[House Hearing, 111 Congress] [From the U.S. Government Publishing Office] [H.A.S.C. No. 111-156] DEFENSE HEALTH PROGRAM __________ HEARING BEFORE THE SUBCOMMITTEE ON MILITARY PERSONNEL OF THE COMMITTEE ON ARMED SERVICES HOUSE OF REPRESENTATIVES ONE HUNDRED ELEVENTH CONGRESS SECOND SESSION __________ HEARING HELD APRIL 21, 2010 [GRAPHIC] [TIFF OMITTED] TONGRESS.#13 U.S. GOVERNMENT PRINTING OFFICE 58-309 WASHINGTON : 2010 ----------------------------------------------------------------------- For sale by the Superintendent of Documents, U.S. Government Printing Office, http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202�09512�091800, or 866�09512�091800 (toll-free). E-mail, [email protected]. SUBCOMMITTEE ON MILITARY PERSONNEL SUSAN A. DAVIS, California, Chairwoman VIC SNYDER, Arkansas JOE WILSON, South Carolina LORETTA SANCHEZ, California WALTER B. JONES, North Carolina MADELEINE Z. BORDALLO, Guam JOHN KLINE, Minnesota PATRICK J. MURPHY, Pennsylvania THOMAS J. ROONEY, Florida HANK JOHNSON, Georgia MARY FALLIN, Oklahoma CAROL SHEA-PORTER, New Hampshire JOHN C. FLEMING, Louisiana DAVID LOEBSACK, Iowa NIKI TSONGAS, Massachusetts Dave Kildee, Professional Staff Member Jeanette James, Professional Staff Member James Weiss, Staff Assistant C O N T E N T S ---------- CHRONOLOGICAL LIST OF HEARINGS 2010 Page Hearing: Wednesday, April 21, 2010, Defense Health Program................ 1 Appendix: Wednesday, April 21, 2010........................................ 31 ---------- WEDNESDAY, APRIL 21, 2010 DEFENSE HEALTH PROGRAM STATEMENTS PRESENTED BY MEMBERS OF CONGRESS Davis, Hon. Susan A., a Representative from California, Chairwoman, Subcommittee on Military Personnel................. 1 Wilson, Hon. Joe, a Representative from South Carolina, Ranking Member, Subcommittee on Military Personnel..................... 3 WITNESSES Green, Lt. Gen. Charles B., USAF, Surgeon General, U.S. Air Force 11 Rice, Charles L., M.D., Performing the Duties of the Assistant Secretary of Defense for Health Affairs, and President, Uniformed Services University of Health Sciences, U.S. Department of Defense.......................................... 5 Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy..... 8 Schoomaker, Lt. Gen. Eric B., USA, Surgeon General, U.S. Army.... 6 APPENDIX Prepared Statements: Davis, Hon. Susan A.......................................... 35 Green, Lt. Gen. Charles B.................................... 96 Rice, Charles L., M.D........................................ 42 Robinson, Vice Adm. Adam M................................... 77 Schoomaker, Lt. Gen. Eric B.................................. 61 Wilson, Hon. Joe............................................. 39 Documents Submitted for the Record: [There were no Documents submitted.] Witness Responses to Questions Asked During the Hearing: Mrs. Davis................................................... 117 Dr. Fleming.................................................. 117 Ms. Shea-Porter.............................................. 117 Ms. Tsongas.................................................. 118 Questions Submitted by Members Post Hearing: [There were no Questions submitted post hearing.] DEFENSE HEALTH PROGRAM ---------- House of Representatives, Committee on Armed Services, Subcommittee on Military Personnel, Washington, DC, Wednesday, April 21, 2010. The subcommittee met, pursuant to call, at 1:40 p.m., in room 2118, Rayburn House Office Building, Hon. Susan A. Davis (chairwoman of the subcommittee) presiding. OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, SUBCOMMITTEE ON MILITARY PERSONNEL Mrs. Davis. Good afternoon. Today the Military Personnel Subcommittee will hold a hearing on the President's fiscal year 2011 budget request for the Defense Health Program (DHP). Testifying before us are the senior medical leaders of the Department of Defense (DOD). Dr. Charles Rice is the President of the Uniformed Services University of Health Sciences, and is currently performing the duties of the Assistant Secretary of Defense for Health Affairs. This office is responsible for the preparation and oversight of the Defense health budget, as well as the execution of private sector care. We also have with us the service surgeons general, Lieutenant General Eric Schoomaker from the Army, Vice Admiral Adam Robinson from the Navy, and Lieutenant General Bruce Green from the Air Force, who are responsible for the provision of care in military hospitals and clinics. Thank you all for being here. Welcome. This year's budget request, much like last year's, lacks many of the objectionable proposals of years past. For example, there are no onerous TRICARE fee increases that seek to place a burden of improving the system on beneficiaries instead of on the Department of Defense. There are no ``efficiency wedges,'' an interesting term that meant ``We think the services are spending too much, but we don't know exactly where, so we are just going to cut their budgets and let them figure it out.'' There are no proposed conversions of military medical positions to civilian medical positions. And the absence of all of these things from the proposed budget is a very good start. However this budget request, while devoid of these negatives, doesn't have so many positives that are forward- looking. We continue to see little if any evidence of a comprehensive, multifaceted strategy for moving the Military Health System (MHS) forward. For the past few years Congress has been pushing the Department of Defense to improve the health status of the beneficiary population and improve cost- effectiveness of the care provided to our beneficiaries by adopting proven practices, the fiscal year 2009 National Defense Authorization Act contains many initiatives to improve preventive and wellness care. But 18 months, now, after it was signed into law, we are still waiting for most of them to be fully implemented. That same bill also gave the Department great latitude and authority to conduct demonstration projects to test other methods of improving health while reducing costs. We would like to hear today how the Department plans to take advantage of that authority. Further, the 2010 National Defense Authorization Act contained a requirement for the Department to undertake actions to enhance the capability of the Military Health System and improve the TRICARE program. Congress felt that such action was needed because private sector care, which was originally intended to be and is still described by the Department as a program to fill gaps in the direct care system, is projected to account for about 67 percent of the Department of Defense health-care expenditures in fiscal year 2011 versus 65 percent this year. It is strange logic to characterize something that accounts for almost 70 percent of a program as a gap-filler. We recognize that several factors have contributed to the unintentional growth in private sector care, such as two wars, staffing shortages, and broad reserve globalization. With that said, without appropriate planning, the effect of these factors could be an irreversible trend, placing medical readiness in future contingencies in jeopardy. Congress clearly believed the Department must develop a long-term plan to maximize the capabilities of the direct care system, and we would like to hear from our witnesses today any ideas they may have. This has been a momentous year for health care in this country. Last month the Patient Protection and Affordable Care Act and the companion improvements bill were signed into law. Further, just last week, the Senate unanimously passed the TRICARE Affirmation Act introduced by the chairman of this committee, Ike Skelton, which had previously passed unanimously in the House. The TRICARE Affirmation Act explicitly states that TRICARE and nonappropriated fund, NAF, health plans meet all of the health-care requirements for individual health insurance under the newly enacted health-care reform law. TRICARE and the NAF health plans already meet the minimum requirements for individual health insurance coverage in the recently enacted health-care bill, and no TRICARE or NAF nonappropriated fund health plan beneficiary will be required to purchase additional coverage beyond what they already have. However, to reassure our military service members and their families and make it perfectly clear that they will not be negatively affected by the health-care reform law, the TRICARE Affirmation Act explicitly states that TRICARE and the NAF health plans meet the minimum requirements for individual health insurance. Now that the bills are law, parents across the country will now be able to extend their health coverage to their dependent children up to age 26. Being true to their word, congressional Democratic leadership ensured that the health reform bills do not involve TRICARE in any way. But since care was taken to guarantee that the Department of Defense health programs under Title 10, U.S. Code, were not touched by the health reform bills, this means that the new law does not allow TRICARE beneficiaries to extend their health coverage to their dependent children. Fortunately, a member of this committee, Mr. Heinrich of New Mexico, quickly crafted and introduced a bill, H.R. 4923, the TRICARE Dependent Coverage Extension Act, that would amend Title 10 to precisely match the health reform law to allow TRICARE beneficiaries to extend their health coverage to their dependent children up to age 26. I want to thank Mr. Heinrich for introducing this important legislation and I want to let everyone know that I certainly intend to include that bill in this subcommittee's mark for this year's National Defense Authorization Act in a few weeks. Since Mr. Heinrich is not a member of the subcommittee, I would ask unanimous consent that he be allowed to participate in today's hearing and be allowed to ask questions after all the members of the subcommittee. Hearing no objection, thank you for being here. Mr. Wilson, we welcome you. We are sorry we got underway because we just had everybody ready to go here and we appreciate the fact that you were trying to get here as well. Please, we are happy to have any of your comments. [The prepared statement of Mrs. Davis can be found in the Appendix on page 35.] STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH CAROLINA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL Mr. Wilson. Thank you, Chairwoman Davis. Today the subcommittee meets to hear testimony on the Defense Health Program for fiscal year 2011. Although we routinely have an annual hearing on the Defense Health Program, I believe there is nothing routine about the Military Health System and the extraordinary care it provides to our service members and their families. I have firsthand knowledge of these remarkable military and civilian medical professions from my second son, who is an orthopedic resident in the Navy, and my other three sons who are current members of the Army National Guard. The subcommittee remains committed to ensuring that the men and women who are entrusted with the lives of our troops have the resources to continue their work for future generations of our most deserving military beneficiaries. I would like to express my deep appreciation to all the Military Health System leadership and personnel who are responsible for delivering the highest quality health care during these most challenging times. To begin, I want to commend the Department of Defense for sending us a budget that does not rely on raising TRICARE fees to help finance the Defense Health Program. It appears the Defense Health Program is fully funded. However, I remain concerned a portion of the funding is based on projected savings from several programs that may not be fully realized. I would like to know how the Department of Defense plans to cover any unexpected shortfalls in the Defense Health Program if the savings from initiatives such as the Federal Pricing for Pharmaceuticals doesn't materialize. With that, I am anxious to hear from our witnesses today about the progress the Department has made in developing a comprehensive approach to providing world-class health care to our beneficiaries while at the same time controlling cost. I would like to know how the Military Health System is meeting the medical needs of our beneficiaries today and what process you use for determining the medical requirements of future beneficiaries. I am interested in knowing how you have included the stakeholders in military health care and the discussions about providing world-class health care in the future of the Military Health System. Further, I would like to hear from the witnesses on how the Defense Health Program supports the critical mental health services needed by our service members and their families, particularly the National Guard and Reserve members who rely primarily on TRICARE standard. I would also like to better understand from our military Surgeons General whether the Defense Health Program will fully support their responsibility to maintain medical readiness, provide health care to eligible beneficiaries, provide battlefield medicine to our brave men and women in Iraq and Afghanistan, care for combat veterans through the long recovery process when they become injured and wounded. Finally, with regard to TRICARE, which is now regarded as a health-care delivery system worthy of emulation, I quite frankly don't understand why the Department of Defense would not want to explicitly protect it from any unintended consequence that may arise from the health-care takeover. Congress has already acted to make clear, explicit, that the recent health-care bill did not, that TRICARE meets the statutory requirement for minimal essential health care. The Department of Defense did not object to that recent congressional action. Now it is time to make explicit in the law what has been promised that would be explicit in the health-care reform. The Secretary of Defense would remain in control of the DOD Health Care Program. No one should object to Congress making that control explicit in the law. While some may feel that this is an unnecessary precaution, we owe our military that clearly stated protection. With that, I would like to welcome our witnesses and thank them for participating in the hearing today. I look forward to your testimony. Mrs. Davis. Thank you, Mr. Wilson. [The prepared statement of Mr. Wilson can be found in the Appendix on page 39.] Mrs. Davis. Dr. Rice, please begin. STATEMENT OF CHARLES L. RICE, M.D., PERFORMING THE DUTIES OF THE ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, AND PRESIDENT, UNIFORMED SERVICES UNIVERSITY OF HEALTH SCIENCES, U.S. DEPARTMENT OF DEFENSE Dr. Rice. Madam Chair, members of the committee, thank you for the opportunity to discuss the military health care system's priorities and our budget submission for fiscal year 2011. It is a privilege to be here with my colleagues, the Surgeons General of the three military services. We have enduring obligations to the men and women of our armed forces, as you have observed, and to their families who serve with them, and to the millions of retired personnel who have served us in the past. This obligation begins the moment a recruit walks through our doors. In our budget for the coming year we acknowledge that lifetime commitment we have to those who serve today, or who have served in the past, and to their families. For those service members who honorably conclude their service before reaching military retirement, we have an obligation to ensure that their medical experience is fully captured and easily shared with the Department of Veterans Affairs (VA) or with their own private physician. For those who retire from military service, our obligation to them and to their families often extends for a lifetime. And for those who have borne the greatest burden through injury or disease suffered in our nation's conflicts, we have an even higher obligation to the wounded and to their families. As Secretary Gates stated with the introduction of the Defense budget, ``Recognizing the strain that post-9/11 wars have put on so many troops and their families, the Department will spend more than $2 billion for wounded warrior initiatives, with a special focus on signature ailments of the current conflict, such as post-traumatic stress disorder and traumatic brain injury (TBI), manifestations of the last injury. ``We will sustain health benefits and enlarge the pool of medical professionals. We will broaden electronic information sharing between the Department of Defense and the VA for wounded warriors making the transition out of military service.'' The budget we are putting forward reflects our commitment to the broad range of responsibilities of the military health care system; the medical readiness requirements needed for success on today's battlefield; the medical research and development necessary for success on tomorrow's; the patient- centered approach to care that is being woven through the fabric of the military health care system; the transformative focus we have placed on the health of our population; the public health role we play in our military community and in the broader American community; the reliance we have on our private sector health-care partners who provide indispensable service to our service members and their families; and our responsibility to deliver all of those services with extraordinary quality and care. The Defense Health Program, the appropriation that supports the MHS, is under mounting financial pressure. The DHP has more than doubled since 2001 from 19 billion to 50.7 billion in 2011. The majority of DOD health spending supports health-care benefits for military retirees and their dependents, not the active force. We projected up to 65 percent of DOD health-care spending will be going towards retirees in fiscal year 2011, up from 45 percent in 2001. As civilian employers' health costs are shifted to their military retiree employees, TRICARE is seen as a better, less costly option, and they are likely to drop their employer's insurance. These costs are expected to grow from 6 percent of the Department's total budget in 2001 to more than 10 percent in 2015. Despite these financial challenges, however, the fiscal year 2011 budget request provides realistic funding for projected health-care requirements, and we are grateful to this committee and to the Congress for affirming TRICARE as a qualifying plan under the health reform act. The unified medical budget, the Department's total request for 2011 is $50.7 billion. This includes the DHP appropriation, including wounded, ill, and injured care and rehabilitation, military personnel, military construction, and normal cost contributions for Medicare-eligible retiree health care. For military personnel, the unified budget includes 7.9 billion to support the more than 84,000 military personnel who provide health-care services in military theaters of operations in fixed health-care facilities around the world. These services include medical and dental care, global aeromedical evacuation, shipboard and undersea medicine, and global humanitarian assistance and response as we recently saw in Haiti. Funding for the military construction (MILCON) includes a billion dollars to improve our medical infrastructure. We are committed to building new hospitals, using the principles of evidence-based design, and excited to be able to open a national showcase in evidence-based design, the new Fort Belvoir Community Hospital, in 2011. MILCON funding will also be directed toward infrastructure enhancements at the interagency biodefense campus at Fort Detrick. Madam Chair, the military health care system continues to provide world-class medical care for a population that demands and deserves the best care anywhere. I am proud to be here on behalf of the men and women who comprise the military health care system, proud to submit to you and your colleagues a budget that is fully funded and that we can successfully execute in the coming year. I look forward to your questions. Mrs. Davis. Thank you. [The prepared statement of Dr. Rice can be found in the Appendix on page 42.] Mrs. Davis. General. STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, SURGEON GENERAL, U.S. ARMY General Schoomaker. Chairwoman Davis and Representative Wilson, distinguished members of the Military Personnel Subcommittee and the full committee, thank you for inviting us to discuss the Defense Health Program and our respective medical service programs. Now in my third hearing cycle as the Army Surgeon General and the Commanding General of the United States Army's Medical Command, or MEDCOM, I can tell you that these hearings are valuable opportunities for me to talk about the accomplishments and challenges of Army Medicine and to hear your collective perspectives regarding military health promotion and health care. And for the reasons, ma'am, that you mentioned in your opening comments, although closely interrelated, I keep military health promotion and health care somewhat separate issues. I am pleased to tell you that the President's budget submission for fiscal year 2011 fully funds the Army Medical Department's needs. Your support of the President's proposed budget will be greatly appreciated. One particular area of special interest to this subcommittee is our comprehensive effort to improve warrior care from the point of injury through evacuation and inpatient treatment to rehabilitation and return to duty. There is nothing more gratifying than to care for these wounded, ill, and injured heroes. We in Army Medicine continue to focus our efforts on our warriors in transition, which is our term for them. And I want to thank the Congress for your unwavering support of these efforts. The support of this committee especially has allowed us to hire additional providers to staff our warrior transition units, to conduct relevant medical research, and to build healing campuses, the first of which will open in Fort Riley, Kansas very soon. I am convinced that the Army has made some lasting improvements. The most important improvement will be the change in mindset from a focus on disability to an emphasis on ability and achievement. Each of these warriors has the opportunity and resources to create their own future as soldiers or as productive private citizens. A second area of special interest for the subcommittee is psychological health. Army Medicine, under the direction of our new Deputy Surgeon General, Major General Patty Horoho who has just relinquished command of the Western Region and has traveled here and is replacing David Rubenstein who is headed to San Antonio, is finalizing a comprehensive behavioral health system of care campaign plan. This comprehensive behavioral health system of care is intended to standardize and synchronize the vast array of activities across the medical command and throughout the Army's force generation cycle, this iterative three-cycle process by which we prepare soldiers and units for deployment, deploy them and support their families back in garrison, bring them back and redeploy them and reintegrate them. I look forward to sharing more information with you over the next few months as we roll out this exciting initiative. In keeping with our focus on preventing illness and injury, Army leadership is fully engaged in an all-out effort to change the military mindset regarding traumatic brain injury, especially the milder form, or a concussion. Our goal is nothing less than a cultural change in fighter management after potential concussive events. Every warrior requires appropriate treatment to minimize concussive injury and to maximize recovery. And to achieve this goal we are educating the force so that we have trained and prepared soldiers, leaders, medical personnel to provide early recognition, treatment, and tracking of concussive injuries from the moment of the injury on the battlefield, homeward. Ultimately this is designed to protect warrior health. This also further highlights strong efforts by the senior Army and DOD leadership to reduce the stigma associated with seeking help for these injuries and for behavioral health problems which might be present, separately or jointly. The Army is issuing very direct standards and protocols to commanders and health-care providers. Similar to aviation incident actions, automatic grounding and medical assessments are required for any soldiers meeting specified criteria. The end state of these efforts is that every service member sustaining a possible concussion will receive early detection, state-of-the-art treatment and a return-to-duty evaluation and a long-term digital health record tracking of their management. Treatment of concussive injury is an emerging science. The Army is leading the way, along with the DOD, in implementing these new treatment protocols both for the DOD, and the DOD is leading the nation. I brought here with me today a brain injury awareness kit that I will share with you and your staff. It contains patient information materials, as well as a very informative DVD, sort of a concussive injury 101. Mrs. Davis. Thank you General. I just ask that that be included in the record by unanimous consent. [The information referred to is retained in the subcommittee files and can be viewed upon request.] General Schoomaker. Thank you. I truly believe our evidence-based directive approach to concussion management will change the military culture regarding head injuries and significantly impact the well-being of the force. Ma'am, in reference to your comments about cost containment and improvements and health outcomes, the Army Medicine is in its fourth year of the performance-based health-care budget program which incentivizes our commanders and our clinicians for practicing evidence-based medicine and improving individual and community health. It has been a very successful campaign. I am very eager to address any questions that you may have about it. In closing, I am very optimistic about the next two years. Logic would not predict that we would be doing as well as we are in attracting and obtaining and career-developing such a talented team of uniformed and civilian military medical professionals. I feel very privileged to serve with the men and women of Army Medicine, as soldiers, as Americans, and as global citizens. Thank you for holding this hearing and for your steadfast support of Army Medicine. I look forward to your questions. Mrs. Davis. Thank you. [The prepared statement of General Schoomaker can be found in the Appendix on page 61.] Mrs. Davis. Admiral Robinson. STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL, U.S. NAVY Admiral Robinson. Good afternoon. Thank you, Chairwoman Davis, Representative Wilson, distinguished members of the committee, Representative Heinrich, I want to thank you for your unwavering support of Navy Medicine, particularly as we continue to care for those who go in harm's way, their families and all beneficiaries. I am honored to be with you today to provide an update of Navy Medicine. Navy Medicine, world-class care anytime anywhere. This poignant phrase is arguably the most telling description of Navy Medicine's accomplishment in 2009 and continues to drive our operational tempo and priorities for the coming year and beyond. Throughout the last year we saw challenges and opportunities, and moving forward I anticipate the pace of operations and demand will continue to increase. We have been stretched in our ability to meet increasing operational and humanitarian assistance requirements, as well as maintaining our commitment to provide care to a growing number of beneficiaries. However, I am proud to say that we are responding to this demand with more flexibility and agility than ever before. The foundation of Navy Medicine is force health protection, and nowhere is this more evident than in Iraq and Afghanistan. During my October 2009 trip to theater, I saw again the outstanding work of medical personnel. The Navy Medicine team is working side by side with Army and Air Force medical personnel and coalition forces to deliver outstanding health care to troops and civilians alike. As our wounded warriors return from combat and begin the healing process, they deserve a seamless and comprehensive approach to their recovery. We want them to mend in body, mind, and spirit. Our patient- and family-centered concept of care brings together medical treatment providers, social workers, case managers, behavioral health providers and chaplains. We are working closely with our aligned counterparts in Marine Corps wounded warrior regimens, and the Navy's Safe Harbor Program to support the full spectrum recovery process for sailors, Marines, and their families. An important focus for all of us continues to be caring for our wounded warriors suffering with traumatic brain injury. We are expanding traumatic brain injury training to health-care providers throughout the fleet and Marine Corps. We are also implementing a new in-theater TBI surveillance system and conducting important research. Our strategy is both collaborative and integrated by actively partnering with other services, Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, the Department of Veterans Affairs, and leading academic medical and research centers to make the best care available to our warriors. We must act with a sense of urgency to continue to help build resiliency among our sailors and Marines, as well as the caregivers who support them. We are aggressively working to reduce the stigma surrounding psychological health and operational stress concerns. Programs such as Navy Operational Stress Control, Marine Corps Combat Operational Stress Control Focus, Families Overcoming Under Stress, Caregiver Occupational Stress Control, and our Suicide Prevention Programs are in place and maturing to provide the support to personnel and their families. Mental health specialists are being placed in operational environments and forward deployed to provide service where and when they are needed. The Marine Corps is sending more mental health teams to the front lines, and Operational Stress Control and Readiness team, also known as OSCAR, will soon be expanded to include the battalion level. A mobile care team of Navy Medicine mental health professionals is currently deployed to Afghanistan conducting mental health surveillance, consulting with command leadership, and coordinating mental health care for sailors throughout the area of responsibility (AOR). An integral part of the Navy's maritime strategy is humanitarian assistance and disaster response. In support of Operation Unified Response Haiti, we deployed USNS Comfort from her homeport in Baltimore within 77 hours of the order, and ahead of schedule. She was on station in Port-au-Prince five days later. From the beginning, the operational tempo on board Comfort was high and our personnel were challenged professionally and personally. For many, this was a career defining experience, and I was proud to welcome the crew home last month and congratulate them for their outstanding performance. I am encouraged with our recruiting efforts within Navy Medicine, and we are starting to see the results of new incentive programs. But while overall manning levels for both officer and enlisted personnel are relatively high, ensuring we have the proper specialty mix continues to be a challenge in both active and reserve components. Several wartime critical specialties, as well as advance practice nursing and physician assistant, are undermanned. We also face shortfalls for general dentists, oral and maxillofacial surgeons, and many of our mental health specialists, including clinical psychologists and social workers. We continue to work hard to meet this demand but fulfilling the requirement among these specialties is expected to present a continuing challenge. Research and development is critical to Navy Medicine's success and our ability to remain agile to meet the evolving needs of our warfighters. It is where we find solutions to our most challenging problems and, at the same time, provide some of medicine's significant innovations and discoveries. Research efforts targeted at wound management, enhanced wound repair and reconstruction, as well as extremity and internal hemorrhage control, phantom limb pain in amputees present definitive benefit. These efforts support our emerging expeditionary medical operations in aid and support to our wounded warriors. Clearly, one of the most important priorities for leadership of all the service is the successful transition to the Walter Reed National Medical Center on board the campus of the National Naval Medical Center, Bethesda. We are working diligently with the lead DOD organization, Joint Task Force National Capital Region Medical, to ensure that this significant and ambitious project is executed properly and without any disruption of services to our sailors, Marines, their families, and all of our beneficiaries for whom we are privileged to serve. In summary, I believe we are an important crossroads for military medicine. Commitment to wounded warriors and their families must never waiver, and our programs of support and hope must be built and sustained for the long haul. And the long haul is the rest of this century when the young, wounded warriors of today mature into our aging heroes in the years to come. They will need our care and support, as will their families, for a lifetime. On behalf of the men and women of Navy Medicine, I want to thank the committee for your tremendous support and confidence and also for your leadership. It has been my pleasure to testify before you today and I look forward to your questions. Thank you. Mrs. Davis. Thank you. [The prepared statement of Admiral Robinson can be found in the Appendix on page 77.] Mrs. Davis. General Green. STATEMENT OF LT. GEN. CHARLES B. GREEN, USAF, SURGEON GENERAL, U.S. AIR FORCE General Green. Chairwoman Davis, Representative Wilson and distinguished members of the committee, thank you for this opportunity to join you today as we address common goals in serving our warriors and their families. The Air Force is all in to support the joint fight, providing global vigilance reaching power for America. The Air Force medical service does whatever it takes to get coalition wounded warriors home safely. I have previously shared the case of a British combatant with wounds requiring removal of a lung. It took three airplanes and nearly a thousand people coordinating his movement on heart-lung bypass to get him back to England. Today he is out of the hospital and back to a normal life in Birmingham, England. You may have seen or heard recent national news reports about an amazing operation that took place last month at the Craig Joint Theater Hospital at Bagram. Air Force Major Dr. John Bini is a seasoned theater hospital trauma surgeon, stationed in Wilfred Hall Medical Center, who is deployed to Bagram. When the radiologist discovered a live explosive round in an Afghan patient's head, Major Bini and his anesthesiologist, Dr. Jeffrey Rengold, put on body armor and went to work. They evacuated the operating room (OR), leaving only themselves and a bomb technician with the patient, because any electrical equipment could detonate the round. They turned to manual blood pressure cuffs and battery-operated heart monitor. Counting drips per minute they administered anesthesia the old-fashioned way. Dr. Bini operated and, within 10 minutes, removed the live round. Miraculously, the patient has been discharged, and is recovering, able to walk, talk, and feed himself. Dr. Bini told the New York Times that technically it wasn't a very complicated procedure; it is just something we train for, although it is a very uncommon event. In short, this is what Air Force and Army medics, along with Navy corpsmen, are all about. We are trained and ready as a team to meet the mission wherever, whenever, and however needed, with cutting-edge techniques and equipment, or the most basic of resources if this is our only option. We have the lowest died-of-wounds rate in history because of well-trained, highly skilled, and extraordinary people. Our country should be very proud of our men and women who put service before self and demonstrate excellence in all we do. We deeply appreciate all you do to ensure we recruit and retain these very special medics who are devoted to providing trusted care anywhere. We could not achieve our goals of better readiness, better health, better care, and best value, for our heroes and their families, without your support. Thank you. [The prepared statement of General Green can be found in the Appendix on page 96.] Mrs. Davis. Thank you very much, to all of you, and for all the programs that you have highlighted. We know that there are men and women behind you that are really performing extraordinary feats and have used their education and their experience to work on behalf of the men and women who are serving, and we are certainly very grateful for that. I wanted Dr. Rice to just pick up with one of the provisions that the National Defense Authorizations Act (NDAA) from 2010, section 721, which basically spoke to the study, and a plan to improve military health-care requirement interim response by the end, actually, of this week. I am just wondering if you know what the status of that response is, whether it is being prepared, sort of what strategic evaluation and planning has gone into that report. Dr. Rice. Madam Chair, I would be happy to get back to you with the details. It is my understanding that the draft is well underway. Obviously we need to coordinate it with the services who deliver the care, but we anticipate having the report in very shortly. [The information referred to can be found in the Appendix on page 117.] Mrs. Davis. Thank you. We will be looking forward to that. In your remarks you mentioned transformative medical care. I wonder if you could--we have heard, certainly from all of you to some extent, on medical homes and more healing communities, issues of that sort, of that kind of transformative look that we are trying to gain, I think, some real progress in today. Is that something that you expect out of the report? And if you could detail for us a little bit more about what is that kind of transformative care that you have in mind, rather than perhaps something that I would think that we are talking about here. Dr. Rice. Well, as you are well aware from the discussions that the Congress has had for the past year, wrestling with the issues of the delivery of health care while controlling costs and ensuring quality is a challenge for the nation as a whole. The military health care system is not isolated or insulated from that. As you are aware, we are close to concluding the award of the third-generation TRICARE contracts. Working with Rear Admiral Hunter, the Deputy Director of the TRICARE Management Activity, we have begun discussions on what the fourth generation of TRICARE contracts should look like, so that we work with our purchase care contract support organizations to incentivize individual patients to take responsibility for maintaining and improving their own health and working both within the direct care system as well as in the purchase care system for making care more efficient, more patient-centered, and more successful. As you may be aware, the Department has adopted, with permission from the Institute for Health Care Improvement, who developed what they refer to as the ``triple aim,'' we have modified that slightly for the ``quadruple aim,'' the four aims that are the experience of care, the quality and safety, an emphasis on population health, doing the very best you can to make care safe, efficient, and cost-effective and all of those surround our core mission which all three of the Surgeons General have alluded to, which is readiness--our responsibility to provide a medically ready force and a ready medical force. We have just begun those conversations on what the fourth- generation TRICARE contracts will entail, what the underlying philosophy is, and I look forward to coming back to report back to you and seek your guidance on ways that we should be thinking about. Mrs. Davis. When do you anticipate that the contracts would be awarded? Dr. Rice. We expect it to be imminent. As the committee is undoubtedly aware, there were protests in two of the regions that were upheld by the General Accounting Office (GAO). The contracting officer has agreed with the GAO's findings, and we are now refining exactly how we will resolve those conflicts. The discussions of that are ongoing within the Department and we hope that we will have that issue resolved very shortly. Mrs. Davis. Thank you very much. I am going to come back later. I am just thinking about this split of direct cost and essentially bought care. Today we are looking at 33 percent, 67 percent. Do you think that is the right mix? Where do we want to be in five years from now in terms of that breakdown? I will come back and let my colleague speak, but that would be something that I would like to explore. Mr. Wilson. Mr. Wilson. Thank you, Madam Chairwoman. Again, thank all of you for your service. All of us are concerned, facing an asymmetric enemy that seems to have zero morality in terms of attacking military civilians. We are so concerned about the post-traumatic stress disorder, mental health issues. And I want to thank you, General Schoomaker, for your information about traumatic brain injury. This is just so helpful and positive. Yesterday in a hearing we were discussing a concern that I know that you have, too, and what can be done; and that is to determine for pre-deployment neurocognitive baseline, and also then to have a post-deployment assessment. For any of who would like to answer that, what is being done and how effective do you feel this is? General Schoomaker. Well, I will take that on, sir. I would say right now the screening for neurocognitive problems as a tool or as an instrument for getting both baselines and post- appointment is fraught with problems. One of the tools that we first turned to that was jointly developed between the University of Oklahoma and the Army was the Automated Neurocognitive Assessment Model, ANAM. ANAM was never designed as a screening tool. It is designed as a prospective ongoing evaluation of neurocognition to see improvements for people who have neurocognitive problems from all causes, not just concussive injury or more severe forms of brain injury. And when we have looked at this--in fact I sent a team down range over a year ago to look in a very careful way at cohorts of known concussed soldiers in combat, non-concussed but ill soldiers from other causes, and then soldiers without any problems whatsoever either from concussion or from other illnesses, and discovered in that cohort controlled study, conducted by neurologists and scientists, that the ANAM as a screening tool was basically a coin flip. We would call it an insensitive and nonspecific test, both for non-concussed soldiers as well as for soldiers who received concussion. So we have turned away from ANAM as a simple screening tool. It still has utility for following longitudinally patients who might have, or soldiers who might have been concussed, but it is not a screen. What we have turned to is what we do every day on sports fields in this country, or following motor vehicle accidents or anything else. If we suspect a soldier, or Marine, or sailor, or airman has had a concussion, we evaluate them at the moment of the concussion, as quickly as we can, and safely. That is what is in that packet there, sir. Mr. Wilson. I looked at it, and this looks very positive, but it is just obviously is a concern that I have that was expressed yesterday. And you are right; whether it be sports or auto accidents, that is where military medicine is leading the way with prosthetics. I am counting on you all on what can be done for pre-deployment, post-deployment. Another concern I have has been with the Walter Reed National Medical Center, which is to be concluded September 2011; and that is, will the wounded warrior facilities be adequate and will they be contracted out? Are we really prepared? I know Admiral Robinson used to have a lot of hair until this issue came up, but what is the status of development? Admiral Robinson. Representative Wilson, the status of development is that the Navy, the Army, the Air Force, Joint Task Force (JTF) CapMed, are meeting and developing plans for wounded warriors. I will speak for the National Naval Medical Center--to become the Walter Reed National Military Medical Center. We have gone through a long series of discussions and talks. There will be 350 wounded warriors coming to the National Naval Medical Center, Walter Reed National Naval Medical Center, with their requisite nonmedical attendants and family members, and also with the requisite staff of individuals that will help care for them in terms of all of the personnel and other issues that men and women in the military need to have. So that number will be 350-plus and there will be a tail with that number. I think that if you look at the average daily census of Walter Reed and Bethesda in terms of their outpatient wounded warriors now, I think you will note there is probably a deficit of some number, between the 350 that I know about and the rest in the National Capital Area. And with that in mind, I think that the JTF CapMed and the services need to make sure that we have a comprehensive plan for whatever that delta may be for those wounded warriors and how they may be in fact cared for in the NCA, National Capital Area. I think that includes--and during discussions last week that will include several other bases in the area, such as Fort Meade. That may include Fort Belvoir. That will include other areas, and that may include also some reconnoitering of the spaces that we have at National Naval Medical Center, so we may have to do something a little different there, too. But there is a deficit of knowledge regarding that delta of wounded warriors in the National Capital Area. Mr. Wilson. I appreciate your efforts. Thank you, Madam Chairwoman. Mrs. Davis. Thank you. Dr. Snyder. Dr. Snyder. Thank you. And thank you, gentlemen, for being here. Mr. Wilson's opening statement made a comment that there is nothing routine about you all's jobs and about military health care, and we appreciate you all trying to stay ahead of changes that occur in the lives of men and women in uniform and their families. Dr. Schoomaker, in the information that you handed out, give me the 10-second summary, why are over-the-counter pain medicines like Ibuprofen not recommended for treatment of mild headache associated with concussion? General Schoomaker. We are very concerned about the use of non-steriodals and aspirin in theater, which would interfere with small-vessel blood clotting---- Dr. Snyder. Okay. General Schoomaker [continuing]. When you are at risk for a concussive injury or something that may require a robust clotting system. So we recommend that soldiers going down range suspend the use of aspirin and the non-steroidals. Dr. Snyder. That makes sense to me. Same thing, Doctor. I had this discussion yesterday, and I want to ask you, and it is the issue of--I guess I will say the moderately severe traumatic brain injury patients. I am talking about the group of people that may have been in your rehabilitation facility for several months, have reached the point at which we think there is probably the steady state, but it becomes apparent to the caretakers and the medical team that they are probably going to need to be in a facility that watches them. I think in the olden days we called it a domiciliary. They may not be able to handle meals or they get lost, a fairly significant injury, but still walk around. Maybe they will do some work under their facility. How do you handle those kinds of folks as time reaches for them to be discharged from the military? How do we make sure that they are immediately transferred to a place in which we won't lose them for an hour, a day, or a week, or a month while we are trying to find a proper placement for them? Is that an issue that you are having to deal with? General Schoomaker. Yes, sir. I would explain that, beyond moderate brain injury, I would talk about anyone who had a lingering or an enduring problem. I think Admiral Robinson talks about this passionately in every forum we get to. We are into an era in which we are going to have an enduring requirement to care for these soldiers and to assist their families for decades and decades to come. We have been intimately involved with the Veterans Administration since the end of the Vietnam War where the Defense Veterans Brain Injury Program, which has a network of certified centers that are community-based, such as you described, for assisting soldiers with moderate brain injury problems, but for rehabilitation and for assisting them in daily living requirements and location. But by extension, anyone who has an enduring physical or behavioral health problem, we partner very closely with the Veterans Administration. Our warrior transition units have veterans, counselors, embedded within them. And we have a program through the Army Wounded Warrior Program, any soldier with 30 percent disability or greater, with coordination of their care that goes into the Veterans Affairs system and beyond. So there is a very, very warm handshake now being conducted both into the VA system, as well as other private sector care that is required for these kinds of patients and patients who have other disabilities beyond just brain injury. Dr. Snyder. Dr. Rice, in your written statement I think you refer to the fact that we still have--I don't know if you said too high--but too high levels of smoking amongst our men and women in uniform. You also talk about the fact of the retiree issue we will be taking care of in terms of health care expenses for we hope decades and decades to come, when they live long, long lives of being productive Americans after a military career. The reality is the expenses for our country and their quality of life will not do well if they are smoking as young people in the military. Now, if we can't get that under control, in the controlled situation of the military, I just don't see how we are going to do it. Why are we lagging behind on that? Dr. Rice. Well, it is a complex issue. As you know, there was an Institute of Medicine Report in 2009 that talked about controlling tobacco use in the DOD and in the VA. The Department has been evaluating that very carefully to see which things the Department can enact and undertake on its own and those things for which it may need assistance from the Congress. The Navy--Admiral Robinson can correct me if I misstate this--but the Navy has already eliminated tobacco products from its commissaries. The Army and Air Force have yet to take that step. But we still have pricing for tobacco products in the military exchanges that are below the comparable civilian market. That is one factor. I think by far the most important factor has to do with role modeling for young men and women. Basic training is already a tobacco-free environment. But as soldiers, sailors, airmen, and Marines transition to their first assignments and they see older, particularly non-commissioned officers, who smoke and, by implication, are led to believe that it is okay for them. As you know, nicotine, tobacco products, are viciously addictive and the Department has--or the Military Health Care System has developed a number of smoking cessation programs, so that we work very hard to get people to stop smoking. This is an effort that will continue for years to come. As I say, there are some areas in which we may need your assistance. Dr. Snyder. Are you going to let us know what those areas are? Dr. Rice. Yes, sir. Dr. Snyder. I thank the gentleman. Mrs. Davis. Mr. Fleming. Dr. Fleming. I thank you, Madam Chairwoman. Well, first of all let me say to Admiral Robinson, I was a physician in the Navy some years ago, and served in three stations, enjoyed that, and certainly looked fondly upon those days, certainly in uniform. And then certainly for General Schoomaker and for Admiral Robinson. I have toured and visited with the wounded warriors at Walter Reed and Bethesda, and I am extremely impressed with the facilities there. You all are taking real good care of our wounded warriors. I appreciate that. I am even more impressed with the warriors themselves, the true warrior spirit. They don't talk about what their service-connected disability will be or what their pension is going to be. I am sure it is appropriate at some point in time or in the future that they will explore that. What they talk about, which inspires me, is when they are going to get back to duty and how they are going to get back to duty, what they are going to do, and what is the best way to do that. So I am extremely impressed with that. Now for some questions. Dr. Rice, I have two major military installations in my district: Barksdale Air Force Base and Fort Polk Army post. I am finding in our area that the reimbursement to physicians through TRICARE is oftentimes slow and low, and that creates an access issue. It doesn't seem to be quite as much a problem at Barksdale, because it is near a very large, or certainly a medium-size city where there are many physicians in the private marketplace to choose from. But in a more rural area like Leesville, Louisiana, there are some limitations. So I want to know, as we move forward with new contracts, is that being addressed and how is it being addressed? Dr. Rice. Dr. Fleming, as you know, the reimbursement level for TRICARE is tied to Medicare rates. And so by law, that has where that is. I am a little surprised and disappointed to hear that perception among the providers is that we are slow to pay. We have always prided ourselves on turning around payments very promptly. So if there is some specific information that you have, I would really be eager to look into that to see if we have a systemic problem that we need to fix. That is not the Department's policy. Dr. Fleming. That is more of a perception from history, not necessarily new information. When you say it is tied to Medicare, are you saying it is exactly the same for the same evaluation and management (E&M) codes or the same procedural codes? Or you are saying it is a percent above or a percent less than Medicare reimbursement? Dr. Rice. I have to check that to make sure, but I believe that it is at the same level as Medicare. [The information referred to can be found in the Appendix on page 117.] Dr. Fleming. Okay, great. And certainly for the panel at large, if you can answer this, I am very interested in the electronic medical records. I think that is a very important thing going forward, particularly in terms of quality of care and the special need for continuity of care when you have a worldwide mission such as our military does. Also, the interactivity or, if you will, the ``interfacement'' with the VA system. There have been some problems. I am told about the slowness of performance; that is, when you are connecting on the Internet and getting records, information exchanging, sometimes that can be so slow as to be impractical. There have been some difficulties with the VA and the active duty military systems talking to one another. Can you bring me up to date on that? Dr. Rice. Yes, sir. As you know, the implementation of an electronic health record is an extremely complex undertaking. Through my civilian academic career, I implemented two intensive care unit-based electronic records and two hospital- based, and I swore I would never do that again, but here I am. There are two or three challenges. First, with respect to response time, as you and Dr. Snyder know, we as physicians will sit down with a medical chart and spend 15 minutes going through to find the consultation report or the laboratory result that we want. But let the computer screen sit blank for five seconds, and our perception is it is slow. With that said, there is no question that performance and stability are key issues. Security and scalability are also important issues. We are having an intense effort inside the Department now to examine the underlying architecture for the electronic health record. Then we need to make sure that we build applications that sit on top of that underlying architecture so that they work for the clinicians. Whether it is the nurses, the physicians, the physical therapists, the pharmacists, whatever, it has to work for them. If it does not work for the clinicians, it is not going to work. I think that is a challenge that we have faced by using a system that was originally developed for other purposes and trying to challenge it towards use as an electronic health record. So it is a subject we are actively and vigorously pursuing and hope to have a very clear vector ahead very shortly. Dr. Fleming. Thank you, I yield back. Mrs. Davis. Thank you. Ms. Shea-Porter. Ms. Shea-Porter. Thank you, and thank you all for being here and for the service you are providing our military men and women. I have had great concerns about the open-air burn pits. And so I wanted to ask you, Dr. Rice, because you did put in your testimony the responsibility for public health for the military. You said they have been there for eight years. And I have received a lot of information over the past year or so about the impact and how soldiers have talked about it and complained about it and gone to health-care clinics and are showing up with skin diseases, blood diseases, neurological problems, et cetera. And so I know we have worked on it, we have got something into the last NDA authorization and will continue to do that. But it is a puzzle to me about how this could have gone on for so long. I would just ask you if you would tell me, has this been something that has been an issue for all of you and has it been discussed? And are you keeping the records that you need for these men and women when they return from service and for the next years of their lives, so we can determine if we have had problems with them because of their exposure? Dr. Rice. Thank you for that question. The environmental impact of burn pits and its impact on our service men and women has been a source of concern. Let me ask General Schoomaker. I think your Public Health Command has taken a keen interest in that problem and has been tracking, which happens; is that right? General Schoomaker. That is right. We have a Public Health Command, previously known as the Center for Health Promotion and Preventive Medicine, and the Veterinarian Command now have been combining Army Medicine into a single Public Health Command. Brigadier General Tim Adams commands that and has subject matter experts who have been tracking all of the topics that you have described ma'am. And we can take that question for the record and give you a more detail accounting of the burn pits. [The information referred to can be found in the Appendix on page 117.] Ms. Shea-Porter. Well, I know it is the acknowledgment now that this could be playing a factor in the health problems that some of the service men and women are experiencing. But my concern here is, is there an integrated approach and are we moving fast enough to find ways to substitute some of the products that are being burned in the pits? For example, we do know that we are still burning the plastics openly, and we could use recyclable materials in the kitchens which are producing a great deal of the plastic refuse each day. So can you step it up? And who are you working with? I know your field is medical, but are you talking to others who are responsible for what is being brought onto the base and how it is being disposed of? Are you fully engaged, in other words, because eight years is a long time and some of our soldiers have been exposed twice, three, and four times to this. General Schoomaker. Well, ma'am, certainly there is a good linkage between public health monitoring and all the services and the operational commanders, specifics about the items you just talked about. I can't speak with any real knowledge about that, but, again, I am more than happy to take that question for the record and give you a detailed accounting to tell you what we have done to coordinate with the in-theater operators. Ms. Shea-Porter. I thank you, General, and I am not trying to trap you. I am just trying to nudge everybody to get this taken care of as quickly as possible. Thank you, I yield back. Mrs. Davis. Thank you. Ms. Tsongas. Ms. Tsongas. Thank you all for your testimony. I appreciate the extraordinary range of issues that you have to contend with for our young soldiers, and I appreciate the efforts that you are putting into it. I would like to ask a slightly different question, an outgrowth of Defense Authorization Bill. As we were leading into it, we were hearing that we needed to extend Reserve component access to early eligibility TRICARE from 90 to 180 days prior to mobilization. I think this was an issue that had been around for some time, and the purpose, obviously, being to allow service members with treatable medical conditions access to TRICARE services earlier, in order to decrease the number of medically non-deployable service members. Can you all explain the implementation plan for providing Reserve component access--to try earlier access to TRICARE services in order to meet the provisions of last year's Defense Authorization Bill? Dr. Rice. Yes, ma'am. I would be happy to tackle the first part of that question and then ask my colleagues to amplify. The Assistant Secretary of Defense for Reserve Affairs has the lead on implementing the statutory change, because it is primarily the determination of eligibility. So Reserve Affairs is now preparing the DOD policy and the functional requirements for the system changes have already been developed. So once the personnel have established the eligibility for reservists and updated the Dependent Eligibility Enrollment Reporting System (DEERS) system, the eligibility recording system, then any DEERS-eligible member who presents for care in the military health care system is provided that care. General Schoomaker. Ma'am, I will just reinforce that to say the Army is very, very reliant on its Reserve, National Guard, and the United States Army Reserve for the conduct of the present conflict. At any one time, tens of thousands of our Reserve component soldiers were mobilized for deployment. And one of the important things in eliminating steps in getting Reserve component soldiers ready to be deployed is medical and dental readiness. We know that there are several factors involved in that identification of problems that need to be reversed in the dental and medical arena. A medical problem that may have a solution before a soldier can be deployed or a dental problem that needs some time for fixing, we find that. For a large portion of the Reserve component who may not have health insurance is a consequence of their employment or maybe for students don't have programs available. This is an important incentive for them to be engaged in their Reserves, and it allows us the time necessary to get them fixed before they can go out the door. So, to my knowledge, the program is being implemented and is felt to be a very important adjunct to using the Reserves, as they are being used in the Army today, as an operational reserve rather than a strategic reserve, held only back for the most nation-threatening advance. We currently use them as a very active part of the force. Admiral Robinson. Ditto, from what has been said earlier from the Navy perspective. In addition, as the service member-- the Reserve component service member is transitioning back to the private sector, whatever injuries and illnesses that that individual may have sustained will be evaluated before they are discharged. So the service member will stay on the active roles until we understand what the medical or condition is. From a family point of view, or from the service member transitioning and being able to utilize the TRICARE benefit for the 180 days, that can certainly be given, too. But my point is, if at 180 days there is not an adjudication, there is not some determination of that, then the service member stays and is fully cared for until we can come up with that. Obviously, the issue is for those people who we say, We think we have the answer, but the service member says, I don't think you have the answer yet--and there are a few people that fall under that category--we usually default--from the Navy and from our point of view, I default towards the service member and the care. So we usually back off until we thoroughly understand what the issue is. So we care for those individuals until we have a determination of what is in fact happening. General Green. And the Air Force has exactly that same program. We keep people who have medical conditions on active duty until we have resolved what is going on, and then have a transition assistance management program (TAMP) that allows them up to six months post-release from deployment, if they need that. Your specific question, however, is with regards to 180 days prior. We have tremendous volunteerism in our Guard and Reserve, and actually get great volunteers to serve. I am not as aware of the 180 days prior, and I am not certain that we have the full guidance yet to establish eligibility for that, so I am going to have to take that for the record and get back to you. [The information referred to can be found in the Appendix on page 118.] Ms. Tsongas. Well, thank you all for your testimony. I know that we heard about this issue. I have heard about it quite frequently, and am also hearing that it is not being implemented as quickly as we might have wished. And so I look forward to hearing a little more about your plans to move it forward. Thank you. Mrs. Davis. Thank you. Mr. Heinrich. Mr. Heinrich. Thank you, Chairwoman. And first I want to thank Chairwoman Davis and the members of the committee for allowing me to be here today. Dr. Rice and Surgeons General, as Chairwoman Davis mentioned a little bit ago, I recently introduced H.R. 4923, the TRICARE Dependent Coverage Extension Act. And if this legislation were to pass, it would allow our service men and women the opportunity to provide uninterrupted health care coverage to their children until the age of 26. This is the same opportunity that has been granted to civilians under the recently passed health-care reform legislation that was signed into law last month. And I was hoping that each of you might be able to give me your thoughts on this proposal, and also let me know if the Department of Defense is considering taking any action similar to this legislation that would bring their policies in line with what is now law for civilians. Dr. Rice. Thank you, Mr. Heinrich. We are well aware of the introduction of H.R. 4923, and have begun thinking through how we would implement it if it becomes law. We do not believe that the Department has statutory authority to extend eligibility up to age 26, absent a change in the law. But if it does become law, we have made preliminary estimates about the number of potential enrollees and the estimated average annual cost for those enrollees. Mr. Heinrich. Well, I look forward to getting together with you as well on some of those numbers, because that would be very helpful for us as well. Are there any other instances that any of you have found, where the rest of the country will have benefits now that are incongruous or inconsistent with what you provide currently under the TRICARE system? Dr. Rice. No, sir. I am not aware of any others. Mr. Heinrich. Thank you very much. I yield back. Mrs. Davis. Thank you. I wanted to go back to my question at the end of the first round and just ask, you know, as we look to the future and we are looking at what makes the best sense for our military health care system, what do you think that mix should be? There is always an ideal. But what is reasonable? Where should we be headed? Dr. Rice. Well, my own view---- Mrs. Davis. Or stay where we are? Dr. Rice. My own view is, as you identified in your opening comments, the purchase care system was originally intended to fill gaps. And the direct care system, I think many of our beneficiaries, if the system is convenient and accessible to them, many of our beneficiaries clearly prefer to be cared for in the direct care system. The challenge, as you pointed out, has been that during this eight year conflict, their primary care providers are deployed or transferred. And our primary focus has to be on the active duty service members. The question of what is the right mix is an intriguing one and can be looked at, in my view, from two or three different perspectives. One is, are we thinking about this from a cost perspective? The other is, are we thinking about this from the desire of the beneficiary population, where they would most likely be seen? And the third aspect that has to be considered is, what is the right mix for the training and education of the next generation of active duty--of military providers, whether nurses or physicians. I am not sure there is a single right answer. There is probably an optimum answer. It is one of the things that we hope to influence. I am not sure that we can control it, but we certainly hope to influence it with the next generation of TRICARE contracts. General Schoomaker. I think we all have pretty strong feelings about this, so I will be as brief as I can. But I think this is one of the central issues that we are all struggling with. And I would point to the recent Military Health System Conference that was conducted in January, in which all three of us and Dr. Rice's predecessor, Ellen Embrey, spoke; and we brought in national experts like Don Berwick, and Jack Wenberg, and John Cortezy and others to talk about the challenges that we face not just in the military health care system, but in the country at large. And I think that what we in the military are focusing upon are some of the central themes in a real health-care reform package, which is evidence-based practices, which is looking at outcomes of care rather than just processes of care. And I alluded earlier in my comments to an effort that we have undertaken now into its, probably, fifth or sixth year within Army Medicine, pioneered it in the southeast, of a performance-based budget program that links incentives to outcomes of care, evidence-based practices, and improvements in Healthcare Effectiveness Data and Information Set (HEDIS) measures, the measures of population health, individual health, and compliance with evidence-based practices for such things as diabetes and asthma and the like. And this has shown very positive results. I think that is one that has got to be a major part of the centerpiece of what we do. We also, I think, universally agree that we need a very robust TRICARE system that is centered around a primary care- based system of the patient- and family-centered medical home process that gives continuity, it gives a site for tailorable, individuated care, and controls the hemorrhage or leak of care into the network. We have got to look very carefully at where that cost is coming from. Frankly, Army Medicine over the last several years has created more capacity. In the last year and a half or so, we have conducted about 1 million additional appointments. And we are continuing to bring more people into the direct care system run by the uniformed side. The problem that we have is that growth, especially in the white space between large installations and large metropolitan centers where we have a very robust system of health care for the direct care system, demand in that white space is increasing as we use Reserves more and as our TRICARE for Life program grows. So we are working very hard, internal to the services, to accommodate more and provide greater capacity. And I think we all agree very much that maintaining a very robust direct care system is one of the centerpieces based upon real reform of the health care. Mrs. Davis. Thank you. Admiral Robinson. I think that what Dr. Rice and General Schoomaker said is right. I am going to come back to the private sector care and the direct care. It is 67 and 33 percent respectively. I think that the problem is, to some extent, that there is a wall between the two care systems. The problem is that there is the direct care system and the private sector care system that TRICARE Management Activity (TMA) helps to build through our networks, and the network providers do an excellent job, but we are separated. We need a care system in which the direct care, the uniformed services are directly aided by the private sector care. They are actually a part of our system. And we can utilize them not only around our medical centers and hospitals, but in the white spaces, too. And the white space is the one area that is harder to get to, so I recognize that private sector care may be the method. We can still do a lot with the private sector care and how we process TRICARE, the types of forms that we use. If we could standardize in terms of, you know, a military medical health care formed by the different forms that we use. But I will get back to this to only say that the direct care system and the private sector care system are separate now in the sense that the monies that go into private sector care must pay bills from the health affairs perspective. I don't disagree with that. But there is not a lash-up between the two systems that really help us provide the care that we need. I think that is the biggest thing that the new contracts--and I am thinking in terms of the T-4--could possibly do that would be revolutionary, in my opinion, for military medicine. Mrs. Davis. General Green, did you want to add anything? General Green. I would. Actually, the reality of our situation is we are the most distributed system of any, with 75 bases and about 80 clinics out there. As medicine has changed over the years and we have seen higher technology and, therefore, larger populations in order to support different specialties, what we have seen is we couldn't always maintain hospitals in these small areas. Average wing for us is about 6,000 people, with families maybe 12,000 to 15,000. It is very difficult to support specialty mix. And so the TRICARE contractors in those areas where we have small populations are really the only way to seek that care. In other areas where we have larger populations and where we have military bases with hospitals, I would love for us to get 100 percent of that care. And that is what Admiral Robinson is talking to, where we try to bring some of the people who are in surrounding areas to our facilities. I think that it is unreasonable for us to think that we would ever be able to provide primary care perhaps to 100 percent of that population, but there are ways that we can reduce federal costs by working arrangements with HMOs, with the VA, even with university partners, wherein either we bring our patients back to our facilities if we are in the area, or, in many cases we take our professionals and work in their facilities so that we can actually maintain skills and be ready for wartime missions. And so I guess I would tell you that it is a mix. In places where we are in rural settings, we really rely on the TRICARE contractors and the network. And so the mix is going to be different. In places where we have hospitals, we should be trying to bring everything that we possibly can back into the hospital to maintain currency. So my goal would be in larger population centers where we have hospitals, to gain 100 percent of the market; and in places where we have clinics, the mix that you described may be real. Mrs. Davis. I appreciate all of your responses. What is obviously important here is that people are working hard, focusing on this and really trying to address it. And the other reality, of course, is there are a lot of other things people are working on. And we need to look to the Defense Military Affairs and figure out whether we have got the people there that are trying to address these issues. And one of the concerns that I think we have is that there haven't been the kind of political appointees that are there in place, nor are the nominations there. And I would think that that is a vital part of what we are talking about and that we do need to get moving with those. Dr. Rice. Dr. Rice. I agree with that. Mrs. Davis. I know you do. Do you have any suggestions? We are open. We are certainly interested. Mr. Wilson. Mr. Wilson. In fact, Dr. Rice, with all the hats you are wearing, back to your TRICARE hat. My understanding, the number of reservists who have taken advantage of TRICARE Reserve Select, TRS, is lower than the Department of Defense anticipated. What factors have contributed to the low take rate? What actions has DOD taken to make the program more attractive? Are members of the Reserves, who may want to enroll in TRICARE Reserve Select, having difficulty finding TRICARE standard providers? Dr. Rice. Let me defer to my colleague, General Schoomaker, who has insight on that. General Schoomaker. Yes, sir. I can answer that. You are right; we are seeing, overall, a rate of use in the Army of TRICARE Reserve Select of only about six percent or so. But it is growing very quickly. And in part, it is based upon the observation that those that don't have a health-care program, we have been quite reluctant to impose a requirement that they maintain medical readiness as a condition of their employment, even though it is, in the Army regulation, already there. In other words, if you are in the Reserves, we expect you to be dentally and medically ready to be deployed. In the past, because we could not offer good programs necessarily, or couldn't require someone who may not have an employment health plan--or maybe a student, or be unemployed--to have a plan to cover them, commanders were very reluctant on the Reserve side to impose or hold them to that standard. I think with the TRICARE Reserve Select program, which is very robustly supported by the military and by Health Affairs, and now with the growing availability of plans under health- care reform and the like, we are putting teeth into that. And I think you will see a growing use of TRICARE Reserve Select as we hold soldiers, appropriately, to the requirement that they be medically fit. Without abusing my executive privilege here, I just want to respond to one last thing on this last item, because we are also passionate about what we can do to sustain this program that we have. We have a very high-quality program. To answer Mr. Heinrich's question earlier, I don't see us having a lesser plan. I think we have a superior plan to the average American right now, and we all want to sustain this. But I think historically what we have focused on is business rules to control costs, and most of us now I think feel very firmly that what we have to focus on is good clinical practices and outcomes. And if we focus on that, the cost will be stabilized and possibly even be reduced. Mr. Wilson. And I want to indeed thank you. I can remember during the debate that we had in the Education and Labor Committee, that as I was working for an amendment to preserve and protect TRICARE, it was brought to my attention--and I can remember very well the organization, it was called the Wilson Institute, and that they had done a study of satisfaction by persons with their health insurance policies, and TRICARE for 9.2 million was at the tops. And of course, I will never forget the Wilson Institute. I was unjustly accused, Madam Chair, of making up an organization, but it actually exists. Dr. Rice, again, or whoever, the Department of Defense has estimated the resulting savings would be $12 billion, fiscal years 2010 to 2015, by obtaining federal pricing discounts for TRICARE prescriptions dispensed by retail pharmacies. Is DOD on track to obtain these estimated savings? Are all drug manufacturers complying with requirements? What steps are underway to ensure that the required federal pricing discounts are obtained? Dr. Rice. Mr. Wilson, we are on track to realize that outcome. There is still--I think I have this right, and if not, I will certainly correct it. I believe there is still a pending appeal, but the actions taken thus far have indicated that the drug manufacturers are prepared to comply with the federal pricing, and we anticipate realizing those savings. Mr. Wilson. It is good to hear something is on track. And in regard to TRICARE in general, any way that I and our subcommittee can be of assistance, we want to work with you. Thank you. Dr. Rice. Thank you, sir. Mrs. Davis. Thank you very much. Thank you, Mr. Wilson. And perhaps I will just go back to one of the questions he raised earlier. Do you think there is any confusion or discomfort believing that perhaps the Secretary of Defense is not in charge of Military Health Affairs? Do you have any? Dr. Rice. I don't think so. I think Secretary Gates has it pretty clearly in his mind that he is. And I certainly have seen some correspondence from Secretary Sebelius where she has indicated that management of the Defense Health Program is under the supervision of the Secretary. Mrs. Davis. Because I know that has been raised in other circles as well, and I appreciate Mr. Wilson raising it. If I could, just quickly, I know we are going to have votes in a few minutes. The budget was characterized as being fully funded. And if I could go to you first perhaps, General Green, is that an accurate statement from your vantage point? General Green. Yes, it is an accurate statement. We are in very good shape for 2011. Mrs. Davis. Admiral Robinson. Admiral Robinson. Yes. Navy Medicine is fully funded. General Schoomaker. Yes, ma'am. Nothing crossed. Mrs. Davis. You don't have another list out there somewhere? Okay. One of the numbers that jumped out at me was just the research and development dollars going down somewhere in the neighborhood of about 61 percent, I believe, partly because there was a reduction in medical research and development (R&D). And I think that reflects dollars, $125 million, transfer of research to Defense Advanced Research Projects Agency (DARPA). But we don't really see an accompanying increase in DARPA's program to accommodate that. Dr. Rice. Yes, ma'am, I can speak to that. There is a decrement of 125 million in the research, development, testing and evaluation (RDT&E) priority elements for fiscal year 2010. There were decisions made in the Department in the fall of 2008 which enhanced the medical R&D budget by about $375 million a year, with the entire new budget going into the Defense Health Program RDT&E budget for fiscal 2010. There was an additional Department decision for fiscal 2011 and out that was that $125 million of that annual cost was to be contributed by DARPA, but under their control; that is, not transferred from DARPA to DHP, which reduced the new budget burden to the Department by 125 million. This would mean that DARPA would have to increase their medical RDT&E spending from about 144 million by an additional 125 for fiscal 2011. And this is a compliance issue that is under that defense development research and engineering oversight. There is programmatic and regulatory risk when the Defense Health Program RDT&E advanced on the portfolio is dependent on the science and technology transitions from another agency within the Department which is more focused on very high-risk and very high-payoff investments. This is under discussion in the Department, but it is that decision that results in the number that you cited. Mrs. Davis. Where would we see the greatest shortfall if somehow this isn't worked through, and what kind of R&D? Prosthetics? Or what kinds of things could that affect? Dr. Rice. It is not clear to me, at least at this point. It could be in a variety of areas, from basic research to information technology research to advanced battlefield efforts. Mrs. Davis. Okay. Thank you very much. Just one follow-up question to earlier discussion about electronic records. And the Virtual Lifetime Electronic Record, VLER, was announced by Secretaries Gates and Shinseki together that it would be this single record. But now I understand that the Department submitted a reprogramming request that would take $42 million from the Defense Health Program to establish the Office of the VLER. So why is the Defense Health Program only paying for that? Dr. Rice. The VLER is in part an electronic health record, but it also in part has to do with personnel records. So that comes outside of the Defense Health Program. Mrs. Davis. Is there a VA piece to this as well then? Dr. Rice. I am sorry? Admiral Robinson. The VLER piece would be actually--and I am probably the least information technology (IT) savvy of this group--but there will be a VA piece with this. And the VLER system will work with an electronic health record system, in this instance AHLTA, and with the VA Vista, to hook us to the commercial sector so that we can transpose that record to hospitals that are not DOD. So there are several sections that go with this. And I can't tell you much more, but that I do know. Mrs. Davis. All right. We hope that comes together and that works out. And I don't really expect you to answer this in any detail, but throughout all of the testimony and through all of the discussions that we know in terms of health care nationwide, the concern about unmanned positions, any number of specialties, practitioners that are needed in this country. Are people thinking out of the box about this enough? Because we know that bonuses are a good idea. We know that there are recruitment strategies, some of which have been very helpful, and I know you addressed that. But it also feels as if we have a lot of people in our country who would have an interest if we actually did something quite substantive in the country. People may not have agreed with the war on poverty, but at that time there were many, many people, myself included, who were incentivized to go into helping professions. And I am wondering now whether the military plays such a large role in this, and particularly among our men and women who are coming back from the war theater and have great, I think, aptitude to be able to do this with the right encouragement, there are some programs out there. Are we spending enough time and effort into trying to really address this problem? Dr. Rice. With my other hat on, as president of the university, I spend a lot of time thinking about what our health-care system, what our health-care workforce is going to look like 15 or 20 years from now. We have an enormous challenge in the country as a whole, of which the military system is just a small part. And that is that the science and mathematics and engineering preparation in our middle schools and high schools has not helped focus our young people on careers in science and technology. And there are a number of misperceptions in students. In my previous job at the University of Illinois, I spent a lot of time going out and talking to middle school and high school students about careers in health care. And there were three things that struck me about what they would say about why they weren't thinking about health care. The first is that they viewed us as low tech. And at times I was signing very large purchase orders for very expensive pieces of equipment. That didn't resonate quite right to me, but that was their perception. The second thing is that if you have dealt with teenagers lately, you know that they are not interested in hierarchies. And the provision of health care is, at least as currently practiced, hierarchical. And the third factor that turned them off was we have schedules. And they are not interested in schedules. So I think we are going to have to rethink how we deliver health care in a pretty dramatic way, exactly as you allude. We are looking at--by the year 2020, it is estimated we will be 1 million nurses short of what we will need. And as I get into my old age, that becomes more and more of an issue for me. We are looking at a substantial shortfall in the number of physicians. And importing them from other countries is not the answer. That simply is not an ethical or moral approach to solving that problem. So I do think it is an issue that we need to spend a lot of time thinking on. Mrs. Davis. I was just going to mention that in last year's bill there was a provision for undergraduate education and for encouraging more students and scholarships. And I don't know whether that is anything that is moving along. General Schoomaker. We have a pretty successful and robust program right now that I think is now being very successfully executed. I certainly agree with everything that Dr. Rice--who has a very long and distinguished career in medical education and the provision of the workforce. We are looking at, I think with the increasing number of women going into medicine and health professions who want to do job sharing, that want to have shifts--and I don't think it is restricted to women only in this perspective--who want to have a career in which they can move in and out of the workforce more agilely. We are looking at a continuum of care between the active component and Reserve component, where you can turn on and turn off that kind of a career. And, quite frankly, even from my experience among children, you have got to begin engaging children who are going into these technical fields, in middle school and sometimes earlier. So programs that are engaging earlier and earlier and getting mentor programs and the like. But I would submit in closing, although this really doesn't address the problem of the workforce per se, that the real out- of-the-box thinking that we have to adopt in this country--and we are in the military--is one that shifts the paradigm from treating disease and treating injury after it has occurred, to preventing disease and preventing injury. I mean at Fort Jackson, South Carolina right now, we pin a hip fracture on a young woman, on average, once a week. Once a week. These are 18- and 19- and 20-year-old women who come into the force, who begin active lives after being sedentary, who are suffering from bone washout from drinking phosphate-rich sodas and being sedentary before they come in. And now we are getting hip fractures in basic training. We have a problem in this country in the overall health and fitness of the population and with growing childhood obesity, the tobacco problems that you addressed earlier. We have got to shift the paradigm away from one of disease and injury treatment to one that prevents it from the get-go. Mrs. Davis. Admiral Robinson, we have to go vote. But if you have a quick comment, that would be great. Admiral Robinson. One other thing. Actually, this is General Green, and that is, he said something the other day that was so intriguing to me; and that is, take enlisted personnel and actually get them certified to do mental health. So I think--and this happens, this works. But I think my addition to everything else is that we need to think in terms of how we provide the care. It needs to be preventative and wellness, and then we need to think in terms of how that care is given. Thank you very much. General Green. And just very quickly, I really do think we need to think out of the box. We are increasing our number of practitioners and extenders. We are looking at the mix to get the right team, using medical home to do outreach. For non- enrolled care, we think emergency rooms are going to be overrun in the near future because of the lack of primary care. We are preparing fast tracks in acute-care clinics to make sure we are ready for the increased workload. And I do think we do need to think beyond traditional mental health and look at the licensed medical counselors, to see whether or not we can train some of our enlisted force. Just like we are bringing enlisted to nurses, we may be able to increase our diversity by bringing enlisted into medical schools as they are prepared. So we are doing a lot of things to try to leverage our enlisted force to try to create new venues of care. Mrs. Davis. Thank you very much. Thank you to all of you. I mentioned earlier, it is the Military Undergraduate Nurse Training, section 525, from the former authorization that I was inquiring about. Dr. Rice. Yes, ma'am. There is a report due to Congress. The three military nursing chiefs are actively working on that and anticipate having a report to you on time. Mrs. Davis. Great. Thank you very much to all of you. I hope that the hearing was helpful to you as well. It was to us. And we look forward to the next one. Thank you very much. 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DAVIS Dr. Rice. The initial report on progress made in undertaking actions to enhance the Military Health System (MHS) and improve the TRICARE program as required in Section 721 of the National Defense Authorization Act for Fiscal Year 2010 has been drafted and is in the coordination process. A high-level working group was formed to address the report requirements and included representatives from a number of MHS entities. The initial report describes the progress made and future plans for improvement of the MHS. DoD senior leadership provided further guidance to the subject matter experts working on the areas Congress requested DoD study and consider planning to improve access to care. Note: Representatives from MHS entities include:Chief, Policy and Operations Branch, TRICARE Policy and Operations Directorate (TPOD) Director, DoD/VA Program Coordination Division Chief, Purchased Care Systems Integration Branch, TPOD Deputy Chief, Human Capital Office OASD(HA) Program Director, Health Budgets and Financial Plans OASD(HA) Director, Operations Division, TPOD Director, Strategic Communications and Transformation OASD(HA) Director, Population Health and Medical Management, Office of the Chief Medical Officer Chief, Program Evaluation Branch, TPOD Chief, TRICARE Operations Center Deputy Chief, TRICARE Division Army Medical Department (AMEDD) One Staff Offices of the Service Surgeons General [See page 12.] ______ RESPONSE TO QUESTION SUBMITTED BY MS. SHEA-PORTER General Schoomaker. Surveillance documents, laboratory data, and field notes are available for future use to investigate the occupational and environmental health risks of respective burn pits. The US Army Public Health Command (Provisional) is the designated DoD lead agent for archiving all deployment occupational and environmental health (OEH) surveillance data for US military operations. It maintains the DoD OEH surveillance documents in Internet-based unclassified and classified document libraries identified as the deployment OEH surveillance data portal. US Army Public Health Command (Provisional) has a separate DoD database for archiving all of the laboratory data and associated field notes for deployment samples (e.g., air, water, soil) sent to the Army Public Health Command for analysis. This sample database is identified as the Defense Occupational and Environmental Health Readiness System--Environmental Health Module. [See page 19.] ______ RESPONSE TO QUESTION SUBMITTED BY DR. FLEMING Dr. Rice. By law, Title 10 United States Code Section 1079(h)(1), TRICARE's payment for a charge for services by an individual health care professional must be equal to an amount determined to be appropriate, to the extent practicable, in accordance with the same reimbursement rules as apply to payments for similar services by Medicare. Statute permits TRICARE reimbursement rates to be less than Medicare rates when providers have agreed to give network discounts. In addition, there is statutory authority to set TRICARE rates above Medicare rates if necessary to obtain an adequate network of providers or to prevent severe access to care deficiencies. [See page 17.] ______ RESPONSE TO QUESTION SUBMITTED BY MS. TSONGAS General Green. Based on my understanding of NDAA 2010, Section 702, when Guard/Reserve members receive federal delayed-effective-date active duty orders for more than 30 consecutive days in support of a contingency operation, the service member and their family are eligible for TRICARE. TRICARE coverage will begin the date the order was issued or 180 days prior to activation date, whichever is later. Current TRICARE coverage is for 90 days prior to activation date. As Dr. Rice mentioned, Reserve Affairs will be sending out the DOD policy to enforce this change. Although eligibility determination belongs to Air Force Manpower & Personnel (AF/A1), the Air Force Medical System (AFMS) will work with AF/A1 to ensure full compliance across the Air Force. We have verified that the implementation date is projected for 1 Oct 10. Once implemented, Guard/Reserve members will need to register their family members and their records in the Defense Enrollment Eligibility Reporting System (DEERS) through the nearest service personnel office, ID card-issuing facility or DEERS Support Office. Once eligibility verification is made by AF/A1 and is accurately reflected in DEERS, the AFMS is prepared to provide the medical care to all eligible members and their dependents. [See page 21.]