improve aeromedical evacuation continues. 
The aeromedical evacuation system uses aircraft of opportunity in lieu 
of a dedicated medical aircraft. For example, through innovative 
efforts of the AFMS we were able to develop a patient loading system to 
enhance the KC-46 strategic tanker as a more effective AE platform. Our 
team is exploring further enhancements to advance patient loading with 
a more portable and agile system.
Building Toward the Future:
    Similar to World War II with the creation of Eighth Air Force under 
the leadership of Brig Gen Eaker, who implemented the day light bombing 
strategy from England, tactics and policies were refined over time. For 
example, then Col LeMay (retired Gen) implemented a staggered formation 
tactic to consolidate fire power for the B-17s. To ensure we win the 
future fight, we are undergoing reviews of critical medic response 
capabilities over the coming year. Our objective is to provide 
commanders with greater flexibility and range of options with advanced 
care that is highly mobile and ready to operate in the most challenging 
of environments. The results of these reviews will inform not only our 
capability requirements but our training, sustainment, and recruitment 
needs in the future.
  --Forward/Austere Deployable Teams: There is no ``one size fits all'' 
        solution and no static solution. Combatant commanders need a 
        medical force that is well equipped and adaptable to rapidly 
        evolving Joint Force requirements. We recently started a review 
        of our ground deployable medical teams to validate their size, 
        scope and capabilities relative to the future fight and 
        technological changes.
  --Expeditionary Medical Support System: The Expeditionary Medical 
        Support System, or EMEDS, is a deployable, full-service medical 
        facility and team. This capability allows the AFMS to save 
        lives in austere deployed environments. For example, at Al 
        Udeid Air Base in Qatar, the 379th Expeditionary Medical Group 
        used this capability to provide urgent medical care for 
        evacuees coming in from Afghanistan. The AFMS team at its peak 
        supported the arrival of nearly 10,000 evacuees in one day. Due 
        to the nature of the population, we were quickly able to expand 
        the EMEDS capabilities to include obstetricians and 
        pediatricians. However, the EMEDS was initially designed two 
        decades ago. It is time for a full review of the capability, 
        exploring needs related to increased modular functions, 
        operations in contested and degraded environments.
    We expect these reviews to be accomplished during 2022.
Protecting Airmen and Guardian Resiliency
  --Mental & Preventive Health: The Air Force has seen successes with 
        various pilot embedded programs like True North. This 
        initiative was designed in part to provide mental health, 
        prevention, and health education capabilities closer to certain 
        operational units. These healthcare providers interacted with 
        Airmen and Guardians in their work environments, focusing on 
        proactive interventions and addressing concerns before they 
        escalate.
    In the spirit of President Washington who is attributed with saying 
``If we cannot learn wisdom from experience, it is hard to say where it 
is to be found,'' we have taken lessons learned from these various 
embedded initiatives to develop an enhanced program called Operational 
Support Teams (OSTs) to optimize performance and readiness using 
evidence based physical and mental health risk mitigation strategies. 
The OST is designed to support every installation at the unit level 
using a hub-and-spoke embedded design. The OSTs will continue to 
leverage MTF capability for higher acuity needs. The OST initiative was 
piloted at nine bases to support both Guardians and Airmen. The focus 
of the OST is on both mental health and musculoskeletal injuries, which 
are the top two medical issues that impact force readiness. We are 
already seeing improvements in access to care and medical deployability 
rates. At three sites, the time for military members to access the 
formal healthcare system and receive follow-up care was reduced. On the 
operational side, one site noted 75 percent of our members who 
completed care in a group counseling format within the unit by an OST 
embedded provider alleviated the member's need for individualized care 
at the military treatment facility.
            creating resilient medics and training platforms
Military--Civilian Partnerships
    The MTFs are a critical training platform for Air Force medics. 
However, some specialties require a more hands-on experience managing 
high acuity patients to hone, sustain, or refine their skills to mirror 
the care for our Airmen and Guardians at deployed locations. The long-
standing partnership with certain civilian hospitals across the country 
will continue to enable currency in trauma care and critical care 
specialties to support combatant commander's requirements. In support 
of the nationwide COVID-19 medical response, this past year 664 AFMS 
medics also partnered with 33 civilian facilities providing over 
743,000 person hours of patient care.
    These partnerships are critical to the readiness of our medics. As 
we review our platforms and requirements for the future fight we 
anticipate that certain aspect of these platforms could change or 
increase based on our future projected needs. The following are 
examples of these civilian partnerships:
  --Center for the Sustainment of Trauma and Readiness Skills (C-
        STARS): The program includes training partnerships with 
        rotational medics embedded full time with civilian hospitals. 
        It allows our Airmen to rotate through those facilities to hone 
        and sustain operational skills based on high acuity and volume 
        of patients not seen at MTFs where the active duty population 
        is often healthier and younger. Partnership sites include R. 
        Adams Cowley Shock Trauma Center in Baltimore, the St. Louis 
        University Medical Center, the University Hospital Cincinnati, 
        and the University of Nebraska Medical Center in Omaha.
  --Air Force-Department of Veterans Affairs Partnerships: Our largest 
        partnership is the Department of Veterans Affairs, Air Force, 
        and Civilian partnership in Las Vegas, NV. The platform allows 
        our Special Operations Surgical Teams, the Air Force School of 
        Aerospace Medicine's Sustained Medical and Readiness Training 
        program (SMART), and the Mike O'Callaghan Military Medical 
        Center at Nellis Air Force Base to partner with several 
        civilian hospitals, including The University of Nevada, Las 
        Vegas School of Medicine and the Veterans Administration 
        Hospital. It includes an opportunity for a rotational cadre of 
        Air Force medics to integrate into these hospitals to gain and 
        sustain readiness training in both trauma and non-trauma skills 
        not routinely performed within the MTF.
Women's Initiative Team--Female Specialized Health Care Programs
    Improving Women's Health is critical to the Air and Space Forces to 
ensure all Airmen and Guardians are ``medically ready.'' We continue to 
remove barriers that get in the way of Airman and Guardian readiness 
and resiliency. The Air Force Women's Initiative Team's Female-
Specialized Health Care Programs examines policies related to women's 
issues. Recently, we participated in updates to hair policies that 
caused headaches and hair loss, improved lactation support for nursing 
mothers, and standardized convalescent leave after pregnancy loss 
policies. Our efforts also expanded medical standards to approve flying 
waivers for additional, precedent-setting diagnoses, based on 
advancements in medical treatments and ability to demonstrate 
acceptable flight safety.
Future Fight--Optimize Patient Care Anywhere
    AFMS's capabilities in how we deliver care, and respond to all 
types of battlefield injuries and illnesses will be impacted with new 
and emerging threats and technologies. Our team seeks to anticipate how 
future challenges may impact how our medical Airmen execute aerospace 
medical operations at contested, remote, and minimally manned bases 
with no hospital support. Historically, we have become increasingly 
modular, lighter, leaner and more effective, but this is continuously 
being assessed with the threats we are facing now. Our medics have to 
be ``Ready Medics'' to perform at the highest levels in extreme and 
harsh environments. We need to ensure that we have the healthiest 
Airmen and Guardians (``Medically Ready'') to thrive in these 
environments as they face peer enemy threats.
    The AFMS continues to seek out, develop, and deploy advance 
technology and capabilities to meet this reality to tomorrow's fight 
today. For example:
  --Virtual Healthcare: We are moving healthcare closer to the point of 
        injury by leveraging virtual healthcare capabilities and by 
        coupling these tools with artificial intelligence to assist 
        field level medical decisionmaking.
  --Medic-X: The AFMS continues to develop a more capable medical force 
        through the Medic-X program. In part it is aimed at equipping 
        Airmen in non-patient care career fields with skills to provide 
        base-level medical support. Medic-X training includes dozens of 
        skills, taking vital signs and documenting care. As the 
        committee was previously informed, 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 personnel. 
        It is continuing to be rolled out in phases across all our 
        bases.
  --Innovation Alliance--Enhancing Government Research Partnering: 
        There is no question the pandemic has forced us all to adapt at 
        breakneck speeds. Airmen and Guardians have responded with 
        creativity. In the midst of these challenges, there has been an 
        uptick in innovative developments and fast-tracked capabilities 
        developed and launched not only with the private sector but 
        through a variety of government agencies.
    The AFMS initiated an informal collaboration effort identified as 
the Operational Air and Space Medical Innovation Alliance to bring 
together diverse Federal partners to accelerate innovation, share 
opportunities, challenges, and potentially to expand cross-agency 
collaboration in research, innovation, and technology advances. 
Collectively, by focusing on areas of common interest, we are not only 
working to enhance future operational readiness capabilities, but also 
the capabilities of our partners. The alliance includes the DHA, the 
Department of Health and Human Services, the National Aeronautics and 
Space Administration (NASA), the Federal Aviation Authority, the 
Department of Veterans Affairs, and other DoD experts.
  --Space Medicine: The AFMS has increased its long-standing 
        relationship with NASA to explore enhanced partnership 
        opportunities for Space Medicine training, consultation 
        services, and beyond. We continue to expand these efforts to 
        support not only the Space Force Guardians but Air Force 
        aerospace programs.
  --Below Zero Medicine: The AFMS's Global Health Engagement 
        initiatives has been postured to prepare for the future fight, 
        preparing medics to operate in extreme environments. 
        Partnerships with nations such as Denmark, Norway and Sweden 
        are providing opportunities to train in an arctic environment, 
        allowing for subject matter expert exchanges and bolstering 
        interoperability between the U.S. and our allies.
                        conclusion--action orders
    Building the AFMS we need requires ready Airmen and Guardians 
equipped and trained based on the support and investment Congress 
provides. The realities of the future require us to continue leaning 
forward, modernizing our capabilities, and building a resilient and 
ready Air Force and Space Force. The Nation deserves our very best, and 
we intend to deliver on that promise. When I became the Surgeon General 
for the Air Force and Space Force last year, I prioritized the AFMS 
Airmen because without them the mission will fail. Our 55,000 Total 
Force Airmen are the most important part of the AFMS, and we intend to 
make them successful. Military service requires balance, and well-
rounded Airmen are better Airmen and medics. We will always prioritize 
currency and competency for our providers, through a culture of 
continuous learning. And last but not least, diversity is one of the 
AFMS's greatest strengths, where everyone belongs and is valued.
    Together, with your support and investment, we can ensure the AFMS 
continues to succeed in generating higher performing Airmen and 
Guardians, enhancing combatant commander capabilities, and maximizing 
human capital and strategic resources. Your investments over the past 
year enabled us to help the Nation with COVID-19, medically evacuate 
troops and allies out of Afghanistan, and transport patients around the 
globe. Your future investments will ensure the Air Force and the Space 
Force are prepared for tomorrow's fight and beyond.
    I would like to thank the Committee for the opportunity and 
continued support of the AFMS Medics, Airmen and Guardians.

    Senator Tester. Thank you, General Miller. And I didn't say 
this, but your entire written statement will be a part of the 
record. So thank you.
    Admiral Gillingham, you are up.
STATEMENT OF REAR ADMIRAL BRUCE L. GILLINGHAM, SURGEON 
            GENERAL OF THE NAVY
    Admiral Gillingham. Chairman Tester, Vice Chairman Shelby, 
distinguished members of the Committee, I am pleased to be with 
you today to provide an update on Navy Medicine. On behalf of 
our mission-ready One Navy Medicine Team, please know that we 
are grateful for the support you provide us, as well as the 
trust and confidence you place in us.
    Navy Medicine is best described as well-trained people, 
working as expeditionary medical experts on optimized 
platforms, demonstrating high reliability performance as highly 
cohesive teams to project medical power in support of naval 
superiority. These priorities guide our deliberate planning 
efforts, resource allocation decisions and strategic program 
investments.
    Consistent with the Chief of Naval Operation's emphasis on 
Get Real, Get Better, I continue to reinforce that rigorous 
self-assessment and rapid cycle feedback remain important 
components of our efforts to objectively evaluate our 
performance and establish high reliability throughout Navy 
Medicine.
    In my written statement, I provide you more details about 
our efforts in many key areas; however, in the interest of 
time, I will highlight 3 important lines of effort: COVID-19; 
Operational capabilities and requirements; and Mental Health.
    In response to the ongoing COVID-19 pandemic, our highest 
priority remains protecting the health of Sailors, Marines and 
families, while maintaining readiness and operational 
effectiveness of the Naval Forces. The most effective and 
advantageous public health preventive measure is vaccination, 
our biological body armor. Demonstrating personal commitment 
and unit responsibility, Sailors and Marines have responded, 
with approximately 97 percent of active Naval Forces fully 
immunized. Throughout the pandemic, naval personnel have shown 
responsibility, resiliency and toughness in helping to protect 
their shipmates, installations and communities from COVID-19.
    We also continue to deploy to render medical assistance to 
our fellow citizens. The operational tempo of our response 
teams over the last 2 years has remained high, as we deployed 
to 28 cities to support civilian medical facilities. There is 
no doubt that these efforts are directly making a difference in 
the lives of our fellow citizens while sharpening the skills 
our teams will use when deployed outside the United States.
    We expect a lot of our Navy Medicine personnel and we 
recognize that we must provide them with the operational 
capabilities, which include responsive and flexible platforms 
and equipment sets, that will allow them to execute their 
demanding responsibilities. To meet the challenges of providing 
force health protection and saving lives at sea, we are 
adapting our Naval Expeditionary Health Service Support 
capabilities in alignment with Distributed Maritime Operations 
and Expeditionary Advanced Basing Operations. We are grateful 
for the Committee's continued support of our requirements.
    A key priority for us is ensuring our Sailors and Marines 
have access to the mental health services they need. This 
includes placing more providers forward and embedded in 
operational platforms. We currently have 36 percent of our 
mental health providers serving Navy and Marines Corps 
personnel in operational and training commands, effectively 
positioning the access to care to where it might be needed 
most.
    In summary, our center of gravity is the commitment to 
provide expeditionary maritime medical care to our forward 
deployed Naval and Joint Forces to ensure their superiority. 
The ability to quickly deploy in support of crisis response 
around the world makes military medicine unique, but, more 
importantly, demands that we are both operationally relevant 
and clinically prepared.
    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, I am pleased to be with you today to provide an update on 
Navy Medicine. On behalf of our mission-ready One Navy Medicine Team, 
please know that we are grateful for the support you provide us, as 
well as the trust and confidence you place in us.
                         strategy and execution
    Navy Medicine is guided by the strategic priorities of the 
Secretary of the Navy, Chief of Naval Operations (CNO) and Commandant 
of the Marine Corps (CMC). Each leader has articulated the importance 
of meeting the operational demands of today and the warfighting needs 
of tomorrow. Collectively, these imperatives provide a foundational 
framework with which Navy Medicine must be aligned in order to 
effectively support Naval Forces.
    Navy Medicine priorities are direct, clear and relevant: Well-
trained People, working as expeditionary medical experts on optimized 
Platforms, demonstrating High Reliability Performance as highly 
cohesive teams to project medical Power in support of Naval 
Superiority. These priorities guide our deliberate planning efforts, 
resources allocation decisions and strategic program investments. 
Consistent with the CNO's emphasis on Get Real, Get Better, I continue 
to reinforce that rigorous self-assessment and rapid cycle feedback 
remain important components of our efforts to objectively evaluate our 
performance and establish High Reliability throughout Navy Medicine.
    Consistent with the CNO's emphasis on Get Real, Get Better, I 
continue to reinforce that rigorous self-assessment and rapid cycle 
feedback remain important components of our efforts to objectively 
evaluate our performance and establish High Reliability throughout Navy 
Medicine.
    In fiscal year 2022, the majority of operating funds for Navy 
Medicine were realigned from the Defense Health Program (DHP) 
appropriation to Operations and Maintenance, Navy (OMN). A smaller, but 
still crucial portion of the operating funds, remain in the DHP 
appropriation. Both appropriations support medical readiness activities 
and together, provide the resources necessary to execute our medical 
readiness responsibilities in support of Naval Forces. Work continues 
with the Defense Health Agency (DHA) on our collective efforts to 
complete Military Health System (MHS) transition activities. In 
addition, we are working through the final aspects of the move to 
Navy's Enterprise Resource Planning system which will improve our 
coordination within the Navy and better support our audit readiness 
posture. Please know that we are grateful for the resources entrusted 
to us and remain committed to sound fiscal stewardship and best value 
business practices throughout Navy Medicine.
                          responding to crisis
    Their work supports our priority of medical knowledge for 
operational advantage.
    In response to the ongoing COVID-19 pandemic, our highest priority 
remains protecting the health of Sailors, Marines and families, while 
maintaining readiness and operational effectiveness of Naval Forces. 
The SARS-CoV-2 virus is formidable, unpredictable and omnipresent, and 
each of its variants bring new challenges. We learned that the Omicron 
variant (B-1-1-259) is highly transmissible with most new COVID-19 
cases occurring in fully vaccinated personnel. Navy Medicine assesses 
the continuous emergence and risk of new COVID-19 variants through 
testing protocols and disease monitoring, while exercising flexibility 
in applying preventive measures and, most importantly, emphasizing 
vaccination (and boosters). Our Navy Medicine Scientific Panel, 
comprised of research scientists, public health experts and clinicians, 
remains on the vanguard of providing Naval leadership with current and 
actionable updates for the COVID-19 fight, as well as other emerging 
medical threats and scientific developments impacting readiness and 
force health protection. Their work supports our priority of medical 
knowledge for operational advantage.
    Our operational commanders are keenly focused on operationalizing 
the best medical and public health guidance. To this end, the Navy 
issued Standardized Operational Guidance (SOG) 5.0 in January 2022 
which, much like the earlier versions beginning in 2020, has proven 
instrumental in quickly applying lessons learned and best medical 
guidance so our ships and personnel stay mission capable despite the 
global pandemic. The SOG, again consistent with CNO's Get Real, Get 
Better direction, represents an overarching commitment to adapt, learn 
and improve. The most effective and advantageous public health 
preventive measure is vaccination--our biological body armor. 
Demonstrating personal commitment and unit responsibility, Sailors and 
Marines have responded, with approximately 97 percent of active Naval 
Forces fully immunized. Throughout the pandemic, Naval personnel have 
shown responsibility, resiliency and toughness in helping to protect 
shipmates, installations and communities from COVID-19.
    While we are administering vaccinations to protect our Sailors and 
Marines and addressing challenges of new variants to keep our ships 
underway and Sailors healthy, Navy Medicine personnel also continue to 
deploy to render medical assistance to our fellow citizens. The 
operational tempo of our response teams over the last 2 years has 
remained high, as we deployed to 28 cities to support civilian medical 
facilities. There is no doubt that these efforts are directly making a 
difference in the lives of our fellow citizens. A highlight for me over 
the last several months has been the opportunity to visit with these 
teams and see firsthand how seamlessly they integrate with their 
civilian counterparts to provide critical medical services in the whole 
of Nation response.
    The operational tempo of our response teams over the last 2 years 
has remained high, as we deployed to 28 cities in support of civilian 
medical facilities.
    In addition, our ongoing our domestic COVID-19 missions, Navy 
Medicine personnel also responded, both overseas and domestically, to 
Department of Defense (DoD) and interagency missions to provide 
essential medical support and public health services associated with 
the relocation of eligible Afghan partners and families. As part of 
Operation Allies Refuge and Operation Allies Welcome, personnel 
supported sites in Italy, Spain, Bahrain and Kuwait, as well as 
domestic locations onboard military installations Marine Corps Base 
Quantico, Joint Base McGuire-Lakehurst-Dix, Fort Pickett and Camp 
Atterbury.
    The safety, care, and well-being of all service members and 
families affected by the drinking water contamination at the Red Hill 
Bulk Fuel Storage Facility remains the Navy's highest priority. Under 
the operational direction of the Commander, U.S. Pacific Fleet, the 
fleet surgeon rapidly established a Joint Health Services Working 
Group, comprised of medical leadership from the Joint Force (Army/Navy/
Air Force/Marine Corps) along with MTF commanders as well as Hawaii 
Department of Health, Centers for Disease Control and Prevention, 
Agency for Toxic Substances and Disease Registry, and other State and 
Federal agencies. This approach was important given the range of 
personnel and families impacted and to leverage the full breadth of 
capabilities in this crisis. In addition to our medical forces 
stationed in Hawaii, Navy Medicine deployed 56 medical personnel to 
increase capabilities to deliver care to personnel and families. We 
also sent public and environmental health experts, as well as 
toxicology and water quality specialists to provide support. The 
working group documented medical encounters for both symptomatic cases, 
as well as screenings. An official incident report to capture 
potentially exposed population was established in the Defense 
Occupational and Environmental Health Readiness System (DOEHRS), the 
official DoD system of record related to environmental, public health 
and occupational exposure for DoD-affiliated personnel. This incident 
report will be available for future action, research, or analysis to 
ensure we track the long-term health of those potentially exposed.
               people: valuing our most critical resource
    The most important asset in Navy Medicine is our people, and quite 
frankly, they represent our competitive advantage. The One Navy 
Medicine Team is comprised of talented, dedicated and diverse 
healthcare professionals who serve around the world to support the Navy 
and Marine Corps. Our efforts remain focused on ensuring that our 
uniformed force is structured to meet the current and emerging 
operational demands of the Naval Force, including Distributed Maritime 
Operations (DMO) and Expeditionary Advanced Base Operations (EABO); 
pandemic response; and embedded mental health (EMH).
    Each of our Medical Department officer Corps (Medical, Dental, 
Medical Service, and Nurse) is critical to our readiness mission. As 
such, we monitor both overall Corps manning, as well as individual 
specialties to ensure alignment to operational medicine requirements. 
This focus includes wartime critical specialties, including mental 
health and other high-demand specialties. Our student programs, along 
with opportunities for Navy graduate health education, remain vital to 
accessing, training, and retaining these officers. We are grateful for 
your sustained funding of recruiting and retention incentives for both 
the active component (AC) and reserve component (RC) personnel.
    The One Navy Medicine Team is comprised of talented, dedicated and 
diverse healthcare professionals who serve around the world to support 
our Navy and Marine Corps.
    The Hospital Corps is the Navy's largest enlisted rating, comprised 
of over 27,000 Corpsmen in the AC and RC. These Sailors are responsible 
for delivering initial care on the battlefield or in isolated 
assignments aboard a ship or submarine. It is evident that their 
performance in Iraq and Afghanistan significantly contributed to higher 
combat survivability rate. Similar to our officer Corps, we carefully 
track both the health of overall manning as well as individual Navy 
Enlisted Classifications (NECs). We continue active recruiting within 
the Hospital Corps for qualified and motivated candidates to become 
Independent Duty Corpsmen (IDCs), as well as working hard to retain 
them given the key roles they have in our operational medical 
framework. Our Navy IDCs operate at the tip of the spear and serve in 
challenging assignments with the Fleet (surface, submarine, and dive) 
and Marine Corps (Fleet Marine Force Reconnaissance).
    Our Navy IDCs operate at the tip of the spear and serve in 
challenging assignments with the Fleet (surface, submarine, and dive) 
and Marine Corps (Fleet Marine Force Reconnaissance).
    Our Navy civilians are critical to the Navy Medicine mission. As 
our military personnel deploy and transfer to other duty stations, we 
rely heavily on our civilians to provide much needed continuity in our 
facilities and mentorship to their new uniformed colleagues. Their 
service allows us to cultivate talent and build teamwork. All of us 
understand that there is strong competition with the private sector to 
attract and retain civilians in high demand healthcare specialties. We 
are grateful for the flexibilities in direct hire authorities to help 
address these challenges, as they aid in ensuring a swifter end-to-end 
administrative hiring process resulting in shorter overall onboarding 
timeframes. We have transferred 43 echelon II and III Navy civilians 
via Transfer of Function, and 63 employees via Management Directed 
Transfer to the DHA. In fiscal year 2022, Navy intends to realign 
funding for 8,649 full time equivalents to the DHA. Consistent with MHS 
transition, these employees currently support the beneficiary health 
mission which is the responsibility of the DHA.
    Robust training and education is a force multiplier and 
foundational to preparing Navy Medicine personnel for their primary 
mission of increasing the survivability of Sailors and Marines. We 
focus on relevant and ready learning and employ a full-range of 
capabilities (both live and virtual) including world-class education 
programs, modeling and simulation capabilities, specific operational 
platform training and strategic partnerships to develop confident and 
ready personnel. It starts with initial training: Sailors earn their 
caduceus and officially become Hospital Corpsmen upon graduation from 
their A school training. In fiscal year 2021, over 2,000 Hospital 
Corpsmen joined the One Navy Medicine Team. We also graduated over 
1,200 Corpsmen from advanced ``C'' school training, and approximately 
the same number completed Field Medical Battalion Training. In 
addition, our graduate health education programs are among the best in 
the Nation and prepare our providers to meet their demanding 
responsibilities. These programs help form the ``industrial base'' of 
Navy Medicine by ensuring we have trained, confident and mission-ready 
personnel.
    These programs help form the ``industrial base'' of Navy Medicine 
by ensuring we have trained, confident and mission-ready personnel.
    Our trauma training partnerships with leading medical centers 
continue to yield high value returns. Navy Medicine personnel are 
getting unmatched clinical experience--which I refer to as ``reps and 
sets''--to prepare them for demanding operational assignments. We 
established Hospital Corpsmen Trauma Training programs at four Level 1 
civilian trauma centers: James H. Stroger Jr. Hospital in Chicago, 
Illinois; University of Florida Health Shands Hospital in Jacksonville, 
Florida; and University Hospital Cleveland in Cleveland, Ohio; and, 
WakeMed Health and Hospitals in Raleigh, North Carolina. In fiscal year 
2021, a total of 186 Corpsmen completed this training, and we are 
projecting this year's throughput to be significantly higher. In 
addition, we will be sending some of our IDCs to Cleveland Clinic for 
additional clinical skills sustainment opportunities. Our newest 
strategic partnership was launched in September 2021 with the 
University of Pennsylvania. We embedded a team of 11 officers and 
Corpsmen for a period of 3 years to work directly with their trauma 
staff. I am confident that this experience will help prepare them to 
save lives at sea or on the battlefield. This partnership joins our 
long-standing training program with and the LA County + University of 
the Southern California Medical Center.
    Our trauma training partnerships with leading medical centers 
continue to yield high value returns.
    As part of our commitment to cultivate a Culture of Excellence, 
Navy Medicine strives to create and maintain a work environment in 
which all personnel are treated with dignity, decency and respect. This 
work includes demonstrating our core values, exhibiting signature 
behaviors and optimizing our collective human performance. We will 
confront new challenges directly and decisively, and must include 
attracting, recruiting and retaining diverse talent. We are stronger 
for our inclusion and continue to leverage the knowledge, experience, 
and perspectives of all members of the One Navy Medicine Team.
    We will confront new challenges directly and decisively, and that 
must include attracting, recruiting and retaining diverse talent.
               platforms: preparing for the future fight
    We expect a lot of our Navy Medicine personnel: They need to 
provide 24/7 force health protection to Sailors and Marines and, when 
Naval Forces go into harm's way, our men and women must do everything 
they can to save lives. In turn, our continuing commitment must be to 
provide the One Navy Medicine Team with the operational capabilities, 
manpower, and equipment to execute these demanding responsibilities. 
Naval Expeditionary Health Service Support is changing with the 
transition to Distributed Maritime Operations (DMO) and Expeditionary 
Advanced Basing Operations (EABO). We recognize that the Fleet and 
Fleet Marine Force will require modular, adaptive, and scalable 
capabilities, to include small agile theater hospitalization, forward 
resuscitative care, small damage control surgery teams, patient 
movement assets, and agile preventive medicine teams.
    Our investments must reflect this priority of adaptive deployable 
medical systems to better support adaptive multi-mission platforms. 
Maritime medicine's pacing challenge in this dynamic environment will 
be the capacity to meet patients at the point of injury and move 
patients through the continuum of care as we know it. Correspondingly, 
the ability to provide maritime Damage Control Resuscitation/Damage 
Control Surgery (DCR/DCS) in kinetic operations as well as testing and 
treating personnel when threatened by infectious disease remain high 
priorities. Navy is expanding its afloat medical capability through 
construction of Expeditionary Fast Transport (T-EPF). T-EPF 14 (USNS 
CODY), with expected delivery in 2023, will be the first Flight II 
variant which will facilitate the embarkation of a Role II enhanced 
medical payload when the ship is tasked as surface ambulance/sea 
connector, functioning as treatment, movement, and patient holding 
capability in the maritime environment.
    Maritime medicine's pacing challenge in this dynamic environment 
will be the capacity to meet patients at the point of injury and move 
patients through the continuum of care as we know it.
    Military treatment facilities are also important readiness training 
platforms. They provide the clinical workload to help build the 
knowledge, skills and abilities (KSAs) of our providers. Collaboration 
with the DHA is particularly important in this area given their 
responsibilities in the administration and management of the MTFs. Our 
Navy Medicine teams deploy in support of Defense Support of Civil 
Authorities missions, humanitarian and disaster response, as well as 
global operational contingency operations. Our personnel directly 
benefit from having access to complex and challenging medical and 
surgical cases at either MTFs or through our civilian partnerships. 
This is an important line of effort, and I am encouraged by initiatives 
such as Project Caladrius underway at Naval Medical Center Portsmouth, 
Virginia to actively recapture this KSA-centric care in a larger 
geographic area. Likewise, the staff at Naval Medical Center Camp 
Lejeune, a Level III trauma center, continues to get firsthand 
experience in managing and treating a full-range of trauma patients in 
eastern North Carolina.
    Given the priority of ensuring our personnel are ready to ``fight 
tonight,'' Navy Medicine Readiness and Training Commands (NMRTCs) 
provide the critical command and control for Navy Medicine personnel, 
as well as the structure essential for proper execution of Service-
specific force readiness requirements. Their work includes the 
development of important Readiness Performance Plans to ensure our men 
and women have the clinical currency and operational competency to 
support expeditionary platforms such as hospital ships, expeditionary 
medical facilities and other deployable medical systems. The role of 
our NMRTCs continues to evolve as we move forward in completing MHS 
transition activities and apply important lessons learned from the 
COVID-19 response and other deployments.
                  performance: supporting naval forces
    Navy Medicine's performance is ultimately measured by those we 
serve--the Naval Forces. As part of our solemn obligation to these 
Sailors and Marines, we are continuing our strong commitment to High 
Reliability in Navy Medicine. The concept of a High Reliability 
Organization (HRO) originated in high-risk Navy environments, such as 
our submarines and aircraft carriers, to enable teams to avoid the 
detrimental impacts of mistakes. High Reliability is particularly 
applicable within military healthcare because the three HRO pillars--
leadership engagement, continuous process improvement, and a culture of 
safety--directly translate to better outcomes and fewer life-
threatening errors.
    Navy Medicine's performance is ultimately measured by those we 
serve--the Naval Forces.
    For Navy Medicine, High Reliability represents a commitment to 
safety, quality, resiliency, and operational success wherever Naval 
Forces operate. The goal remains building a system of capabilities that 
optimizes the One Navy Medicine team to proactively communicate, 
anticipate, identify, resolve and share to solve problems that threaten 
warfighter readiness and survivability. I want to emphasize that the 
study of lessons learned is necessary, but not sufficient. Those that 
are value-added must be quickly applied. I am encouraged with the 
robust implementation of Team Strategies and Tools to Enhance 
Performance and Patient Safety (TeamSTEPPS) in the Fleet, as well as 
increased participation in basic and advanced HRO training in place at 
our Navy Medicine Quality and Safety Leadership Academy. We continue to 
implement these principles and practices within the Fleet and Fleet 
Marine Force, as well as leverage ongoing collaboration with DHA to 
build a strong HRO foundation within the MTFs.
    We recognize that it is every leader's responsibility to help 
develop Sailor resiliency and toughness as well as foster a Culture of 
Excellence to counter destructive behaviors. This commitment also 
includes ensuring that our warfighters have access to mental health 
services when needed. There is ``no wrong door'' for our Sailors and 
Marines to get help. Mental health and substance misuse services are 
available worldwide within primary care and specialty clinics at MTFs, 
on the waterfront, embedded within the Fleet and Fleet Marine Forces, 
at Navy and Marine Corps installation counseling centers, and from our 
Chaplains. We continue to prioritize support at the deck plates, with 
our embedded mental health providers. We currently have 36 percent of 
active duty mental providers and 30 percent of behavioral health 
technicians assigned to EMH billets. They support platforms including 
Aircraft Carriers, Submarine Forces, Amphibious Assault and Surface 
Combatant ships, Naval Expeditionary Combat Command units, Naval 
Information Forces, Marine Corps Ground Combat, Logistics and Command 
Element units, Navy and Marine Corps Special Operations, and various 
training commands.
    We currently have 36 percent of active duty mental providers and 30 
percent of behavioral health technicians assigned to EMH billets.
    In addition, we continue to leverage virtual mental health 
capabilities to improve access and continuity of care. Sustaining our 
commitment to providing care during the COVID-19 pandemic has resulted 
in significant increases in the use of virtual health by both patients 
and providers, particularly in primary care and mental health. In 
fiscal year 2021, almost 20 percent of mental health appointments for 
Sailors and Marines were conducted virtually.
    Disaster mental health services are also important in order to 
provide rapid and targeted care and coordination. Navy's Organizational 
Incident Operational Nexus (ORION) Trauma Tracking program provides 
long-term tracking of Sailors and Marines involved in unit-level 
traumas and targets outreach to Naval Forces at elevated risk for 
psychological injury. In 2021, ORION was activated seven times. 
Correspondingly, our Special Psychiatric Response Intervention Teams 
(SPRINT), which were deployed for 10 events in 2021, provides on-site 
short-term mental health support immediately after critical events when 
local resources are overwhelmed or do not exist.
    Our Navy Medicine Female Force Readiness Strategy guides our 
efforts in support of our female Sailors and Marines. Two priority 
initiatives are to optimize health and readiness by expanding access to 
women's healthcare in operational settings and to increase the women's 
health proficiencies of our operational providers. In addition to 
providing full-scope contraception walk-in clinics, we established two 
waterfront pilot sites for our Embedded Women's Health Provider Program 
that offered convenient access to women's health services. Given our 
positive results, we are assessing opportunities to expand this 
initiative. We are also focusing on performance improvement in several 
areas including family planning, mental health, and neuro-
musculoskeletal; all of which are consistent with our commitment to HRO 
and Get Real, Get Better.
    We are also keenly focused on maximizing the deployability of our 
Sailors and Marines. As part of the COVID-19 response, we integrated 
virtual health capabilities to support individual medical readiness 
requirements, including the periodic health assessments. While these 
efforts have been effective in reducing backlogs brought about by the 
pandemic, moving forward, the application of virtual health represents 
an opportunity to ensure timely completion of these assessments. We 
also implemented decision support tools in our conditions-based limited 
duty assessments to provide current clinical guidelines and support an 
expeditious return to duty.
    The continued deployment of MHS GENESIS remains an important 
component of HRO. This single, integrated electronic health record 
supports our beneficiaries through the continuum of care. Importantly, 
the expansion of the Joint Health Information Exchange capability can 
improve patient safety by affording our providers greater access to 
healthcare data from the Department of Veterans Affairs medical 
facilities and civilian healthcare systems. I am encouraged with the 
progress we have made in the rollout of MHS GENESIS, including using 
our seasoned subject matter experts to support site implementations as 
well as rapidly applying lessons learned at successive deployment 
sites.
                    power: increasing survivability
    The Navy Marine Corps Public Health Center (NMCPHC) serves as the 
DON's primary command for public health issues that potentially impact 
operations across the globe, for both expeditionary and installation-
based environments. Navy Environmental Preventive Medicine Units, 
including their Forward Deployed Preventive Medicine Units, are public 
health lifelines for Navy and Marine Corps operational forces worldwide 
and their work enhances readiness, both ashore and afloat. Since the 
early stages of the COVID-19 outbreak, NMCPHC has been at the forefront 
of our response with actionable, high impact capabilities to contain 
outbreaks, and deliver commanders important modeling and surveillance 
analytics. Their contributions continue to support other environmental 
health issues confronting our personnel and their families. Our Naval 
operational commanders rely on NMCPHC and their unique maritime 
expeditionary public health capabilities to maintain mission 
effectiveness and provide force health protection to Naval Forces.
    Navy Environmental Preventive Medicine Units, including their 
Forward Deployed Preventive Medicine Units, are public health lifelines 
for Navy and Marine Corps operational forces worldwide.
    The Naval Medical Research and Development (NMR&D) enterprise is 
focused on developing cutting edge materiel solutions and knowledge 
products to enhance the readiness and health of Naval Forces. 
Partnerships with nations on six continents, academia, non-profit 
organizations, and the private sector, in addition to a worldwide 
network of scientists, allow for research focused on the mission of 
maintaining healthy and ready Sailors and Marines. Their work includes 
a range of operationally-relevant research including: infectious 
diseases; warfighter health, performance and operational support; 
combat casualty care; bio-effects risk mitigation and countermeasures; 
physical, mental and behavioral health; and research support and 
execution.
    NMR&D work continues to be pivotal in our COVID-19 pandemic 
response activities, including their specialized diagnostic testing and 
development of countermeasures including vaccines, therapeutics and 
enabling technologies. To improve Naval operations, our biomedical 
prototyping efforts advanced medical technologies including shipboard 
decontamination devices that mitigate spread of respiratory disease and 
novel therapeutics for bacterial infection and antimicrobial 
resistance. In addition, work continues on their seminal study 
initiated at Marine Corps Recruit Depot, Parris Island, COVID-19 Health 
Action Response for Marines (CHARM) to understand long term clinical 
outcomes of a young, healthy population previously infected with SARS-
CoV-2. NMR&D publications and data from these studies will continue to 
inform DoD and wider COVID-19 policies. Our operational commanders 
place high value on the work being conducted by NMR&D to meet the 
current and future needs of Naval Forces. Since the early stages of 
this pandemic, we have consistently demonstrated the synergy that 
occurs, and is needed, between R&D and Public Health to mitigate the 
threat of COVID-19.
    Our operational commanders place high value on the work being 
conducted by NMR&D to meet the current and future needs of Naval 
Forces.
    Projecting medical power is also reflected in our Global Health 
Engagement (GHE) activities. GHE remains a critical element of global 
stability and national security. There has been a steady increase in 
demands from the operational forces for GHE activities as a security 
cooperation tool to promote and enhance partner nation stability and 
security and develop military and civilian partner nation capacity. 
Navy GHE is also an effective readiness tool utilized as a training 
platform for personnel to foster resiliency and increase their medical 
and non-medical knowledge, skills, and abilities in unfamiliar 
environments with limited resources. Our Global Health Specialist 
Program is the foundation of the Navy GHE. We currently have 279 active 
and reserve component Navy Medicine personnel that have earned the 
Global Health Specialist additional qualification designator, which 
requires extensive experience in critical areas of security 
cooperation, public health, diplomacy, and other GHE competencies. In 
May 2022, hospital ship USNS MERCY (T-AH 19) will get underway in 
support of Pacific Partnership 2022, the largest multinational 
humanitarian assistance and disaster response mission in the Indo-
Pacific area of responsibility. These exercises provide our personnel 
with significant readiness training opportunities, particularly in the 
maritime environment.
                              way forward
    We recognize the demands of ensuring the readiness and health of 
our Naval Forces in rapidly changing and increasingly more dangerous 
operational environments. To meet these current and future challenges, 
the One Navy Medicine Team remains focused on employing our people, 
platforms, performance and power in support of Naval superiority. Our 
center of gravity is the commitment to provide expeditionary maritime 
medical care to our forward deployed Naval and Joint Forces. The 
ability to quickly deploy in support of crisis response around the 
world makes military medicine unique, but, more importantly, demands 
that we are both operationally relevant and clinically prepared. For 
over 30 years, Navy Medicine has proudly flown our signal flags to 
reflect our mission posture. Correspondingly, these flags have evolved 
as our missions changed: From ``Charlie Golf One'' (Standing by to 
Assist) in 1987 to ``Charlie Papa'' (Steaming to Assist) following 
September 11, 2001. In November 2021, we transitioned to ``Charlie 
Mike'' which appropriately communicates ``Rendering Assistance''. This 
is the mission of the One Navy Medicine Team--protecting the health and 
increasing the survivability of our Naval Forces. Again, thank you for 
your support.

Navy Medicine
``Charlie Mike''
Rendering Assistance

    Senator Tester. Thank you, Admiral Gillingham. And I want 
to thank you all for your testimony.
    I am going to start with some questions that revolve around 
mental health, and they are for you Dr. Smith. We have seen the 
rate of suicide rise among military members over the last 5 
years, I would say significantly. We could blame that on a lot 
of things, on COVID-19, on economic strain, there are a lot of 
pressures out there. The question for you is, what programs and 
strategies is the Department using to reverse this alarming 
rate of suicide amongst military members?
    Dr. Smith. Thank you, Senator Tester. We agree with you 
that it is an alarming rate, and any suicide is clearly a 
tragedy. We are using a public health approach, recognizing 
that medical is one component but that there are clearly 
requirements across the Force to be able to try to tackle this, 
and suicide clearly is multi-factorial in our examination and I 
think most would affirm there are many different factors that 
go into it, as you have already recognized in your comments.
    We have a number of different pieces going on, encouraging 
help-seeking behavior, looking at stigmatizing language 
throughout our policies, clearly increasing access to mental 
health with telehealth, we also have made sure that all of our 
providers are trained in cognitive behavioral therapy, which is 
one of the modalities that has clearly been shown in randomized 
trials to be helpful in suicide. But we know that it is an all-
hands priority for our Secretary, and something that all the 
members of this panel have been actively engaged in.
    Senator Tester. So the policies that you have put forth to 
deal with mental health, are they measurable, and are you 
measuring them?
    Dr. Smith. Yes, sir, we are; particularly looking at access 
to make sure that we have ready access to that.
    Senator Tester. Okay.
    Dr. Smith. We also, as you are probably aware, screen our 
folks in with our PHA (Periodic Health Assessment), also with 
our--before they deploy, and after they deploy, but we, from an 
access point of view, we are challenged like the rest of the 
Nation, but we have a standard that they need to be seen within 
28 days, we are running at about, for active duty, 11 to 13 
days for their initial appointment. And then for follow-up 
appointments it is variable, but on average it is about 15 to 
17 days.
    Senator Tester. Thank you. Now I want to go in a little bit 
of a different direction, and discuss the folks getting out of 
the Service. I think we have an obligation to the folks who 
serve in the military to make sure that that the transition 
that is occurring is done successfully, and we are seeing, once 
again, suicide as a huge problem with transitioning from 
military to the civilian life. There was a DoD IG (Department 
of Defense Office of Inspector General) report that came out in 
November 2021, and you probably know what it said.
    It said that 70 percent of transitioning service members 
are receiving a required physical examination upon separation, 
physical examination, and that exam does not include any mental 
health screening. Only five questions were asked about mental 
health history, with no follow-up questions.
    So Dr. Smith, what is the DoD doing to ensure that 100 
percent of transitioning Service members receive the physical 
examination prior to their military separation? And while you 
are on that, what are we doing to make sure that mental health 
is addressed in that separation?
    Dr. Smith. Yes, sir. The separation health physical exams 
have been a targeted focus. We have been working closely with 
the VA (Department of Veterans Affairs) also in this to make 
sure that there is a warm handoff, if you will, for anyone that 
is known or recognized, whether it is with that separation 
health physical exam or it is--you know, they are already in 
our care.
    And each of our components, I have been working to try to 
improve that. We have also just recently revised the policy and 
it is in the process to further assure on the separation health 
physical exam, but I will defer to some of my other teammates 
to see what additional comments they would like to make 
relative to that.
    Senator Tester. So I am out of time on that. If any of the 
other folks, the Surgeon Generals, want to respond to that in 
writing I would appreciate it if you could. I just have one 
more, and I know I am over time, but I have got to follow up on 
this.
    Mental health, I have been here 15 years, we have been 
talking about mental health for 15 years on the VA Committee. 
These are folks who are coming out of the military and they are 
killing themselves. The mental health component was not a part 
of the evaluation that is being done. Only 70 percent of the 
folks are doing the evaluation to begin with.
    And now once the IG report comes out, and I think it was 
November of 2021, now it is going to take 2 years, until 
November of 2023, before it includes mental health screening. I 
understand it takes a while for government to do stuff, and it 
is tough to get the ship turned around, but I would just say 
this, if mental health is a huge issue, and it is, and you guys 
all know it, most of you all addressed it in your opening 
statement, why are we tolerating the mental health screening to 
take 2 years to get into the transition?
    Dr. Smith. Sir, I will take that, for the record, because 
it is my understanding that we have mental health screening 
questions as part of that examination. So I will take that back 
and provide an input on it.
    Senator Tester. Okay. There are five questions now, there 
are no follow-up questions, and they all deal with family 
history, is my understanding. But I would just say that I can 
tell you, if Moran was here he would say this, he is on the VA 
Committee with me, he is ranking member--we have got a huge 
problem, we have got a problem with the fighting force to begin 
with, as we pointed out with the first question, and we have 
got as big or bigger problem when they are transitioning out of 
the military. I think it is a bigger problem actually.
    So we need to get this right, and we need to get it done 
right soon. I appreciate your attention to this matter. Senator 
Shelby.
    Senator Shelby. Thank you, Mr. Chairman. General Place and 
Dr. Smith, I will direct this to you. Medical care costs are 
continuing to increase year after year, as we all know. The 
medical community says it is already preparing for the next 
pandemic which you need to do. The Biden administration's 
Military Health System requests were $54 billion, with major 
supply chains affecting pharmaceuticals, and inflation at an 
all-time high, can you tell me what the Department and the DHA 
are doing to help find cost effectiveness, if you can do it, 
within the military health budget considering all the above? 
That is a tough question to answer, I know it is.
    Dr. Smith. Yes. Yes, sir. I will start. I think we have 
been--and I will defer to General Place on the specifics--but 
because of the consolidation we have been able to do more with 
standardization. In the pharmaceutical area, as an example, we 
have been taking advantage of our size, along with the VA, to 
be able to keep those costs in check as much as possible.
    We are continually looking at our logistics chain, and our 
other aspects of how can we, you know, maintain our 
effectiveness but increase our efficiency. And a lot of that, I 
believe, is standardization, larger buying power, et cetera. 
But I will defer to General Place.
    General Place. Yes sir, I will agree with that. So it is 
pharmacy, it is equipment, it is supplies, it is personnel 
contracts, it is all of them being more efficient, but even 
more than that when you narrow it down to fewer options then 
the requirement to maintain them is also less, because we have 
fewer options that patient safety events are also less. 
Therefore we are not paying for harm that we are causing 
because of it. So it is a huge amalgamation of the 
standardization effectiveness drill that we do.
    Senator Shelby. I will direct this to each of the Surgeon 
Generals. Now that the administration has completed its 
National Defense Strategy would each of the Surgeon Generals 
speak to what their respective services are doing to adapt, to 
innovate, and modernize their medical service capabilities to 
respond to the current, and the future needs of the combatant 
commands?
    General Dingle. Senator Shelby, I will start off. Within 
the Army the one mandate we have is to provide trained and 
ready forces. And so as we look forward into the future, and 
modernization, we are focusing our strategy on maximizing human 
potential, pushing medical capabilities far forward, providing 
robotic semi-autonomous support systems, medical command and 
control systems, the medical information management, 
biosurveillance, biodefense, medical operations, and I could go 
on and on.
    The key point is that as modernization occurs Army Medicine 
is not going to be left behind. We are inculcated tightly with 
our Army Futures Command, and I know that there are some 
concern about research and development transitioning. It is our 
expectation that the Army strategy to ensure Force health 
protection and conservation of soldiers on the battlefield, 
will remain that same research priority as we transition. But 
we are very active to include an arctic strategy in which Army 
Medicine can serve in that fighting strength in support of any 
strategy that comes out of the Army.
    Senator Shelby. Thank you. Yes, sir.
    General Miller. Vice Chairman Shelby, Air Force Medicine is 
equally concerned about the requirements and how to best 
support the war fighters from the various combatant commands. 
Our niche, obviously, is air and space medicine, and so we know 
that a lot of emphasis needs to go on those domains, in 
particular I would say aeromedical evacuation, and en-route 
care is one area that we will continue to emphasize, our CCAT, 
critical care transport capability, and other ways of moving 
patients, as need be, will continue to evolve and be a 
challenge.
    In addition, the experience of COVID in these last few 
years have made us want to re-look at our readiness structure, 
and so we are taking a hard scrub of our present team 
composition to make sure that we stand ready based on the 
requirements that are given tous moving forward.
    Senator Shelby. Yes, sir.
    Admiral Gillingham. Thank you, Senator Shelby. As I said in 
my opening statement in the Navy and the Marine Corps we are 
moving to concept of operation of Distributed Maritime 
Operations, Expeditionary Advanced Basing Operations, and 
Littoral Operations in a contested environment. And so we are 
actively involved in adapting our medical capabilities to 
provide medical power for naval superiority in those 
environments.
    The support that this committee has provided, specifically 
with regard to the expeditionary fast transport, will be very 
helpful in that, and that helps us be able to provide afloat 
role to surgical and medical care in that environment.
    Senator Shelby. Recently it has been noted that cyber 
security is one of the top concerns across the Department. Is 
the Agency anticipating increases to cyber security costs, 
because I think that is something you have to deal with? Who 
wants to deal with that? Sir, yes.
    General Place. Yes. Senator Shelby, I will handle that. So 
cyber security in the in the medical network is my 
responsibility. We are effectively funded for cybersecurity 
now. One of the benefits of the investments that you all have 
made in our next generation electronic health record, MHS 
GENESIS, decreases our virtual footprint, therefore making it 
harder for potential adversaries to get into our network. So 
no, we are good for now. The fact that we are shrinking our 
footprint makes us a less vulnerable target even in the future.
    Senator Shelby. Okay. Thank you.
    Senator Tester. Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman. In 2016 the Jason 
Simcakoski Memorial and Promise Act was signed into law. I 
authored that bill in response to a tragic and preventable 
death of a veteran at the Tomah VA Hospital in Wisconsin. Among 
other things, this legislation helped strengthen oversight of 
VA opioid prescribing practices and improved our investment in 
non-opioid pain management techniques to help our veterans. I 
am pleased to report that the VA opioid prescribing practices 
now adhere much more closely to the CDC (Centers for Disease 
Control and Prevention) guidelines.
    Dr. Smith, in 2020 a Department of Defense Inspector 
General Report found that the Department of Defense had a lot 
of work yet to do in its management and oversight of 
prescribing practices, and in ensuring that providers were 
working within the CDC guidelines. At the time the Department 
of Defense did not have an effective way of monitoring 
prescribing rates, something that is supposed to be addressed 
partially by the new electronic health record system, which is 
not fully implemented yet.
    Can you update us on current prescribing rates compared to 
previous years? And can you inform us of how you are monitoring 
prescribing rates now? And how the Department is prioritizing 
non-opioid first courses of action for pain management, such as 
holistic therapies?
    Dr. Smith. Yes, Senator Baldwin. We consider obviously pain 
management and opioid safety to be a critically important part 
of our practice. As you are probably aware the Military Health 
System has instituted a stepped care model which actually looks 
at alternatives and very consistent with what CDC recommends 
along with working with the VA in partnership with our CPGs 
(Clinical Practice Guidelines) around this area.
    We also require opioid prescriber safety training for 
anyone who is credentialed or privileged to be able to provide 
opioids, and we now have our Prescription Drug Monitoring 
Program which allows us to interface with States, and to be 
able to share information on what individuals may have been 
prescribed, and it is now up to 29 States, if I remember my 
numbers correctly.
    And we also know that in the active duty force it is now 
about 0.07 percent of the active duty, and we find that with 
our opioid prescribing, that less than 1 percent actually run 
into issues compared to somewhere between 8 to 12 percent 
outside the DoD. Specifically how we are monitoring the 
practice of our individuals, I will either defer to General 
Place, or take that one for the record to make sure that I give 
you the right information on that.
    Senator Baldwin. Go ahead, General.
    General Place. Yes, Senator Baldwin. The first thing we do 
is, within the pharmacy itself, we monitor every single one of 
our prescribers who have the authority to prescribe scheduled 
medications. And secondarily, as Dr. Smith mentioned, when it 
comes to ongoing, on-site, credentialing and privileging the 
amount and number of scheduled medications, not just opioids, 
but scheduled medications that are prescribed is one of the 
things that is evaluated in the reapplication for clinical 
privileges.
    Secondarily, we have added safety nets to those patients 
that our providers believe are at risk. There is Naloxone 
therapy, and that is a first-step therapy that goes with 
opioid. But in addition to that, we have given the authority to 
our pharmacists for those that they consider at risk for 
opioids, to have the ability to use Naloxone.
    And then finally, you mentioned in your introductory 
comments about the nonprescription methodologies for pain 
control. We continue to evaluate all aspects of it, yoga 
massage, chiropractor, acupuncture, et cetera, for the state of 
the science, for the potential of making those, TRICARE 
eligible therapies, but only with science behind it. And so we 
are continuing to do all that.
    Senator Baldwin. Thank you. Dr. Smith, as the Department 
knows the National Guard has become an increasingly integral 
part of our Total Force, but according to the National Guard 
over 66,000 guard members are uninsured, roughly 16 percent of 
the guard. Many of these individuals are students who are at 
risk, and in need of mental health services and resources.
    I am sure that you would agree that if 16 percent of the 
active duty service members lacked access to quality health 
care, it would present a serious readiness issue for the 
Department. Would you agree that this is critical that all 
National Guard members have healthcare coverage, and that it is 
important, as a part of our total force, that we should 
consider this a readiness issue as it affects the Guard?
    Dr. Smith. We do think that healthcare coverage is an 
important issue for the Total Force, absolutely. We do offer 
for the National Guard, as you are probably aware, a TRICARE 
Reserve Select, it is substantially underwritten by the 
government, but there is a premium associated with that.
    The uptake rate is not as high as we would like, and 
clearly we continue to try to educate, but as you know, young 
individuals often consider themselves invincible, so making 
that case can be challenging. But that is what, at this present 
time we offer, and then of course when they come on active duty 
they are eligible for the full TRICARE benefit. So I hope that 
answers your question.
    Senator Tester. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman. I want to follow 
up on the question that Senator Baldwin just asked. Maine 
National Guard members have told me that there is a need to 
extend TRICARE Reserve Select at no cost to the Guard members 
who do not currently qualify for premium free TRICARE. One of 
the concerns that has been raised is that service members have 
to change healthcare plans when individual duty status or 
orders change, and that affects continuity of care.
    Given that National Guard members need to maintain medical 
deployability requirements, ensuring consistent and reliable 
healthcare for all of our National Guard members is indeed a 
readiness issue, as Senator Baldwin said. As an example of that 
we are soon going to see a large group of Maine Army National 
Guard members deployed to Poland.
    So, do you see benefits to medical readiness that we might 
expect by extending this TRICARE eligibility for these Guard 
members?
    Dr. Smith. So yes, ma'am. I think there are pros and cons 
to that obviously. I clearly would think that having TRICARE 
Reserve Select, essentially the TRICARE Program for our 
National Guard should facilitate medical readiness. On the con 
side would be, there is a substantial cost associated with 
expanding the TRICARE benefit to the National Guard. Also we 
have to be cognizant of how that may affect ability to recruit 
and retain active duty versus reserve and guard as we sort of 
equalize the benefits that are accrued with that employment, as 
another potential side effect of expanding the program to the 
entire National Guard. Over.
    Senator Collins. If you could provide us with current 
budget estimates for the record that would be very helpful to 
us.
    My second question which is for General Dingle, follows up 
on the excellent concerns and questions that our Chairman 
raised which I very much share, about the rate of suicides, and 
other mental health challenges facing some of our service 
members. I was surprised to see that the number of behavioral 
health encounters actually fell from 2.05 million in fiscal 
year 2020, to 1.68 million in fiscal year 2021, and yet suicide 
numbers remain very consistently high.
    So I would like to ask you, General, to elaborate on the 
factors so that I can better evaluate this declining statistic, 
because it does not seem to be correlating with a similarly 
substantial decline in suicides, for example.
    So my questions are: Were there fewer behavioral health 
patients? Were there medical staffing challenges that you 
mentioned as an issue? Or was Army Medicine unable to 
facilitate certain visits due to facility closures, or other 
complications that perhaps are related to the pandemic, even 
though we saw an up-tick in telehealth encounters which I think 
was very valuable, could you elaborate further on the factors 
for that decline?
    General Dingle. You know, Senator that, I mean that is a 
great question that I do not know the exact answer to. As we 
look at it across the board, and across the United States Army, 
one of the things that we are trying to get across is to remove 
the stigma so that our soldiers will, in fact, seek behavioral 
mental health. That it is okay.
    And so we have implemented several programs at the 
strategic operational and tactical level to get after that. In 
some cases, some areas we have programs like Operation Victory 
Wellness, or Mission 100, which every soldier must see a mental 
behavior health provider within that years' timeframe, to 
ensure that their needs are being addressed.
    We also have a major campaign throughout the Army, at the 
strategic level. We have a spiritual readiness initiative, 
leveraging our chaplains to help make soldiers feel at ease 
that they can access care, increasing that access to care with 
the mental behavioral health that are in our medical treatment 
facilities, and then our spiritual readiness initiative, again, 
selling that it is okay to get help.
    In addition to that, Commanders' Risk Reduction Tool, this 
is my Squad Golden Triangle that that every soldier is a battle 
to a soldier, and it is okay to help and identify when someone 
is in need. And then, again, at the operational level in our 
divisions and corps, many programs that, again, mandate a touch 
point, yet also in conjunction with DHA, leveraging behavioral 
telehealth.
    Interesting, I will close with this. I just came from 
Alaska, and Alaska the behavioral health--the telehealth went 
down, everywhere else is skyrocketing, and couldn't figure it 
out. After talking to family members and soldiers, the soldiers 
said this, they said, you know, General Dingle, we don't want 
to talk to a television, we would rather wait you know for 
access to care.
    And when it came to the family members, there are some 
things we are working with the DHA for higher ends, to get 
after the family members but the soldiers and service members 
we were able to support. But we were actively, aggressively 
trying to attack that, Senator.
    Senator Collins. General, did you want to add something? I 
might be misreading your body language there. I am really 
interested, if the Chairman will indulge me in just 30 seconds 
more, in what you just said about telehealth, because our 
experience in Maine has been exactly the opposite. What we have 
found is that telehealth counseling reduces the stigma. As one 
hospital administrator told me, when they moved all of their 
behavioral health sessions to telemedicine during the pandemic, 
their no-show rate went to zero, to zero.
    What I have also heard from others in the VA, is that they 
will call someone if they don't show up and find that they can 
do the counseling that way, and thus they have driven down the 
no-show rate. So maybe this is an anomaly with Alaska because 
it seems at odds with the experience that I am seeing in Maine, 
and hearing from healthcare professionals, that our veterans 
and our service members don't want--it is sad that there is a 
stigma, but they don't want to be seen going into a 
psychiatrist's, psychologist's, social worker's office, but 
they are very comfortable with video conferences. So that is 
really interesting that you found the opposite in Alaska.
    General Dingle. Yes, ma'am. And let me clarify. The one 
thing that the family members and soldiers were saying, it 
wasn't the attribution to the stigma in Alaska so much, it was 
more so the 24 hours of darkness, the cold weather, where they 
are in a cocoon. You know, and so they are in a cocoon so much 
that for them to do a behavioral health, they are like, no, no, 
via telehealth; they said, we would rather wait and I want to 
see Dr. Lyons or Dr. Jones in person versus talking over a 
telephone, which was their preference, which is where we are 
trying to educate them on the benefits of the virtual platform 
in the meantime until getting a person-to-person.
    Senator Collins. Thank you. That is a good point. Thank you 
very much.
    Senator Tester. No, I think it is a good point. These folks 
were being dealt with on the telephone and not by video?
    General Dingle. Video, you leverage both platforms, we use 
telephone and video.
    Senator Tester. Okay. The information I have gotten is 
exactly the same as Senator Collins. That it is actually less 
threatening. And by the way, I would have never thought that, 
the very first hearing I had, when they said to use telehealth, 
I said it would never work.
    I am going to ask a couple more questions, so if you 
(Senator Collins) want to stick around, you sure can. This 
question is for General Place, and then with a follow-up for 
General Dingle.
    Currently most defense medical research is done by the 
Army's Medical Research and Development Command. The fiscal 
year 2019 NDAA (National Defense Authorization Act), required 
that all medical research be consolidated under the DHA by 
October 1 of this year. Besides the core medical R&D efforts, 
the consolidation of medical research under the DHA would 
include the Congressionally Directed Medical Research Program, 
Congress is concerned that there is no disruption in the CDMRP 
process.
    So General Place, please give us an update on the status of 
required consolidation of medical research under DHA.
    General Place. Yes, sir. So thanks for the question. It is 
on track, we are in close collaboration between not just the 
Defense Health Agency and Army's Medical Research and 
Development Command, but across all three of the services to 
transition all aspects required under that law, done this 
fiscal year with very warm collaboration between all of us, 
such that no disruption in the congressionally designated 
research program will happen. I think we will all assure you 
that that is our motivation, and we will attest to that.
    Senator Tester. Okay. The consolidation is happening in a 
way that would reflect the statement that you just made?
    General Place. Yes, sir.
    Senator Tester. Okay. Do you plan on making any changes to 
congressionally directed research once these efforts of 
transferring are totally made to the DHA?
    General Place. We have no plans to make any changes to it, 
Senator.
    Senator Tester. Okay. So from your perspective General 
Dingle, I recently visited the U.S. Army Medical Research and 
Development Command at Fort Detrick. How do you envision 
supporting the Army's mission for research and development to 
prevent or treat current threats to our soldiers, while the 
medical research and development assets and infrastructure are 
moved to DHA?
    General Dingle. So Senator, we believe that there will be 
no change. As close as we are working together with this 
transition we anticipate that as the DHA consolidates the 
research across the services that each of the services' 
strategies and priorities will be inculcated under one 
umbrella. At the same time as you know, we take great pride in 
CDMRP, and as General Place just said they have promised, and 
have put in the way ahead that no changes will be made.
    So we are anticipating the best practices will be 
maintained, which includes a consolidation of each of our 
priorities when it comes to research and development.
    Senator Tester. Thank you. Before I turn it over to Senator 
Moran, I want to make a statement, if you guys want to respond 
to it you can. I am Chairman of the VA Committee, we are 
working on toxic exposure. It is a huge issue because, number 
one, there are inaccurate records of exposure as folks come out 
of the military. The toxic exposure issue is huge, and will end 
up costing, if we do the right thing, hundreds of billions of 
dollars. There is just no doubt about it.
    This isn't the first time we have been at this rodeo. We 
have had mustard gas, we have had radiation, we have had Agent 
Orange, and now we have toxic exposure with burn pits. I hope 
that this is on your guys' radar so that we can figure out how 
to do better moving forward. What is done, is done. Why we had 
burn pits and not incinerators will be a mystery to me, because 
it seems like an unnecessary harm that we have inflicted on our 
service members.
    So hopefully this was on your guys' radar screen so that we 
can do better. I would love to say we will never have another 
conflict, but the way Putin is acting it is hard to say that. 
So there will be another toxic exposure issue that is going to 
come down the pipe, and if we have good record keeping it could 
end up being a lot better for everybody.
    Dr. Smith. Yes, sir. We wholeheartedly endorse what you are 
saying. Clearly, it is high on our radar, and we are 
continually looking at mechanisms to improve. We, as you are 
probably aware, have created the ILER, the Individual 
Longitudinal Exposure Record that both we and the VA have 
access to. It consolidates, and all of the information that has 
been collected relative to where I have been during my career, 
and will be readily available, and is now at the point where 
that information has been uploaded and is available. The 
features that are coming on now is, which is very exciting from 
a research point of view, is we are going to be able to look by 
exposure and develop cohorts to help our development relative 
to ILER.
    We have also put into the PHA, and PDHRA (Post-Deployment 
Health Reassessment), and the various screenings that we have, 
questions to probe and find out about exposures that folks may 
have had to be able to document that. The long pole, still, is 
being able to do individual exposure monitoring it is all area 
in monitoring, we clearly are concentrating on getting the 
right training, and the folks available to be able to do that, 
but our research and development side is looking at, how can we 
better, through wearables, and other kinds of technology, be 
able to do exactly what you are suggesting, of having a much 
better idea of exposures.
    Senator Tester. Thank you.
    Dr. Smith. Now, war of course is unpredictable.
    Senator Tester. Yes.
    Dr. Smith. But it is clearly top on our list of priorities.
    Senator Tester. All right. Thank you. Senator Moran.
    Senator Moran. Chairman, thank you. I came back to ask 
questions that you apparently have already asked. But maybe I 
can be more articulate than you were.
    [Laughter.]
    Senator Tester. That is always the case.
    Senator Moran. First of all, thank you all for your 
service, and for being here. Just in a comment, back to Dr. 
Smith, the Individual Longitudinal Exposure Record does not get 
high marks from those who are experiencing toxic exposure, as 
far as the records being accurate or available.
    We find veteran after veteran who says there is nothing in 
their record that indicates exposure during service, and maybe 
that is just a matter of catching up and time, I don't know but 
it apparently needs more attention than it has received.
    I understand, in my absence, that the chairman--my chairman 
here, and my chairman on the Veterans Committee has asked about 
the discussion we had regarding the November 2021 report 
evaluating the Department of Defense's implementation of 
suicide prevention resources and following its compliance with 
Executive Order 13822, regarding mental health, and if these 
questions have been asked, I just would add my agreement with 
what I assume the Chairman's point was, that there needs to be 
greater progress at the Department in implementing the 
Inspector General's report, and maybe you have answered that 
question. What are the barriers that have been identified in 
DoD's ability to provide seamless transition for mental 
healthcare services to those service members already enrolled 
in mental healthcare, and what changes either administrative or 
legislatively need to be put in place, in order to make all 
transitioning service members receiving a mental health 
screening before leaving the service? If you have answered that 
Dr. Smith, you can tell me just to refer to the record, and to 
the Chairman's question.
    Dr. Smith. Well we have partially answered that question. 
We are actively engaged with anyone that is already in our 
system with the VA to make sure that there is a warm transfer, 
if you will, that they are aware of the case, that the 
individual is aware of how they can access the VA.
    We also have, as Senator Tester and I discussed, there are 
questions in the SHPY, the Separation Health Physical 
Examination that tries to address mental health, really as a 
screening, and then of course as a provider if there are flags 
that come from those questions, then our expectation, what I 
think happens is that they will get a follow-up in reference to 
that. I don't know if anyone else wants to add to my response, 
but that is mine.
    Senator Moran. So I think I am hearing that you saying that 
you think the things that need to be done are being done?
    Dr. Smith. We are working on it. I think there is always 
more we can do, and I don't think that it is at all perfect. 
But there is clearly a prioritization on the importance of that 
transition, and we had have been fine-tuning it, if you will, 
across our policies relative to all the different elements of 
the Total Force also, to include guard, reserves, to make sure 
that that is a warm hand-off, but I recognize there are still 
dropped balls.
    Senator Moran. In almost every instance in which we in the 
Veterans Committee have looked at veteran suicide, it is that 
transition period of time in which the vulnerabilities are the 
greatest. So I encourage you to pay significant attention, and 
keep trying to eliminate whatever flaws still exist.
    Let me ask General Dingle. I want to talk about in INICO, I 
think there is a total of eight sites on military bases that 
treat service members with the effects of traumatic brain 
injury, behavioral health, and other conditions, with a broad 
range of innovative and emerging treatments and therapies.
    This is the National Intrepid Center for Excellence--excuse 
me. As the Army and Intrepid Fallen Heroes Fund looks to 
establish additional sites on military bases, is there any 
reason why Fort Riley would not be on a short list, especially 
with the warrior transition unit, and veteran population that 
could benefit from a joint VA/DoD site to serve both 
populations?
    And I would be interested in knowing if there is something 
which, I don't expect you necessarily to be able to answer that 
question at the moment, but if there could be follow up, if 
there is something missing at Fort Riley that would enhance 
their chances of being able to treat their soldiers and 
veterans, I would be delighted, and very interested in knowing, 
General.
    General Place. Senator, if I could take that one.
    Senator Moran. Sure.
    General Place. The responsibility for all the Intrepid 
Spirit Centers, is now within the Defense Health Agency.
    Senator Moran. Okay.
    General Place. And it is largely, as you have already 
indicated, in the troop concentration centers that in our 
interaction with the Intrepid Fallen Heroes Foundation that the 
sites have been funded by the Foundation, and then we manned 
them, and organize, and utilize them later. I am not aware of 
where the potential for Fort Riley is, but as a major troop 
concentration for the Army, certainly it would be on the list. 
I would be happy to engage with you and your staff further 
about where that might be.
    Senator Moran. That is a perfect answer. Thank you very 
much.
    General Place. Yes, sir.
    Senator Moran. Mr. Chairman, thank you.
    Senator Tester. Thank you, Senator Moran for those very 
important and articulate questions.
    [Laughter.]

                     ADDITIONAL COMMITTEE QUESTIONS

    Look, we appreciate your testimony here today. Senators may 
submit additional questions, and I will have a few. We ask you 
to respond to them within a reasonable time. I think a 
reasonable time is probably 10 days or sooner, if you could.
    [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. David J. Smith
               Questions Submitted by Senator Jon Tester
    Question. Asked surgeon generals to follow up in writing regarding 
what is being done to ensure all transitioning service members receive 
a physical examination upon separating and whether or not a mental 
health screening is included. Dr. Smith also volunteered to look into 
the status of whether a mental health screening is currently included 
as part of the separation exam.
    Answer. Section 1145(a) of Title 10, United States Code requires a 
separation physical examination and separation mental health 
assessment. This section was amended by Section 706 of the fiscal year 
(FY) 2018 National Defense Authorization Act (NDAA) to include a 
requirement for mental health assessments (MHAs) prior to separation 
from the Armed Forces. Although a ``separation exam'' is not currently 
a term used in policy, MHAs for separation must be current, and the 
requirement for a separation MHA can be satisfied by: DD Form 2795, 
``Pre-Deployment Health Assessment''; DD Form 2978, ``Deployment Mental 
Health Assessments''; DD Form 2900, ``Post Deployment Health Re-
Assessment''; or the DD Form 3024, ``Periodic Health Assessment.'' DoD 
intends to include both the Separation Physical Examination and Mental 
Health Assessment within a combined form, common with the Department of 
Veterans Affairs, under the name Separation Health Assessment.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
    Question. As you know, service members and their families are 
affected by eating disorders at elevated rates compared to their 
civilian counterparts. That is why I wrote the SERVE Act to expand 
access to eating disorder treatments for service members and their 
families. I was pleased to see the fiscal year 2022 NDAA include my 
bill, however it only expanded coverage to current service members and 
military families--not retirees and their families. I understand that 
can be achieved for a minimal amount of money.
    Would you support expanding eating disorder coverage to military 
retirees and their families?
    Answer. No, because it is not necessary via a statutory 
modification. The Department concurs that eating disorders are a 
significant problem in society as a whole and in particular in the 
military community. Treatment of eating disorders is challenging and 
usually requires a multidisciplinary, long-term approach which the 
TRICARE program currently provides to all beneficiaries. First, the 
bill is unnecessary as the Secretary already has the authority to issue 
regulations to add new providers and benefits when the care would be 
medically necessary and appropriate, as well as proven safe and 
effective. Statutory relief is unnecessary to expand already-covered 
care to individuals over the age of 21. Should the Department determine 
that the care is supported by reliable evidence, the Secretary may 
issue regulations to modify the definition of an RTC and expand the 
benefit under existing authorities. Additionally, TRICARE currently 
provides comprehensive medically necessary care and treatment for all 
beneficiaries diagnosed with eating disorders in all of the healthcare 
settings proposed in the bill, except that RTCs are only covered for 
beneficiaries under the age of 21. This provision is not new to the 
TRICARE program and is based upon accepted standards of practice and 
input from Department consultants and the provider community. We note 
that this existing age limit for RTCs is geared to ensuring that 
TRICARE beneficiaries are receiving medically necessary care at the 
appropriate level and age of care. Consistent with the CMS, the TRICARE 
regulation defines an RTC as a facility that provides to beneficiaries 
under 21 years of age a medically supervised, interdisciplinary program 
of mental health.
    Question. Do you know of any reason why that coverage cannot be 
extended under your current authorities without congressional action?
    Answer. The authority exists should RTC care for eating disorders 
(or other psychiatric disorders) be supported by sufficient reliable 
evidence as proven safe and effective.
    Question. Can you discuss what the Department of Defense is doing 
to ensure that direct care providers are trained to screen, briefly 
intervene, and treat eating disorders?
    Answer. All primary care providers in MTFs are trained to recognize 
and screen for eating disorders, especially for adolescents. If 
clinically indicated, providers will send the patient for testing as 
part of the standard medical work-up to include testing for liver 
enzymes, kidney studies, electrolyte and blood counts. Finally, the 
provider will refer the patient to behavioral health in the MTF if 
available or if not, to care in the TRICARE network.
    Question. Providing our service members with the same access to co-
pay free contraceptives and reproductive care as their civilian 
counterparts is not only the ethical thing to do but it will also 
improve our retention and overall force readiness. My bill, the Access 
to Contraception for Servicemembers and Dependents Act, would provide 
that long-overdue right to equitable healthcare.
    We will continue to work on this issue in Congress, but do you have 
any existing authorities which may allow you to expand this coverage?
    Answer. Contraceptive medical services (sterilization, intrauterine 
devices, injections, implants) and prescriptions are provided free of 
charge to all beneficiaries at military medical treatment facilities 
(MTFs). ADSMs and ADFMs under TRICARE Prime do not pay cost shares for 
contraceptive medical services obtained from network providers, however 
copays are usually required for non-network providers. The Department 
does not have authority to waive copays for prescription contraceptives 
(a statutory change would be required). The agency is currently 
evaluating options to waive copayments for contraceptives under both 
the medical and pharmacy benefits. However, the length of time required 
for those changes depends on the authority used, and any changes are 
subject to agency approval.
    Question. If not, will commit to working with Congress to expand 
coverage?
    Answer. If legislation is enacted to provide that authority, the 
rule making process would follow to include a review by the Office of 
Management and Budget to evaluate the costs to the Department for such 
a waiver.
    Question. Last summer, the Office of the DoD Inspector General 
released a report identifying deficiencies in the Department's approach 
to analyzing PFAS in firefight blood samples--testing required by a 
provision I authored in the fiscal year 2020 NDAA. In December, Senator 
Murkowski and I led a letter with twenty of our colleagues to Assistant 
Secretary of Defense for Readiness Skelly regarding this issue and 
requesting a briefing. I am pleased that the Department responded by 
swiftly providing that briefing--during which DoD officials referred to 
a report expected this month containing the first analysis of 
firefighter blood samples from last year.
    What is that status of that report?
    Answer. The DoD Firefighter Blood Testing Results report for fiscal 
year 2020 will be available in July 2022. This report will also be 
incorporated into the RTC, ``Perfluorinated Chemicals Contamination and 
First Responder Exposure,'' as directed by the fiscal year 2022 House 
Defense Appropriations bill (due September 12, 2022).
    Ongoing work includes a draft DoD Firefighter Blood Test Results 
report that will be available from the Navy and Marine Corps Public 
Health Center (NMCPHC) this month (Estimated Completion: April 2022). 
The draft NMCPHC report will then be reviewed internally by the DoD. 
Simultaneously, reference materials are being updated to support and 
accompany the report for use by DoD firefighters, healthcare providers, 
public and environmental health scientists and engineers, and others. 
(Estimated Completion: May 2022.)
    The Department looks to the Centers for Disease Control and 
Prevention (CDC) National Institute for Occupational Safety and Health 
(NIOSH) as the U.S. Government lead for research efforts on 
occupational exposures to PFAS. Therefore, we plan to have NIOSH review 
the results report as an external (independent) reviewer prior to 
finalizing the report. (Estimated Completion: June-July 2022).
    Question. As you know, I have long been concerned with the 
Anomalous Health Incidents impacting DoD personnel and their families. 
Last month, Senator Collins and I sent a letter urging the newly-
appointed AHI coordinator to address some of the most pressing issues--
at the top of that list is equitable access to care for victims.
    How has access to care for AHI victims evolved over the past year, 
including providing care for non-DoD personnel impacted by AHIs?
    Answer. Non-DoD healthcare beneficiaries have been evaluated and 
cared for in the military health system under Secretary of Defense 
Designee Status. That process for approval has been markedly 
streamlined over the last year, allowing for quicker access to 
services. Additionally, Section 732 of the NDAA for fiscal year 2022 
allows for the medical assessment at military medical treatment 
facilities for U.S. Government employees and their families diagnosed 
``with an anomalous health condition or a related affliction.''
    Question. In incidents with suspected exposure for child 
dependents, how are we ensuring that their experiences are captured to 
ensure that we are caring for them now and into the future, when their 
symptoms may become more apparent?
    Answer. For children present during an AHI, but for whom no 
symptoms are identified, they will nonetheless be included in the 
fiscal year 2022 NDAA, Section 732 required medical registry to ensure 
their potential exposure is documented. This will allow for future 
engagement, should our improving understanding of the EXPOSURE identify 
recommendations which could benefit them. All results of the medical 
evaluations that are conducted on potentially affected children are 
recorded in the DoD EMR for future reference. Additionally, these 
children, with their parent's permission, will be included in the AHI 
Registry established under fiscal year 2022 NDAA, Section 732. This 
will allow for documentation of the reported event and information for 
future care providers as needed.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell
Fort Knox
    Question. Does DHA plan to conduct a manpower review at the Ireland 
Army Health Clinic at Fort Knox? If so, when do you expect to complete 
this review?
    Answer. Now that DHA has finally assumed authority, direction, and 
control of military medical treatment facilities (MTFs), DHA will 
conduct a manpower demand and productivity assessment of all MTFs to 
include Ireland Army Health Clinic. DHA is identifying the objective 
criteria and decisionmaking data. DHA projects to complete the review 
of all MTFs by the end of fiscal year 2023.
    Question. What are DHA's greatest challenges to fully staffing 
military treatment facilities?
    Answer. First, DHA must develop its own objective staffing model 
for all specialties. In the past, each Military Medical Department had 
its own manpower model. Second, the Military Medical Department 
maintains control of the assignment of Active Duty personnel. Finally, 
civilian personnel hiring regulations do not allow the Military Health 
System (MHS) to offer competitive pay compared to civilian healthcare 
organizations in many MHS markets.
Community Care
    Question. What steps do military treatment facilities take to 
ensure those who are referred for treatment through the TRICARE Network 
receive timely care?
    Answer. DHA is responsible for ensuring that access to care 
standards are met for those who are referred to the local TRICARE 
network. DHA monitors whether access to care standards are met.
    Question. Does DHA have programs to help improve community 
hospitals near installations that do not have a full-service hospital?
    Answer. TRICARE implemented a new Sole Community Hospital (SCH) 
reimbursement system in 2014 that aligns more closely with Medicare's 
reimbursement, which reimburse an SCH by multiplying the SCH's billed 
charge by the Medicare inpatient cost-to-charge ratio. Additionally, a 
Year-end aggregate payment is made back to the SCH if their 
reimbursement under the SCH system is less than what they would have 
been paid under TRICARE's Diagnosis-Related Group (DRG) based payment 
system. There is also a special payment provision for SCHs who have 
reached their Medicare CCR level that provides labor/delivery and 
nursery care with an increase of 130 percent reimbursement applied to 
specified labor/delivery DRGs. Finally, Network SCHs serving a 
disproportionate number of active duty service members and active duty 
family members may qualify for an adjustment. Those network SCHs, as 
well as Critical Access Hospitals, that are deemed essential to 
readiness, and whose actual costs exceed TRICARE reimbursements to SCHs 
and CAHs (or for which other extraordinary economic circumstances 
exist) may qualify for the adjustments referred to as General Temporary 
Military Contingency Payment Adjustments (GTMCPA).
                                 ______
                                 
            Questions Submitted by Senator Susan M. Collins
    Question. Requested an estimate for how much it would cost to 
extend Tricare coverage to the National Guard.
    Answer. In an October 2021 report, the Institute for Defense 
Analyses provides a range of cost estimates for extending TRICARE 
coverage to all Ready Reserve and National Guard members, depending on 
how implemented and the resulting take-rate. The report did not 
restrict its estimates only to National Guard components, but the 
report also included all Reserve and National Guard components.
    Under the TRICARE Reserve Select (TRS) program, Reserve/Guard 
members, who are not currently activated for greater than 30 days and 
are members of the Selected Reserve (SELRES) of the Ready Reserve as 
reflected in the DEERS eligibility database, have the option to 
purchase TRICARE Select coverage for either Member-only or Member-plus-
family with the Government subsidizing part of the premium cost. 
Offering TRS with no premium charged to Reserve/Guard members, but 
still charging a premium cost for their family members, is estimated to 
cost $700 million to $2.1 billion (B) annually, depending on the 
proportion who choose to accept this option. Offering TRS with no 
premium charged for Reserve/Guard members or their family members is 
estimated to cost $1.1B--$2.8B.
    While activated, Reserve/Guard members are eligible for the same 
TRICARE benefit provided to Active Duty members and their families. 
Under a ``TRICARE for All'' scenario in which Reserve/Guard members 
(and their families) are made eligible for the TRICARE benefit 
regardless of the member's activation status, costs are estimated to 
range from $1.6B--$2.9B annually, depending on the resulting take-rate 
for the benefit.
                                 ______
                                 
             Questions Submitted by Senator Lisa Murkowski
    Question. More research is needed to better understand the regional 
differences in suicide mortality across the United States. Rural areas, 
such as Alaska, are highly diverse with respect to their landscapes, 
demographic composition, and socioeconomic conditions. I was pleased to 
see $3 million in funding was put towards suicide prevention with a 
focus on rural, remote, isolated and OCONUS installations in the fiscal 
year 2022 budget. This is just the beginning of studies we will need to 
identify risk and protective factors for mental health outcomes within 
different types of rural communities where many of our service members 
are stationed.
    Do you believe enough research on suicide prevention with a focus 
on rural, remote, isolated and OCONUS installations is currently being 
done to understand the high rate of military suicides in remote 
locations?
    Answer. DoD is making substantial investments in studying suicide 
prevention efforts in rural and remote settings. Although none of our 
current studies are limited to Alaska, all of the investigations listed 
below would provide information about or relevant to Alaska. The list 
of research projects below include those funded by the DHP.
  --LINKS to Behavioral Health Treatment: Training to Increase Buddy 
        Support and Reduce Suicide Risk
  --Behavioral Health Care in the Military Health System--Access and 
        Quality for Remote Service Members
  --Modified Global Assessment Tool Development and Validation for 
        Individual and Unit-Level Resilience
  --BH Pulse electronic versus paper-pencil administration
  --Analytics for Remote Combat Exposure Assessment
  --Mobile Interpretation Bias Modification Clinical Trial
  --Behavioral Economics Intervention to Increase Treatment Seeking in 
        the National Guard
  --Facilitating Assessment of At-Risk Sailors with Technology
  --Increasing Connection to Care Among Military Service Members at 
        Elevated Suicide Risk: A Randomized Controlled Trial of a Web-
        Based Intervention
  --Mobile Stress and Anger Management Tool (Medical Technology 
        Enterprise Consortium--Design Interactive collaboration with 
        Walter Reed Army Institute of Research)
  --Peer-to-Peer Programs for Military Suicide Prevention
  --Integrating Social Networks and Team Intervention Approaches to 
        Reduce Ostracism in the Military Funding
    Additionally, the Department has research underway to understand 
unique risk factors associated with living on remote and/or OCONUS 
installations as well as the training and support needs of Service 
members and families in those locations. Specific efforts are:
  --A funded study to examine community- and individual-level 
        indicators of financial distress that are associated with 
        Service member suicide, with a special focus on remote and 
        OCONUS locations.
  --Conducting a spouse survey to understand suicide thoughts/behaviors 
        and help-seeking for remote and OCONUS spouses.
  --Expanding the Resources Exist, Asking Can Help (REACH) Pilot to 
        tailor/adapt the content/resources to geographically isolated 
        and OCONUS areas. The expanded pilot will help DoD better 
        understand what needs to be changed regarding content and 
        dissemination processes, and to evaluate training outcomes of 
        REACH within this population.
    Question. Do you anticipate that an increase in funding will be 
needed to continue research to better understand the contributors to 
suicide in remote and rural areas?
    Answer. An increase in funding is beneficial to continue research 
to better understand what the unique contributing factors might be for 
suicides that occur in remote and rural areas. For example, this may 
include qualitative research to characterize the stressors or concerns 
associated with living in remote and rural areas.
    Qualitative research is critical to understanding whether suicide 
risk can be directly attributed to environmental concerns or whether 
there are mediating or moderating factors that account for any 
increased risk. Determining the most direct links to suicide risk is 
important because targeting those links with interventions should 
provide the best cost-to-benefit ratio when applying suicide prevention 
funds to address environmental contributors to risk.
                                 ______
                                 
               Questions Submitted by Senator John Hoeven
    Question. Nationwide, we are seeing an increase in the number of 
individuals with substance use disorders as well as a continued 
increase in the number of deaths attributable to opioid misuse. More 
than 104,000 Americans died due to a drug overdose in the 12-month 
period ending in September 2021.
    On the battlefield, pain management for far forward battlefield 
injury largely remains limited to treatments--including fentanyl--that 
carry addiction potential and can result in severe health effects.
    Do you believe that DoD can and should improve its practices when 
it comes to pain management for our warfighters, including for 
battlefield injuries?
    Answer. Following our decades of experience caring for casualties 
in Iraq and Afghanistan, the DoD has been on the forefront of national 
efforts to implement improved pain management practices and address the 
U.S. epidemic of prescription medication (e.g., opioid) overuse, 
diversion, and overdoses. As far back as 2010, the DoD's Pain 
Management Task Force recognized that an overreliance on opioids for 
treating the pain conditions facing wounded, ill and injured Military 
Service members was associated with both short and long term negative 
health outcomes, including accidental overdose. The respective 
comprehensive pain management programs from each of the Uniformed 
Services have been realigned under the Defense Health Agency (DHA). 
This includes implementing the evidenced-based Stepped Care Model of 
pain management that formalizes the correct escalation of pain 
management therapies across the continuum of acute and chronic pain 
conditions and clinical settings. The DoD also has an ongoing 
collaboration and synchronization with the VA's Veterans Health 
Administration's pain management strategies and initiatives.
    While the DoD acknowledges the inherent risks associated with the 
use of opioids, it would be difficult to identify a more appropriate 
use for these medications than for the immediate treatment of severe 
pain associated with traumatic battlefield injuries. However, the DoD 
has also embraced the medical evidence that the most effective and safe 
pain care practices include multiple pain therapies (known as multi-
modal therapy) rather than opioid-only pain management. DoD pain 
management practices include utilizing opioids at the lowest effective 
dose while supplementing with other effective non-opioid medications 
and therapies.
    In many cases, DoD's field hospitals are able to reduce acute 
opioid use with traumatic extremity injuries by utilizing regional 
anesthesia. Patients can be kept relatively pain free peri-operatively 
through the evacuation process with these opioid sparing nerve blocks. 
Additionally, the DoD has trained thousands of providers in Battlefield 
Acupuncture (BFA), a basic acupuncture technique that utilizes very 
small needles inserted around a patients ears. Uniformed Service 
University of Health Sciences has integrated BFA in the training 
programs for our future DoD physicians and advanced practiced nurses. 
BFA has been effectively utilized as a pain treatment at the point of 
battlefield injury, in field hospitals, during evacuation from theater, 
and in our military medical treatment facilities. In many cases, BFA 
reduces or eliminates the requirement for opioids.
    DoD has also developed and implemented several clinical decision 
support and assessment tools to assist clinicians in providing safe and 
effective pain care. The DHA Patient Look-up Tool, primarily used by 
pharmacists, and the DHA Opioid Registry, used by prescribers, both 
report a patient's level of risk for opioid overdose and indications 
for prescribing the opioid overdose antidote, Naloxone. All DoD 
prescribers who are authorized to prescribe opioids are required to 
first complete the DoD Opioid Prescriber Safety Training (OPST). OPST 
includes an orientation to the DoD stepped care approach to pain 
management, DoD opioid prescribing policies and guidelines, DHA 
clinical decision support tools, and an emphasis on use of non-opioid/
non-pharmacolgic pain treatments and naloxone.
    We believe that our efforts are proving to be effective. The 
prevalence of opioid use disorder resulting from medically prescribed 
opioids in Military Service members is less than 1 percent. This rate 
is significantly lower than the 8-12 percent of the U.S. adult 
population that develop an opioid use disorder from prescribed opioids 
according to a 2017 study from the Substance Abuse and Mental Health 
Services Administration. In 2012, 29.0 percent of Active Duty Service 
Members received one or more prescriptions for an opioid. By fiscal 
year 2018, that rate had plummeted to 16.8 percent, a reduction of more 
than 40 percent and the lowest proportion in over a decade.
    The DoD will continue implementing and improving our comprehensive 
pain management and opioid safety strategy, utilizing all of the 
emerging medical evidence and DoD experience.
    Question. Will you work to advance alternative pain management 
options that can help reduce the possibility of addiction?
    Answer. DHA's pain management and opioid safety policies have 
already driven care of the warfighter towards a more multidisciplinary, 
multi-modal pain management strategy that leverages selected 
complementary and integrative health (CIH) modalities such as 
acupuncture, medical massage therapy, movement therapies (yoga/tai 
chi), chiropractic care, and mindfulness. These modalities, used 
alongside more conventional pain management treatments such as 
medications and interventional procedures like injections and nerve 
blocks, account for the increase in use of complementary integrative 
pain management treatments. A RAND study showed that between fiscal 
years 2013-2018, approximately 482,500 acupuncture, 1.8 million 
chiropractic, and 744,600 osteopathic manipulation encounters were 
provided to Military Health System beneficiaries. In 2020, DHA 
published ``Acupuncture Practice in Military Medical Treatment 
Facilities,'' the first policy standardizing the utilization, clinical 
practice, education, training, and coding for a CIH modality.
    The Department regularly reviews whether specific CIH modalities 
meet the evidence-based criteria for inclusion in the TRICARE benefit. 
This medical benefit determination process requires an extensive review 
of available safety and effectiveness evidence as required by law.
                                 ______
                                 
       Questions Submitted to Lieutenant General Ronald J. Place
             Questions Submitted by Senator Jeanne Shaheen
    Question. As you know, service members and their families are 
affected by eating disorders at elevated rates compared to their 
civilian counterparts. That is why I wrote the SERVE Act to expand 
access to eating disorder treatments for service members and their 
families. I was pleased to see the fiscal year 2022 NDAA include my 
bill, however it only expanded coverage to current service members and 
military families--not retirees and their families. I understand that 
can be achieved for a minimal amount of money.
    Would you support expanding eating disorder coverage to military 
retirees and their families?
    Answer. No, because it is not necessary via a statutory 
modification. The Department concurs that eating disorders are a 
significant problem in society as a whole and in particular in the 
military community. Treatment of eating disorders is challenging and 
usually requires a multidisciplinary, long-term approach which the 
TRICARE program currently provides to all beneficiaries. First, the 
bill is unnecessary as the Secretary already has the authority to issue 
regulations to add new providers and benefits when the care would be 
medically necessary and appropriate, as well as proven safe and 
effective. Statutory relief is unnecessary to expand already-covered 
care to individuals over the age of 21. Should the Department determine 
that the care is supported by reliable evidence, the Secretary may 
issue regulations to modify the definition of a residential treatment 
center (RTC) and expand the benefit under existing authorities. 
Additionally, TRICARE currently provides comprehensive medically 
necessary care and treatment for all beneficiaries diagnosed with 
eating disorders in all of the healthcare settings proposed in the 
bill, except that RTCs are only covered for beneficiaries under the age 
of 21. This provision is not new to the TRICARE program and is based 
upon accepted standards of practice and input from Department 
consultants and the provider community. We note that this existing age 
limit for RTCs is geared to ensuring that TRICARE beneficiaries are 
receiving medically necessary care at the appropriate level and age of 
care. Consistent with the Centers for Medicare and Medicaid Services 
(CMS), the TRICARE regulation defines an RTC as a facility that 
provides to beneficiaries under 21 years of age a medically supervised, 
interdisciplinary program of mental health.
    Question. Do you know of any reason why that coverage cannot be 
extended under your current authorities without congressional action?
    Answer. The authority exists should RTC care for eating disorders 
(or other psychiatric disorders) be supported by sufficient reliable 
evidence as proven safe and effective.
    Question. Can you discuss what the Department of Defense is doing 
to ensure that direct care providers are trained to screen, briefly 
intervene, and treat eating disorders?
    Answer. All primary care providers in military medical treatment 
facilities (MTF) are trained to recognize and screen for eating 
disorders, especially for adolescents. If clinically indicated, 
providers will send the patient for testing as part of the standard 
medical work-up to include testing for liver enzymes, kidney studies, 
electrolyte and blood counts. Finally, the provider will refer the 
patient to behavioral health in the MTF if available or if not, to care 
in the TRICARE network.
    Question. Last summer, the Office of the DoD Inspector General 
released a report identifying deficiencies in the Department's approach 
to analyzing PFAS in firefight blood samples--testing required by a 
provision I authored in the fiscal year 2020 NDAA. In December, Senator 
Murkowski and I led a letter with twenty of our colleagues to Assistant 
Secretary of Defense for Readiness Skelly regarding this issue and 
requesting a briefing. I am pleased that the Department responded by 
swiftly providing that briefing--during which DoD officials referred to 
a report expected this month containing the first analysis of 
firefighter blood samples from last year.
    What is that status of that report?
    Answer. The DoD Firefighter Blood Testing Results report for fiscal 
year (FY) 2020 will be available in July 2022. This report will also be 
incorporated into the Report to Congress (RTC), ``Perfluorinated 
Chemicals Contamination and First Responder Exposure,'' as directed by 
the fiscal year 2022 House Defense Appropriations bill and due by 
September 12, 2022.
    Ongoing work includes a draft DoD Firefighter Blood Test Results 
report that will be available from the Navy and Marine Corps Public 
Health Center (NMCPHC) this month (Estimated Completion: April 2022). 
The draft NMCPHC report will then be reviewed internally by the DoD. 
Simultaneously, reference materials are being updated to support and 
accompany the report for use by DoD firefighters, healthcare providers, 
public and environmental health scientists and engineers, and others. 
(Estimated Completion: May 2022.)
    The Department looks to the Centers for Disease Control and 
Prevention (CDC) National Institute for Occupational Safety and Health 
(NIOSH) as the U.S. Government lead for research efforts on 
occupational exposures to PFAS. Therefore, we intend for NIOSH to 
review the results report as an external (independent) reviewer prior 
to finalizing the report. (Estimated Completion: June-July 2022).
    Question. As you know, I have long been concerned with the 
Anomalous Health Incidents impacting DoD personnel and their families. 
Last month, Senator Collins and I sent a letter urging the newly-
appointed AHI coordinator to address some of the most pressing issues--
at the top of that list is equitable access to care for victims.
    How has access to care for AHI victims evolved over the past year, 
including providing care for non-DoD personnel impacted by AHIs?
    Answer. Non-DoD healthcare beneficiaries have been evaluated and 
cared for in the military health system under Secretary of Defense 
Designee Status. That process for approval has been markedly 
streamlined over the last year, allowing for quicker access to 
services. Additionally, Section 732 of the fiscal year 2022 National 
Defense Authorization Act (NDAA) allows for the medical assessment at 
MTFs for U.S. Government employees and their families diagnosed ``with 
an anomalous health condition or a related affliction.''
    Question. In incidents with suspected exposure for child 
dependents, how are we ensuring that their experiences are captured to 
ensure that we are caring for them now and into the future, when their 
symptoms may become more apparent?
    Answer. For children present during an AHI, but for whom no 
symptoms are identified, they will nonetheless be included in the 
Section 732 fiscal year 2022 NDAA-required medical registry to ensure 
their potential exposure is documented. This will allow for future 
engagement should our improving understanding of the exposure identify 
recommendations that could benefit them. All results of the medical 
evaluations that are conducted on potentially affected children are 
recorded in the DoD electronic medical record for future reference. 
Additionally, these children, with their parent's permission, will be 
included in the AHI Registry established under Section 732 of the 
fiscal year 2022 NDAA. This will allow for documentation of the 
reported event and information for future care providers as needed.
                                 ______
                                 
             Questions Submitted by Senator Lisa Murkowski
    Question. Service members who need behavioral health support should 
have access to timely treatment--ideally within two weeks, not 2 
months. For U.S. Army Alaska, the average wait time for a first 
appointment is 15.5 days for specialty care and that often was just an 
intake session to gather background information for follow-on 
treatment. A behavioral health technician who cannot offer treatment or 
a group educational session should not be considered satisfactory and 
it's clear that our service members need access to treatment sooner.
    Can you provide a timeline on when the Department of Defense will 
complete its behavioral healthcare workforce plan, as required by Sec. 
721 of the fiscal year 2017 NDAA so the committee can properly allocate 
resources to remedy this issue? HRP&O
    Answer. The Report to Congress (RTC) on the Department's plan to 
reduce military medical personnel submitted in August 2021 meets the 
fiscal year 2017 NDAA Sec. 721 requirement, which gives the Department 
the authority to convert military medical and dental positions to 
civilian positions if they are not necessary to meet operational 
medical force readiness requirements. Appendix B--Methodology by 
Service (starting on page 35) of the RTC describes in detail each 
Services' methodology for determining the medical operational manpower 
requirement.
    The Department has two pertinent studies underway, the Integrated 
CONUS Medical Operations Plan (ICMOP) and the Operational Medical 
Requirements study, both of which are expected to take approximately 18 
months to complete. The results of these two studies could make 
adjustments to the Department's medical operational manpower 
requirements.
    The DoD OIG recommended that the Defense Health Agency Director 
develop a single Military Health System-wide staffing approach for the 
Behavioral Health System of Care that estimates the number of 
appointments and personnel required to meet the enrolled population's 
demand for mental health services. In January 2022 the DHA developed 
the first draft of a BH staffing model, which focuses on supply and 
demand. The DHA continues to work with the Services and internal 
partners to finalize the BH staffing model. It is anticipated that the 
model will be ready to start piloting in October 2022. The pilot will 
occur from October 2022 to September 2024 to allow for synchronization 
with the military assignment cycle and to collect data. Data and 
feedback will be used to refine the staffing model prior to launching 
MHS-wide in September 2024.
    Question. Do you believe the Department of Defense is sufficiently 
meeting access to care standards for our service members? If not, what 
can this committee do to help remedy this issue?
    Answer. Presently, the Military Health System (MHS) does 
sufficiently meet access to care standards for Military Service Members 
as the current average days to an initial appointment meet the internal 
Defense Health Agency (DHA) goal of 14 days to care; however, the MHS 
access standard is 28 days across the enterprise. DHA's ability to 
sustain sufficient access to care is threatened by chronic shortages in 
civilian providers. Unfilled civilian positions are not a new problem 
but has been magnified post COVID-19.
    Question. I understand that tele-behavioral health appointments for 
service members stationed in Alaska are limited to providers in the 
Pacific region, primarily Tripler Medical Center in Hawaii. It seems 
like any military behavioral health provider with appropriate 
appointment availability, regardless of location, should be able to 
serve our military personnel in Alaska via tele-behavioral health.
    What is needed in order to increase tele-health appointment 
availability for service members stationed in Alaska?
    Answer. The Virtual Medical Center can coordinate Tele-Behavioral 
Health (TBH) support for the Alaska Market or from any specific MTF 
within the region. In order to provide assistance, the Virtual Medical 
Center needs to understand the requirement (i.e., how many appointments 
a day are needed to meet demand, the projected timeframe, etc.). 
Requests for TBH assistance can be made at the Virtual Medical Center's 
SharePoint at https://info.health.mil/army/VMC. Currently and as a 
legacy program, Tripler Medical Center is the main TBH provider for 
Alaska; however, any provider could provide TBH appointments for Alaska 
MTFs if the remote providers have the equipment, IT access, privileges, 
time availability, and support staff. Because of the high demand for 
behavioral health services, there is limited excess capacity across the 
enterprise. To apply additional supply for behavioral health (BH), the 
DHA is in the process of implementing a tele-BH contract, which can be 
controlled centrally to meet demand for care with virtual BH visits, 
especially overseas and in remote regions.
    Question. Does DHA anticipate an increase in funding will be needed 
to expand tele-health availability so service members can connect with 
a provider quickly, regardless of location?
    Answer. In order to meet access needs of MHS beneficiaries, DHA 
will be launching a new, centralized TBH enterprise solution to 
supplement care for military MTF-based providers at the end of fiscal 
year (FY) 2022. This solution will provide TBH appointments to all 
Military Departments in both the Continental United States and outside 
the Continental United States (OCONUS) and operational/garrison domains 
for active duty service members (ADSMs). The MHS is exploring expansion 
of TBH capabilities also to provide care to Active Duty Family Members 
on a space available basis. Presently, no additional funding is 
required to support this initiative.
                                 ______
                                 
               Questions Submitted by Senator John Hoeven
    Question. In recent years, the DoD and VA have been working 
together to develop a single, comprehensive separation health 
assessment for those leaving service. A mental health assessment is now 
a part of the separation exam, which is an important addition.
    The Senate report of the National Defense Authorization Act (NDAA) 
for fiscal year (FY) 2022 contains language I proposed encouraging DoD 
to extend the Separation History and Physical Examination (SHPE) to 
members of the National Guard and Reserves. It also directs DoD and VA 
to determine the number of separating Guardsmen and Reservists who 
elected to receive a SHPE over the last year.
    Will you keep me updated on the forthcoming report and work with me 
to ensure that Guard and Reserve members have access to this important 
benefit, just like their Active Duty counterparts?
    Answer. DoD Senate Report 117-39, which accompanied a Senate 
version (S. 2792) of the fiscal year (FY) 2022 National Defense 
Authorization Act (NDAA), requested a briefing on Selected Reserve 
Separation History and Physical Examinations (SHPEs). For that 
population, the brief will provide a data-driven discussion of SHPEs, 
comparable physical examinations delivered prior to separation, 
Department of Veterans Affairs (VA) healthcare enrollments, and VA 
compensation and benefits applications. The brief is in development, 
and its delivery is expected in late 2022.
    Question. Our National Guard members, particularly those in rural 
areas, are having difficulties when seeking mental healthcare. TRICARE 
requires that its mental health counselor's graduate from a Council for 
the Accreditation of Counseling and Related Educational Programs 
(CACREP) accredited school. TRICARE does not currently recognize that 
Licensed Addiction Counselors (LACs) in North Dakota may practice 
unsupervised. Furthermore, Health Service Centers are TRICARE in-
network providers, and only accept patients with a disability rating of 
50 percent or more, generally a score that does not fit Active Duty or 
National Guard populations.
    Is DoD working in coordination with states like North Dakota so 
that the mental healthcare workforce can be bolstered while ensuring it 
remains well-trained and properly credentialed?
    Answer. HealthNet Federal Services (HNFS), the regional Managed 
Care Support Contractor for North Dakota, regularly pursues recruitment 
opportunities by reviewing claims data, utilizing local providers and 
professional relationships to obtain leads, performing extensive 
Internet research, provider call outs, availability surveys, and 
encouraging provider groups to give updates on their new providers. In 
addition, HNFS has worked to increase availability of providers and to 
offer shorter appointment wait times by contracting with two national 
telemedicine groups that offer virtual behavioral health appointments 
to TRICARE beneficiaries. These two groups, Doctor on Demand and 
Telemynd, have made available five North Dakota licensed psychiatrists 
and five behavioral health providers of various areas of specialty and 
licensing disciplines, including Psychology and Social Work. 
Beneficiaries can ``connect'' securely from their home computers and/or 
devices.
                                 ______
                                 

                          SUBCOMMITTEE RECESS

    Senator Tester. The Defense Subcommittee will reconvene on 
Tuesday, April 26, at 10 a.m. for a classified hearing on the 
Missile Defense Agency.
    I will recess by saying, thank you folks for all your work. 
It is very, very important work, and also know that the work 
that you guys do dealing with active military, and transition, 
and mental health, and all the other things that you have 
talked about in your opening statements, and during the 
questions and answers, is not only important for the military 
but it is important for our country overall, because you guys 
lead the charge on medical research issues, and we thank you 
for that.
    And with that, the subcommittee stands in recess.
    [Whereupon, at 11:10 a.m., Tuesday, March 29, the 
subcommittee was recessed, to reconvene at 10 a.m., Tuesday, 
April 26.]