[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

[H.A.S.C. No. 112-120]

HEARING
ON
NATIONAL DEFENSE AUTHORIZATION ACT
FOR FISCAL YEAR 2013
AND
OVERSIGHT OF PREVIOUSLY AUTHORIZED PROGRAMS

BEFORE THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

SECOND SESSION

__________

SUBCOMMITTEE ON MILITARY PERSONNEL HEARING

DEFENSE HEALTH PROGRAM

BUDGET OVERVIEW

__________

HEARING HELD
MARCH 21, 2012

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SUBCOMMITTEE ON MILITARY PERSONNEL

JOE WILSON, South Carolina, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
MIKE COFFMAN, Colorado ROBERT A. BRADY, Pennsylvania
TOM ROONEY, Florida MADELEINE Z. BORDALLO, Guam
JOE HECK, Nevada DAVE LOEBSACK, Iowa
ALLEN B. WEST, Florida NIKI TSONGAS, Massachusetts
AUSTIN SCOTT, Georgia CHELLIE PINGREE, Maine
VICKY HARTZLER, Missouri
Jeanette James, Professional Staff Member
Debra Wada, Professional Staff Member
James Weiss, Staff Assistant

C O N T E N T S

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CHRONOLOGICAL LIST OF HEARINGS
2012

Page

Hearing:

Wednesday, March 21, 2012, Defense Health Program Budget Overview 1

Appendix:

Wednesday, March 21, 2012........................................ 23
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WEDNESDAY, MARCH 21, 2012
DEFENSE HEALTH PROGRAM BUDGET OVERVIEW
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
Wilson, Hon. Joe, a Representative from South Carolina, Chairman,
Subcommittee on Military Personnel............................. 1

WITNESSES

Green, Lt Gen Charles B., USAF, Surgeon General, U.S. Air Force.. 10
Horoho, LTG Patricia D., USA, Surgeon General, U.S. Army......... 5
Nathan, VADM Matthew L., USN, Surgeon General, U.S. Navy......... 7
Strobridge, Col Steve, USAF (Ret.), Co-Chair, The Military
Coalition...................................................... 11
Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for
Health Affairs, U.S. Department of Defense..................... 4

APPENDIX

Prepared Statements:

Davis, Hon. Susan A.......................................... 28
Green, Lt Gen Charles B...................................... 109
Horoho, LTG Patricia D....................................... 55
Nathan, VADM Matthew L....................................... 83
Strobridge, Col Steve........................................ 129
Wilson, Hon. Joe............................................. 27
Woodson, Hon. Jonathan....................................... 29

Documents Submitted for the Record:

Statement of the National Military Family Association........ 169
Statement of the Reserve Officers Association of the United
States and the Reserve Enlisted Association................ 161
Statement of The Military Coalition.......................... 196

Witness Responses to Questions Asked During the Hearing:

Dr. Heck..................................................... 223

Questions Submitted by Members Post Hearing:

Ms. Bordallo................................................. 237
Mrs. Davis................................................... 227
Mr. Jones.................................................... 237
Mr. Loebsack................................................. 241
DEFENSE HEALTH PROGRAM BUDGET OVERVIEW

----------

House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Wednesday, March 21, 2012.
The subcommittee met, pursuant to call, at 3:10 p.m. in
room 2212, Rayburn House Office Building, Hon. Joe Wilson
(chairman of the subcommittee) presiding.

OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM
SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

Mr. Wilson. Ladies and gentlemen, good afternoon. I would
like to welcome you to a meeting of the Military Personnel
Subcommittee. This will be a hearing on the Defense Health
Program budget overview. And I want to thank people for
attending today and certainly thank our witnesses.
Today the subcommittee meets to hear testimony on the
Defense Health Program for fiscal year 2013. I would like to
begin by acknowledging the remarkable military and civilian
medical professionals who provide extraordinary care to our
service members and their families and veterans here at home
and around the world, often in some of the toughest and most
austere environments. I have firsthand knowledge of their
dedication and sacrifice from my son, Addison, who is an
orthopedic resident in the Navy and who has served in Iraq.
Even in this tight fiscal environment, the Military Health
System must continue to provide world-class health care to
beneficiaries and remain strong and viable and fully funded in
order to maintain that commitment. The Department of Defense
has proposed several measures aimed at reducing the cost of the
Defense Health Program. Unfortunately, all of the proposals
simply shift the cost burden to TRICARE fee and cost-share
increases to not only our working-age retirees but, for the
first time, to our most senior military retirees.
The subcommittee has a number of concerns about the
Department's initiatives. To that end, we would expect the
Department's witnesses to address our concerns, including that:
first, the proposed TRICARE Prime fee increases, which have
been characterized by military leaders as modest, will raise
fees in fiscal year 2013 by 30 to 78 percent over the current
rate. Over 5 years, the fees would increase by 94 to 345
percent.
The proposed increases may be designed to cause military
retirees to opt out of TRICARE, choose a TRICARE option that is
less costly to DOD, or decrease their use of TRICARE. The
proposal would establish an annual enrollment fee for retirees
who use TRICARE Standard and Extra and, for the first time,
would require our most senior retirees to pay an enrollment fee
for TRICARE For Life.
What is not clear to me is why, aside from the revenue
being generated from the fees, DOD believes enrolling these
participants is necessary. What benefit can these individuals
expect to receive from enrolling?
And, finally, 60 percent of the estimated cost savings from
TRICARE proposals is based on military retirees opting out of
TRICARE or using it less. Frankly, I think this plan is
wrongheaded.
Finally, I would like to hear from the military surgeons
about efforts they are taking within the military departments
to increase the efficiency of the military healthcare system
and reduce cost. I would also like the military surgeons' views
on areas where additional efficiencies can be gained across the
DOD health system. I hope our witnesses will address these
important issues as directly as possible in their oral
statements and in response to Member questions.
Before I introduce our panel, let me offer Ranking Member
Susan Davis of California an opportunity to make her opening
remarks.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 27.]

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

Mrs. Davis. Thank you, Mr. Chairman.
I look forward, as well, to hearing from Assistant
Secretary Woodson on his views on the status of the military
healthcare system, particularly the TRICARE system, and the
Department's efforts to improve the care that we are providing
to our service men and women, retiree survivors, and their
families.
I am also looking forward to hearing from our Surgeon
General, General Green. Welcome back, and thank you for your
service.
Admiral Nathan and General Horoho, welcome. I believe that
this is your first testimony before the committee. We are happy
to have you. Thank you for your service. I know that you will
continue the laudable efforts of your predecessors.
And, finally, Mr. Strobridge from The Military Coalition,
welcome. We appreciate your joining us to share your views, as
well.
The last decade of conflict has been weathered on the backs
of our remarkable forces, in particular those who serve in our
military healthcare system. The constant demands borne by those
in uniform and those in support of them have yielded incredible
successes on our battlefields--our battlefields abroad and at
home here in the States.
While I suspect that much of this hearing will focus on the
healthcare proposals of the Department of Defense, this hearing
should also provide the members of the subcommittee an
opportunity to understand and to examine some of the difficult
challenges facing the military healthcare system, from our
reductions in resources to meeting the ever-increasing demand
for mental health services.
Our military personnel and their families consistently
exceed expectations under tremendous strains and pressures. And
their access to quality health care should not be added to
their plights. I look forward to your testimony on how we are
caring for our service members and their families, particularly
our injured, ill, and wounded, and how we can continue to
improve our healthcare system in the new fiscal environment
that we will be facing.
Thank you all.
Thank you, Mr. Chairman.
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 28.]
Mr. Wilson. Thank you, Ms. Davis.
We have five witnesses today. We would like to give each
witness the opportunity to present his or her testimony and
each Member an opportunity to question the witnesses. I would
respectfully remind the witnesses that we desire you to
summarize to the greatest extent possible the high points of
your written testimony into 3 minutes. I assure you your
written comments and statements will be made part of the
hearing record.
At this time, without objection, I ask unanimous consent
that additional statements from the Reserve Officers
Association, the National Military Family Association, and The
Military Coalition would be included in the record of this
hearing.
Without objection, so ordered.
[The information referred to can be found in the Appendix
on pages 161, 169, and 196, respectively.]
Mr. Wilson. Let me welcome the panel.
Welcome back, Dr. Jonathan Woodson--thank you--as Assistant
Secretary of Defense for Health Affairs. And we have Lieutenant
General Patricia D. Horoho, the Surgeon General of the
Department of the Army--thank you for being here; and Vice
Admiral Matthew L. Nathan, Surgeon General, Department of the
Navy; and Lieutenant General Charles Bruce Green, Surgeon
General, Department of the Air Force; and Colonel (Ret.) Steve
Strobridge, co-chairman, The Military Coalition.
Before we begin, I would like to recognize General Horoho
and Admiral Nathan and extend a special welcome to them, as
this is their first appearance before the subcommittee since
becoming Surgeon Generals. Congratulations to both of you.
And I want to join with a fellow nurse of General Horoho,
and that is Jeanette James. She is so excited, rightfully so,
of you being the first nurse to serve as Surgeon General. So
congratulations, and I am very proud for you.
General Green, I understand you are retiring--at an early
age--this summer, so this may be your last DHP [Defense Health
Program] hearing. Your leadership has been instrumental in the
tremendous advances made in the aeromedical evacuation system
that is key to the extraordinary survival rate of our wounded
and injured around the world. Thank you, and best of luck to
you.
I also want to announce that, to ensure that Members have
an opportunity to question our witnesses, we will use the 5-
minute rule when recognizing Members for questions.
And we will now begin with the testimony from the
witnesses. And we have Jeanette James keeping the time, and she
is above reproach. So when she says time is up, we will all
follow through. So thank you so much.
Dr. Woodson.

STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT SECRETARY
OF DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE

Secretary Woodson. Thank you, Mr. Chairman, Ranking Member
Davis, members of the committee. Thank you for the opportunity
to appear before you today to discuss the future of the
Military Health System, in particular our priorities for this
coming year.
Over the last 10 years, the men and women serving in the
Military Health System have performed with great skill and
undeniable courage in combat. Their contributions to advancing
military and American medicine are immense. The Military Health
System's ability to perform this mission and be able to respond
to humanitarian crises around the world is unique among all
military and non-military organizations on this globe, and I am
committed to sustaining this indispensable instrument of
national security.
One of the most critical elements of our strategy is to
ensure the medical readiness of men and women in our Armed
Forces. We are using every tool at our disposal to assess the
service member's health before, during, and following
deployment from combat theaters. And for those who return with
injuries and illnesses, we continue to provide comprehensive
treatment and rehabilitation services supported by medical
research and development portfolios appropriately focused on
the visible and invisible wounds of war.
Concurrent with our mission of maintaining a medically
ready force is our mission of maintaining a ready medical
force. This ready-medical-force concept has many interdependent
parts. It requires our entire medical team to be well trained.
It requires development of our physicians in active accredited
graduate medical education programs. It requires our military
hospitals and clinics to be operating at near-optimal capacity.
And for our beneficiaries, it requires an active decision to
choose military medicine as their preferred source of care.
To meet these readiness imperatives means we need to
compete with the rest of American medicine to recruit and
retain top talent, to provide state-of-the-art medical
facilities that attract both patients and medical staff, and to
sustain a high-quality care system.
The budget we have proposed provides the resources we need
to sustain the system. As we maintain our readiness, we must
also be responsible stewards of the taxpayers' dollars. The
2011 Budget Control Act required the Department to identify
$487 billion in budget reductions over the next 10 years.
Healthcare costs could not be exempt from this effort.
The Military Health System is undertaking four simultaneous
actions to reduce costs: one, internal efficiencies to better
organize our decisionmaking and execution arm; two, a
continuation of our efforts to appropriately pay providers in
the private sector; three, initiatives that promote health,
reduce illness, injury, and hospitalization; and four, proposed
changes to the beneficiary cost-sharing under TRICARE.
The military and civilian leaders in the Department
developed these proposals and have publicly communicated their
support for these proposals to you in writing and in person. I
want to identify the core principles to which we adhered to in
developing these proposals.
We believe the TRICARE benefit has always been one of the
most comprehensive and generous health benefits in our country,
and our proposals keep it that way. In 1996, military retirees
were responsible for about 27 percent of overall TRICARE costs.
In 2012, the percentage share of costs borne by beneficiaries
has dropped to a little over 10 percent of overall costs. If
these proposals we put forward are accepted, beneficiary out-
of-pocket costs will rise to 14 percent of costs by 2017. This
is about half of what beneficiaries experienced in 1996.
Second, we have exempted the most vulnerable populations
from our cost-sharing changes. Medically retired service
members and the families of service members who died on Active
Duty are both protected under this principle. Additionally, we
have introduced cost-sharing tiers based upon retirement pay,
reducing the increases for those with lower retirement pays.
And this was uniform and line-led.
Mr. Chairman, we recognize the concerns the members of the
committee and the beneficiary organizations have voiced
regarding these proposals. I want to emphasize that these
proposals are targeted to mitigate the burden on any one
particular group of beneficiaries while simultaneously meeting
our congressionally mandated cost-saving responsibilities under
the Budget Control Act.
We have also recently submitted to Congress the Secretary's
recommended path forward on how we reorganize the Military
Health System. We have learned a great deal from our joint
medical operations over the last 10 years, and we recognize
that there is much opportunity for introducing even a more
agile headquarters operation that shares services and
institutes common business plans and clinical practices across
our system of care.
The budget we have put forward for 2013 is a responsible
path forward to sustaining the Military Health System in a
changing world and recognizes that the fiscal health of the
country is a vital element in our national security. I am proud
to be here with you today to represent the men and women who
comprise the Military Health System, and I look forward to your
questions.
[The prepared statement of Secretary Woodson can be found
in the Appendix on page 29.]
Mr. Wilson. Thank you very much.
And Dr. Horoho.

STATEMENT OF LTG PATRICIA D. HOROHO, USA, SURGEON GENERAL, U.S.
ARMY

General Horoho. Chairman Wilson, Ranking Member Davis, and
distinguished members of the committee, thank you for providing
me this opportunity to share with you today my thoughts on the
future of Army Medicine and highlight some of the incredible
work being performed by dedicated men and women, with whom I am
honored to serve alongside.
We are American's most trusted premier medical team, and
our successful mission accomplishment over these past 10 years
is testimony to the phenomenal resilience, dedication, and
innovative spirit of soldier medics, civilians, and military
families throughout the world.
From July to October of 2011, I was privileged to serve as
the International Security Assistance Force Joint Command's
special assistant for health affairs. My multidisciplinary team
of 14 military health professionals conducted an extensive
evaluation of theater health service support to critically
assess how well we were providing health care from the point of
injury to evacuation from theater. It cannot be overstated that
the best trauma care in the world resides with the U.S.
military in Afghanistan and Iraq.
The AMEDD [United States Army Medical Department] is
focused on building upon these successes on the battlefield as
we perform our mission at home and is further cementing our
commitment to working as a combined team anywhere, anytime. We
are at our best when we operate as part of the joint team, and
we need to proactively develop synergy with our partners as
military medicine moves toward a joint operating environment.
Continuity of care and continuity of information are key to the
delivery as DOD [Department of Defense] and the VA [Department
of Veterans Affairs] team provides care.
There are significant health-related consequences over the
10 years of war, including behavioral health needs, post-
traumatic stress, intensive care of burns or disfiguring
injuries, and chronic pain. A decade of war in Afghanistan and
Iraq has led to tremendous advances in knowledge and care of
combat-related physical and psychological problems. We have
partnered with the Department of Veterans Affairs, the Defense
and Veterans Brain Injury Center, and the Defense Centers of
Excellence for Traumatic Brain Injury and Psychological Health
in academia, as well as the National Football League, to
improve our ability to diagnose, treat, and care for those
affected by traumatic brain injury.
Similar to our approach with concussive head injuries, Army
Medicine has harvested the lessons of almost a decade of war
and has approached the strengthening of our soldiers' and
families' behavioral health and emotional resiliency through
the comprehensive behavioral health system of care. It is a
system of systems built around the need to support an Army
engaged in repetitive deployments, often in intense combat,
which then returns to home station to restore, reset the
formation, and reestablish family and community bonds. The
system is underpinned by the multiple touchpoints across the
time, in which soldiers receive mandatory behavioral health
assessments from pre-deployment to post-deployment and into
garrison life.
The warfighter does not stand alone in support of a nation
in persistent conflict with the stresses resulting from 10
years of war. Army Medicine has a responsibility to all those
who serve, to include our family members and our retirees who
have already answered the call to our Nation. We are committed
to ensuring the right capabilities are available to promote
health and wellness and are focused on decreasing variance,
increasing standards and standardizations across Army Medicine.
I am incredibly honored and proud to serve as the 43rd
Surgeon General and the Army Commander of the U.S. Army Medical
Command. There are miracles happening every day at our command
outposts, forward operating bases, posts, camps, and stations
every day because of the dedicated civilians and soldiers that
make up the Army Medical Department.
With the continued support of Congress, we will lead the
Nation in health care and health, and our men and women in
uniform will be ready when the Nation calls them to action.
Army Medicine stands ready to accomplish any task in support of
our warfighters and families.
Thank you for the opportunity to talk with you today, and I
look forward to your questions.
[The prepared statement of General Horoho can be found in
the Appendix on page 55.]
Mr. Wilson. Thank you very much.
And Admiral Nathan.

STATEMENT OF VADM MATTHEW L. NATHAN, USN, SURGEON GENERAL, U.S.
NAVY

Admiral Nathan. Thank you, Chairman Wilson, Ranking Member
Davis, distinguished members of the subcommittee. I am pleased
to be with you today to provide an update on Navy Medicine,
including some of our collective strategic priorities,
accomplishments, opportunities, and challenges.
I want to thank the committee members for the tremendous
confidence and support shown to Navy Medicine.
I can report to you that Navy Medicine remains strong,
capable, and mission-ready to deliver world-class care
anywhere, anytime, as is our motto. The men and women of Navy
Medicine are flexible; they are agile and resilient. They are
meeting their operational and wartime commitments, including
humanitarian assistance and disaster relief response, and
concurrently delivering outstanding patient- and family-
centered care to our beneficiaries.
Force health protection is what we do. And we do it at the
very foundation of our continuum of care in support of the
warfighter, and optimizes our ability to promote, protect, and
restore their health.
One of my top priorities as I assumed my role as Surgeon
General in November has been to ensure that Navy Medicine
remains strategically aligned with the imperatives and
priorities of the Commandant of the Marine Corps and the Chief
of Naval Operations. Each day, we are fully focused on
executing the operational missions and core capabilities of the
Navy and Marine Corps, and we do this by maintaining warfighter
health readiness, delivering the continuum of care from the
battlefield to the bedside and from the bedside either back to
the unit, to the family, or to transition.
We are honored to be entrusted with the health care of all
we serve. We are aligned with our Navy and Marine Corps
leadership as we support the defense strategic guidance,
``Sustaining U.S. Global Leadership: Priorities for the 21st
Century,'' issued by the President and Secretary of Defense
earlier this year.
The Chief of Naval Operations, in his sailing directions to
us, has articulated the Navy's first principles, and these
include: warfighting first, operate forward, be ready. Earlier
this month, Secretary Mabus launched the 21st-Century Sailor
and Marine Program, a new initiative focused on maximizing each
sailor's and marine's personal readiness. This program includes
comprehensive efforts in key areas such as reducing suicides,
curbing alcohol abuse, and reinforcing zero tolerance on the
use of designer drugs or synthetic chemical compounds. It also
recognizes the vital role of safety and physical fitness in
sustaining the force readiness.
Navy Medicine is synchronized with those priorities and
stands ready to move forward at this pivotal time in our
history. We appreciate the committee's strong support of
resource requirements. The President's budget for FY [fiscal
year] 2013 adequately funds Navy Medicine to meet its medical
mission for the Navy and Marine Corps. We recognize the
significant investments made in supporting military medicine
and providing a strong, equitable, and affordable healthcare
benefit for beneficiaries.
Moving forward, we must innovate, operate jointly, position
our direct care system to recapture private-sector care, and
deliver best value to our patients. Briefly, I will share with
you a few specific areas of our attention.
Combat casualty care: Navy Medicine, along with our Army
and Air Force colleagues, are delivering outstanding combat
casualty care. There is occasional discussion about what
constitutes ``world-class,'' and I can assure you that the
remarkable skills and capabilities in places like the Role 3, a
multinational medical unit in Kandahar, is, in fact, world-
class trauma care, now even deploying MRI [magnetic resonance
imaging] technology to investigate if this can be meaningful in
changing the diagnosis and/or therapy in theater.
Another area is TBI [traumatic brain injury] and PTSD
[post-traumatic stress disorder]. Caring for our sailors and
marines suffering with traumatic brain injury and post-
traumatic stress and/or PTSD remains a top priority. While we
are making progress, we have much work ahead of us as we
determine both the acute and the long-term impact on our
service members. Military medicine cannot do this alone. We
must continue active and expansive partnerships with the other
services, our centers of excellence, the VA, and leading
academic, medical, and private sectors. We wish to make the
best care available to our warriors affected with TBI. I have
been encouraged by our progress, but I am not yet satisfied.
And, also, wounded warrior recovery: Our wounded, ill, and
injured service members need to heal in body, mind, and spirit.
And they deserve a seamless and comprehensive approach to their
recover along that journey with their families. Moving forward,
we must continue to connect our heroes to approved emerging and
diagnostic therapeutic options, both within our medical
treatment facilities and outside of military medicine through
collaborations with major centers of reconstructive and
regenerative medicine. Our commitment to these men and women
will never waiver.
And one last point on Medical Home Port, our adaptation of
the successful civilian patient-centered medical home concept
of care, which is transforming delivery of primary care across
many managed care agencies in the country. We have completed
our initial deployment of Medical Home Port throughout the Navy
Medical Enterprise, and preliminary results in the first sites
show better value, better health--preventative health, cost
utilization of those enrolled.
Also, our innovative research, including the critical
overseas laboratories that not only provide world-class
research but invaluable engagement with host and surrounding
nations to strengthen theater security cooperation in places
like Egypt, South America, Southeast Asia, along with excellent
medical education and training programs ensure that we have the
capabilities to deliver the state-of-the-art care now and in
the future. They are truly force multipliers.
We continue to welcome and leverage our joint relationships
with the Army, the Air Force, the VA, as well as other Federal
and civilian partners in these important areas. I believe this
interoperability helps us create systemwide synergies and
allows us to invest wisely in education, training, research,
and information technology.
None of these things would be possible without our
dedicated workforce, a team of over 63,000 Active Component and
Reserve Component personnel, Government civilians, as well as
contract personnel, all working around the world to provide
outstanding health care and support to their beneficiaries. I
am continually inspired by their selfless service and sharp
focus on protecting the health of sailors, marines, and their
families. And I am particularly grateful for your support in
helping us recruit and retain the best of these.
In closing, let me briefly address the MHS [Military Health
System] governance. We appreciate the opportunity to begin the
dialogue with you a month ago, when there was a hearing held on
this issue. The Deputy Secretary of Defense has submitted his
report to Congress, required by Section 716 of the fiscal year
2012 National Defense Authorization Act. It addresses the
Department's plans, subject to review and concurrence by the
GAO [Government Accountability Office], to move forward with
governance changes.
Throughout my remarks this morning and in my statement for
the record, I referred to our jointness in theater, in our
classrooms, our laboratories, and our common pursuit of
solutions for challenges like TBI. I again stress our
commitment to interoperability and cost-effective joint
solutions in terms of overall governance.
Navy Medicine looks forward to working on the next phase of
the Deputy Secretary's plan. We must proceed and deliver it in
a measured manner to ensure that our readiness to support our
service's missions and our core warfighting capabilities will
be maintained and our excellence in health care will be
sustained.
On behalf of the men and women of Navy Medicine, I want to
thank the committee for your tremendous support, your
confidence, and your leadership. It is my pleasure to testify
before you today, and I look forward to your questions.
[The prepared statement of Admiral Nathan can be found in
the Appendix on page 83.]
Mr. Wilson. Thank you very much, Admiral.
General Green.

STATEMENT OF LT GEN CHARLES B. GREEN, USAF, SURGEON GENERAL,
U.S. AIR FORCE

General Green. Thank you.
Chairman Wilson, Representative Davis, and distinguished
members of the committee, thank you for inviting me here today.
The Air Force Medical Service could not achieve our goals of
readiness, better health, better care, and best value without
your support, and we thank you.
To meet these goals, the Air Force Medical Service is
transforming deployable capability, building patient-centered
care, and investing in education, training, and research to
sustain world-class health care.
This year, we established 10 new expeditionary medical
support health response teams. These 10-bed, deployable
hospitals enable us to provide emergency care within 30 minutes
of arrival at scene and perform surgery within 5 hours in any
contingency. Light and lean, it is transportable in a single C-
17, with full base operating support requiring only one
additional C-17. The health response team was used successfully
in the Trinidad humanitarian mission last May and is our new
standard package for rapid battlefield care and humanitarian
assistance.
Critical care air transport teams and air evacuation
continue to be a dominant factor in our unprecedented high
survival rate. To close the gap and enter a critical care
continuum, we applied the CCAT [critical care air transport]
concept to tactical patient movement, delivering the same level
of care during intratheater transports on rotary platforms.
The Tactical Critical Care Evacuation Team was fielded in
2011, and five teams are now trained. Two teams are currently
deployed to Afghanistan, and each team has an emergency
physician, two nurse anesthetists. And we are able to move
critical patients between level 2 and level 3 facilities even
more safely.
At home we enrolled 920,000 beneficiaries--actually, today
it is 940,000 beneficiaries--into team-based, patient-centered
care at all Air Force medical treatment facilities. This care
model reduced emergency room visits, is improving health
indicators, and achieved unprecedented continuity of care for
our military beneficiaries.
The Air Force remains vigilant in safeguarding the
wellbeing and mental health of our people. Post-deployment
health reassessment completion rates are consistently above 80
percent for Active Duty, Guard, and Reserve personnel. The new
Deployment Transition Center at Ramstein Air Base, Germany,
provides an effective reintegration program for our deploying
troops, and more than 3,000 have been through to date. We focus
on our highest-risk patients, our beneficiaries. And a study of
the airmen who have attended showed significantly fewer systems
of post-traumatic stress and lower levels of both alcohol use
and conflict with family or coworkers upon their return home.
By this summer, behavioral health providers will be
embedded in every primary care clinic in the Air Force. And we
reach our Guard and Reserve members through telemental health
efforts and embedded psychological health directors, and we are
further increasing mental health provider manning over the next
5 years.
New training to support air evacuation and expeditionary
medical capability is now in place. Our training curriculums
are continuously updated to capture the lessons from 10 years
of war. And our partnerships with civilian trauma institutions
have proved so successful in maintaining wartime skills that we
have expanded the training sites to establish new programs with
the University of Nevada-Las Vegas and Tampa General Hospital.
We also shifted our initial nursing training for new Air
Force nurses to three civilian medical centers. The Nurse
Transition Program now at the University of Cincinnati, at
Scottsdale, and in Tampa broaden our resuscitative skills and
experience.
Air Force graduate medical education continues to be the
bedrock for recruiting our top-notch physicians. Our graduate
programs are affiliated with Uniformed Services University and
civilian universities. And these partnerships build
credibility, both in the U.S. and international medical
communities.
One of our most significant partners is the Department of
Veterans Affairs. And we are very proud of our 6 joint
ventures, 59 sharing agreements, and 63 joint incentive fund
projects, which are improving services to all beneficiaries.
We also note significant progress has been made toward the
integrated electronic health record, to be shared by DOD and
the Department of Veterans Affairs.
In the coming year, we will work shoulder-to-shoulder with
our Army, Navy, and DOD counterparts to be ready, to provide
better health, better care, and best value to America's heroes.
Together, we will implement the right governance of our
Military Health System. We will find efficiencies and provide
even higher-quality care with the resources we are given.
I thank this committee for your tremendous support to
military medics. Our success, both at home and on the
battlefield, would not be possible without your persistent and
generous support.
Thank you, and I look forward to answering your questions.
[The prepared statement of General Green can be found in
the Appendix on page 109.]
Mr. Wilson. Thank you very much, General Green.
And Mr. Strobridge.

STATEMENT OF COL STEVE STROBRIDGE, USAF (RET.), CO-CHAIR, THE
MILITARY COALITION

Colonel Strobridge. Thank you, Mr. Chairman, Ranking Member
Davis, and distinguished members of the subcommittee.
Less than 3 months ago, the fiscal year 2012 Defense
Authorization Act became law, which let the Administration
implement the TRICARE fee increases it recommended last year.
Now, when the ink is hardly dry, the new proposal would impose
far higher increases for TRICARE Standard, TRICARE Prime, and
TRICARE For Life, plus a doubling and tripling of new pharmacy
co-pays.
It would raise health costs $1,000 to $2,000 a year or more
for retirees, and the large pharmacy fee hikes would affect
many currently serving people, as well--families, the family
members. Defense leaders say they will keep faith with the
currently serving on retirement reform, but thousands who
retire in the next year would incur these new fees. If
``keeping faith'' means no changes for today's troops on
retirement, then it is breaking faith to raise their fees by
$2,000. That is no different than a $2,000 retired pay cut. And
if it is breaking faith to change the rules for someone with 1
year of service, then it is doubly so to do that to those who
have already completed 20 or 30 years.
For generations, the Government has induced millions to
complete arduous service careers in uniform with promises that,
for rendering that sacrifice, they would earn the current
retirement and healthcare package. In other words, their
extended service and sacrifice constituted their prepaid
premium. Now, after retirees have done their part, Pentagon
leaders say their service isn't worth so much anymore and they
should pony up thousands more every year for the rest of their
life.
They blame the budget crunch but balk at changes to make
the system significantly more efficient. Many studies document
the inefficiencies of DOD's fragmented healthcare systems, but
the recent review made only minimal changes, in part because a
key decision criterion was how hard the change would be. So the
first choice was to make retirees pay more because it was
easier.
Another argument is that military programs should move
toward market rates and be more like civilian plans. After all,
they say, military retirees pay far less for health care than
civilians do. Whenever somebody gives me that argument, I ask,
``If the military deal is so great, are you willing to pay what
they did to earn it? Would you sign up to spend the next 20 or
30 years being deployed to Iraq, Afghanistan, or any other
garden spot the Government wanted to send you to?''
Military people pay far steeper premiums for health
coverage than any civilian ever has or ever will. That is why
military coverage is supposed to be top-tier coverage, not just
the civilian median.
One example: Fifty-six percent of civilian employer plans
charge $25 co-pays or less for brand-name medications. That
puts the new $26 TRICARE proposal in the bottom half of
civilian plans. Further, TRICARE's $5 retail generic co-pay
that was implemented last October is already more than
civilians with no insurance at all pay at Wal-Mart and many
other pharmacies. And they want to raise the military co-pay
again.
As for the plan to means-test retiree health fees, that is
patent discrimination against the military. No other Federal
retiree has service-earned health benefits means-tested, and it
is rare in the civilian world. Under that perverse system, the
longer and more successful you serve, the less benefit you
earn. The Coalition believes strongly that the proposed rates
are significantly too high for all military beneficiaries.
Finally, the Coalition objects very strongly for tying
TRICARE fee growth to any index of health-cost growth. On
behalf of the MOAA [Military Officers Association of America]
and 22 other associations, we strongly support the position you
established in the fiscal year 2012 Defense Authorization Act:
that the percent growth in TRICARE fees in any given year
should not exceed the percentage growth in military retired
pay.
We are grateful for this opportunity to present our views,
and I will be pleased to answer any questions.
[The prepared statement of Colonel Strobridge can be found
in the Appendix on page 129.]
Mr. Wilson. Thank you very much, Mr. Strobridge.
And as we begin--and I am going to be on the 5-minute clock
myself. But as we begin, I want to thank you. And I agree with
General Horoho that miracles are performed every day. And as a
military parent, as a veteran, I appreciate so much your
service. It is so reassuring to know that the survival rate of
our military is the highest in world history and, also, the
technological advances for our wounded warriors is the best,
again, in world history. And it is just reassuring as a parent.
As we prepare today, Dr. Woodson, I am concerned--and I
appreciate the points made by Mr. Strobridge. Based on your
projections, 60 percent of the savings from the TRICARE
proposals will come from beneficiaries choosing not to use the
benefit they earned by serving or by using it less.
How did DOD calculate the estimated savings from
beneficiaries opting out of TRICARE?
Secretary Woodson. Thank you, Mr. Chairman, for the
question.
I must admit I am a little perplexed at how those numbers
are summed up. Our rationale going into deriving the fee
adjustments were coming from the issue of what we needed to
achieve in cost savings over 10 years. That is the $487 billion
and, over the FYDP [Five-Year Defense Plan], of $269 [billion].
And although personnel benefits are a third of DOD's costs,
90 percent of the savings actually comes from reduction in
weapons programs, force reductions, and the like. And, as I
mentioned in my opening statement, healthcare costs could not
be excluded and had been the subject of some review over a
number of years, as the fees for TRICARE had not increased for
some 15 or 16 years until the recent NDAA [National Defense
Authorization Act].
And so we were left with about $29 billion to look at. And
even with that $29-billion sort of assessment, we only took
really less than half of that, $12.9 billion, really over the
FYDP and applied those really to sort of the fee adjustments,
and then spread it across all of the programs so, again, no one
beneficiary group was unduly affected.
So the real issue is about a rebalancing. And it is not
even rebalancing to the original cost-share formula that
Congress agreed to when we started the program. And the
Secretary and the line leadership, who were heavily invested in
both the adjustments and the tiering--remember, these are
members in uniform, who spent the 35 years in uniform and are
going to retire and are going to be subjected to these fees--
felt strongly--and this included the senior enlisted
leadership--felt strongly that there should be tiering and that
they were the right adjustments to make at this time.
And I remind the committee also that we were guided by
prior studies, such as the 2007 task force on the future of
health care, which specifically, among other things, noted that
these are one of the reforms that we should undertake.
So that is how we arrived at it. It wasn't an issue of
trying to force people out of TRICARE. And, in fact, our
numbers suggest that, considering the rise in premiums in the
private sector and considering some of the other issues that
affect health care, we may have more people taking advantage of
their TRICARE benefits, so quite the opposite.
Now, the truth is that maybe some may want to switch to
Standard, which has a different cost share, but there is no
attempt, absolutely no attempt, to drive people away from their
TRICARE benefit.
Mr. Wilson. Well, I know of your personal commitment, but I
am concerned about the formula, particularly with TRICARE fee
increases, that an E-7 who served 28 years is going to pay more
than an E-7 who served 20 years. And that doesn't seem fair to
me, that people who serve longer pay more.
Secretary Woodson. Well, you are speaking to the formula--
again, line-driven, uniform-driven on this. I can't emphasize
that enough, that they took the mantle on this. The issue is
that they felt strongly that those who make more should pay
more. Their increases over the years, in fact, have been
proportionally more because they come out with more retired
pay. But for 16 years there has been no increase. So the issue
is, they felt strongly that this was a fair way to go.
Mr. Wilson. Thank you.
We now proceed to Ms. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
And I certainly can acknowledge that we are all probably
going to dig in on this issue to a certain extent. But I think
it is also very fair to ask what would happen if, in fact,
approval of these changes did not go forward.
Secretary Woodson. Thanks again for that very important
question because if--as I mentioned, 90 percent of the savings
came from other areas, so planes, ships, people. If we don't go
forward with these TRICARE fee adjustments, we will have to
look at planes, ships, and people again.
And so the issue is that, if we look at people, we are
looking at maybe a 50 percent more increase in the reduction of
the force. And while I wouldn't want to fix a number on this,
we are talking about anywhere from, you know, 30,000 to 50,000
troops.
Mrs. Davis. Okay. Well, thank you. I mean, we know we are
in a very difficult space.
And I guess, Mr. Strobridge, you probably have the most
difficult job of anybody up there, in many ways. And I think in
your comments you also were looking at ways that we could
expand benefits while at the same time, I think quite
eloquently, saying that, you know, this is not the place to
increase these on the men and women who serve and sacrifice for
our country.
But, within that, of looking to expand and wanting to not
change anything, where do you see any kind of wiggle room
there?
Colonel Strobridge. Well, there are various views among the
associations. And, as I said a little earlier, MOAA and 22
other associations have not taken the view that there should
never be a single fee increase. We think that, you know, over
time, as retired pay rises, there is an expectation that fees
will rise. But we think that they have to be reasonable. And we
think that the standard that the committee established last
year, by tracking to the COLA [cost-of-living adjustment]
percentage, is reasonable.
I would like to make one comment in terms of, you know,
what are the alternatives. One of the things that we have said
very consistently is that there are ways to make the system
more efficient without raising beneficiary fees. We have talked
to people who have done reviews in the last couple of years who
have raised the figure of a potential savings of 30 percent if
you reorganized the system, with no requirement to cut benefits
and no increases in beneficiary fees. That entails significant
reorganization of how health care is delivered in the military
system.
I was the defense implementation officer for the Goldwater-
Nichols provisions, the jointness provisions. And I can tell
you, at that time, all the hearings said it was too hard, we
can't do it. None of the Services wanted to do it. We did it,
because Congress directed it. And I believe the same potential
lies here.
Mrs. Davis. Yeah. Thank you.
You asked my next question for me. I appreciate that.
Because I wanted to turn to Dr. Woodson, because we know that
the Department of Defense has proposed another change in
governance structure. In 2006, we saw a change to that.
And I am just wondering, of the--I believe there were seven
governance initiatives that were supposed to achieve some
economies of scale and operational efficiencies, how many have
projected any estimated savings? Do we see savings there? How
much of the $200 million annual savings has been realized that
I think we were hoping for? And going back to Mr. Strobridge's
question--and I know I am running out of time--how does that
improve jointness?
Secretary Woodson. Thank you very much for this important
question.
Clearly, it improves jointness, and I will return to that
in just a minute.
But just to put it in context, you know, when we talk about
30 percent savings and what is achieved by reorganization, you
are focusing really on the least costly part of the Military
Health System--that is, the headquarters and sort of the
administrative activities. And so that is about 2 percent of
budget. The real area that you need to affect is in sort of the
cost of delivery of care, so what we call Budget Area Group 1
and 2, which is the big balloons, you know, accounting for
probably out of the DHP $25 billion or more in that situation.
And so the thing that everyone needs to understand is that
we are committed to restructuring the MHS to produce the most
efficient administrative system. So we are already bought off
on that, and that is why we made the proposal to the DHA
[Defense Health Agency]. But it really is a leverage to produce
the efficiencies and developing the strategies for delivering
the care so that we improve access and quality at a lower cost,
so a better value for the dollars that are spent.
But to speak to what we have already done, clearly, you
know, we have made amazing changes over the years in terms of
the administrative structure to drive out that waste. We
accepted, actually, MOAA's suggestion some years ago about
looking at our pharmacy approaches and going to Federal ceiling
pricing, and we have already saved $3.4 billion in talking
about administrative process; and fraud and recuperation of
fees, $2.6 billion; medical acquisitions, $31 million a year.
We have reduced headquarters already last year by 440 FTEs
[Full Time Equivalents] and are on track to reducing it to the
total of the 680 that we talked about with Congress last year.
And so we have undertaken a lot of initiatives, some of
which I won't talk about now. So the issue is, we have really
squeezed that lemon called an administrative process. And with
the report to Congress, I think we are doing the right things
in terms of reform.
With the Defense Health Agency that is proposed, you know,
we will be focusing on the issues of health IT [information
technology], of medical education, of medical logistics, of
sort of research and development, and being able to reduce an
additional probable, at least, on the conservative side, 300
FTEs out of the administrative process.
So I think we have worked diligently together to look
forward and design a system that is responsive, not only to
sort of our mission, to try and do our mission better, but to
do it in a cost-efficient way. But the key is that that is only
2 percent of our budget.
Mr. Wilson. Thank you, Ms. Davis.
And we will now proceed by order of appearance. And Dr.
Heck ran across the street. I saw him, so he was here first.
Dr. Joe Heck from Nevada.
Dr. Heck. Thank you, Mr. Chairman.
And thank you all for being here, and thank you all for
your service to our Nation, both in and out of uniform, and to
the men and women that are still serving.
We talk a lot about dollars, but to me it doesn't make a
difference, the dollar amount, if there is no access. And so,
Dr. Woodson, primarily I have two questions regarding access
that I would like to bring up, two issues.
One is the contracting process by which the TRICARE
contracts are awarded. As I am sure you are aware, there was
recently an appeal in the TriWest region, in the west region,
that resulted in a change of the contract provider. And that
appeal occurred almost 2 years after the contract was awarded
and after the other entity lost an appeal in another region.
And so I am wondering, what is the process that allows that
to happen, where you are appealing in one region, you are not
successful, and then you reserve the right to appeal in another
region 2 years later after the awardee has already, you know,
been providing very good quality care?
And in full disclosure, I say it as a former not only
TriWest beneficiary but a TriWest provider. How does that--I
mean, that whole acquisition and contracting process just
doesn't seem like it is something that should be working in
that regard.
Secretary Woodson. Thank you very much for the question.
And I think it is actually quite the reverse. The acquisition
process is a difficult, somewhat cumbersome process, but it is
carried out according to due process to ensure fairness. And
some of the protests that have been raised have been protests
about the process, and that is why you have to do it with all
due diligence.
We have, you know, in place the requirement that no one
provider or group can operate in two different regions. And
that has to do with making sure that if there was a serious
problem in any one provider, it would put at jeopardy too much
of our network, if you will.
And so what happens is that you just have to go through the
rather laborious legal and regulatory steps in order to get to
a final decision and give the competing entities the right to
appeal. It is just part of the process. And we know it takes
time.
But one of the things that we have done is, we have
actually reformed our acquisition process to ensure that there
is fair adjudication of the individuals or the entities that
are competing for these contracts. And it is understandable
that they would protest. These are very large contracts, and it
is important to their business. And it is just a process that
needs to be played out.
Dr. Heck. Well, I can appreciate that, but it would just
seem odd that you can maintain a right of appeal in one region
while you are being adjudicated on a protest in another region,
and if that doesn't work, then you can come back, you know, and
protest another place after that original awardee has put
together their care provisions.
Is that a statutory, a regulatory, is that a DOD policy?
Where does that fall, that process that is in use?
Secretary Woodson. Well, it is statutory, regulatory. It is
all of those things, if you will.
I am not sure that the two are necessarily tied, as
suggested. Each of the regions went through their process of
sort of looking at the proposals and adjudicating them and
ranking them and making decisions by the source authority,
basically, and it was played out.
Dr. Heck. Well, I appreciate that.
Secretary Woodson. And it is a complicated process, but it
is there for everybody's protection.
Dr. Heck. And just quickly in my last few remaining seconds
here, I recently received a letter that the Department of
Defense is considering not recognizing the accreditation of
osteopathic residency programs. And when we talk about
maintaining access to quality healthcare providers, I was
wondering if you have had any visibility on that. We sent a
letter off asking for further information, but we would
certainly appreciate follow-up on that, as well.
Secretary Woodson. I had not heard about that as an issue,
but I will take that for the record and I will respond to you.
[The information referred to can be found in the Appendix
on page 223.]
Dr. Heck. Thank you.
Thank you, Mr. Chair. I yield back.
Mr. Wilson. Thank you very much, Doctor.
And we now proceed to Congresswoman Madeleine Bordallo of
Guam.
Ms. Bordallo. Thank you, Mr. Chairman.
And to all of our witnesses, I thank you for your testimony
today.
Dr. Woodson, I have a question for you. Do you have any
statistics in regards to the rise and/or fall of military
healthcare costs as we drew down in Iraq?
Secretary Woodson. Thank you for the question, and it is a
little bit of a complicated answer, and here is the reason why.
Some of the costs of medical care are funded by OCO
[Overseas Contingency Operations] funds. And if you look at
probably the last 10 years of war, as best as we can dissect
out sort of the relative cost, the increase in costs for the
overall DHP is probably only in the range of about 6 percent.
But I want you to understand that it depends on how you dissect
out the cost.
But the point I want to make is that most of the rise in
costs is really parallel to what is experienced in the civilian
sector in terms of health inflation costs, which has been
relatively steep over--at least particularly in the first part
of the first 5 years of the century. So the issue of the
defense health costs are really driven by that equation, what
we pay for care in the private sector and the cost of
delivering care in our direct care setting, the medical
treatment facilities.
And that is why I pointed out before that, as much time as
we spend talking about reorganizing and restructuring the
administrative process, most of the money is in bag one and bag
two, which is what we pay for care in the direct care system
and in the purchased care system.
So, to sum up, it is hard to answer your question. We
haven't seen a reduction in the cost coming out of Iraq.
The other thing I would mention to you is that, just
because the kinetic war stops today, we have a huge tail in
terms of taking care of the wounded and injured. So we are not
likely to see, even if there was a precipitous increase in cost
due to the war, a drop-off.
What is interesting, also, for the committee to know about
is that last week we convened a 1-day conference looking at the
long-term healthcare needs of wounded, ill, and injured. So we
are talking about what they are going to need 10, 20 years down
the pike or more. And we got a lot of interesting information
about what that tail looks like and what we should be focusing
on going forward.
So the answer to your question is, no, we haven't seen a
reduction in the cost. The tail will be there for a long time.
And there still are unknown factors that will affect those
costs.
Ms. Bordallo. Thank you.
Another question for you, Dr. Woodson. What efforts is the
Department of Defense taking to find efficiencies within its
overall medical system?
For example, we may have moved to a joint medical facility
up in Bethesda, but I am not certain we have a truly joint
medical system that reduces redundancies between each of the
Services' healthcare providers. So I hope you can elaborate on
what is being done to make a more joint healthcare delivery
system and finding ways to reduce cost.
Secretary Woodson. Thanks again. And I think that speaks to
the report to Congress and our proposal to develop a defense
health agency. It is looking at all of those shared and common
services that have redundancies within each of the Services,
trying to move them into a single management agency, reduce the
cost. We talked about probably saving 300 FTEs. And that is
just one model of looking at how do you reduce costs.
We really do believe that there are other efficiencies that
will be driven, so that within the health IT we will be able to
make some additional reductions. Within medical training, we
will be able to make some reduction. Medical logistics, we will
make some reductions. So the modest end of what we will achieve
is represented by, you know, the 300 FTE reduction, which
equates to about $50 million to $100 million a year.
Ms. Bordallo. Fifty million to $100 million?
Secretary Woodson. Yes.
Ms. Bordallo. Great. Thank you very much, Doctor.
And I yield back my time. Thank you, Mr. Chairman.
Mr. Wilson. Thank you very much.
We now proceed to Colonel Allen West of Florida.
Mr. West. Thank you, Mr. Chairman and Ranking Member.
And thanks to the panel for being here.
And, look, I am going to be very honest. I didn't go to law
school, nursing school, medical school. I went to airborne
school, so I am going to use a little paratrooper logic here.
Mr. Strobridge, Dr. Woodson, did we have any consultation
about this whole plan with military veteran organizations?
Colonel Strobridge. No.
Secretary Woodson. We had no direct consultation with the
military organizations in putting this proposal together. What
we did have is information that they had provided to us over
years about their thoughts on these same issues, since this is
not a new set of issues that has come up.
Colonel Strobridge. Well, I would say, no, there wasn't any
consultation.
A couple of examples: You know, the one comment was made
that we are talking about just the headquarters. The issue on
reorganization isn't the headquarters. The issue is
consolidation of responsibility and accountability for the
budget, which we don't have right now. When a base wants to
save money and they get ordered to cut their budgets, they can
reduce the medications and the formularies, send people
downtown, which costs more money but it doesn't affect them
because the charge goes to DOD. It is those kinds of
inefficiencies that you have to eliminate by the reorganization
in terms of how you deliver care, so that you get rid of that,
you know, ``I will just shift my expense over to somebody
else.''
The other example was the mail-order pharmacy, which Dr.
Woodson is correct, we have pushed the Defense Department for
several years to put more effort into promoting the mail-order
pharmacy. We had a formal proposal to form a partnership with
them by which the associations would go out and put out a
common package developed by the Department of Defense that we
would work with the Medicare supplement insurance companies,
who also have an incentive to reduce their expenses if people
reduce their drug expenses. After a year, we got one meeting
for a half-hour. We have had nothing since.
Mr. West. If I am correct, the population of the United
States of America is about 350 million. Correct? Somewhere
thereabout? And when I am reading through this, you provide to
about 9.6 million beneficiaries. Are we supposed to believe
that less than 1 percent are causing the fiscal woes of this
country? That is something that really disturbs me.
Furthermore, I read that in fiscal year 2013 we are looking
at $452 million of savings; fiscal year 2013 to 2017, we are
talking about $5.5 billion of savings. Last year, the GAO put
out a report, February 2011, that said there is $200 billion to
$300 billion of redundant and duplicative Government programs
out there. Why don't we look at that before we start penalizing
the people that have, you know, given a lifetime of service to
this country?
The next question, is there any effect to DOD civilian
healthcare plans, any changes to their plans?
Secretary Woodson. Let me address a couple of things.
Your last question first: No. And in part because we don't
control that, but, more importantly, they already go through a
yearly adjustment in fees and have done so over the last decade
so that they pay about 30 percent of the cost. They already
have had those adjustments, and civilians have had a pay
freeze. But that is not within our line of authority, really,
to address.
In regards to your first point about the issue of military
folks being responsible for the national debt crisis, I don't
think anyone is really saying that. What we are really saying
is that----
Mr. West. I mean, let's look at it. I mean, $487 billion,
and now we are talking about another $600 billion, you know,
through sequestration. I think that the message coming out of
Washington, D.C., is that the military is going to be the bill
payer for the fiscal irresponsibility of Washington, D.C.
Furthermore, we are going to look at the men and women who have
given a lifetime of service and say that you are on the cut
line. That is the message.
When I briefed this at a town hall meeting in south
Florida, which has one of the highest percentages of the
retirees, they were livid because no one is talking about this.
So this is not about a dollar amount, this is really about
a trust factor. And what are we saying to future generations of
retirees and veterans? I mean, we already talked about the ink
hadn't dried off of fiscal year 2012 and we are doing this in
2013. What is going to happen in 2014?
I am not upset with you all here, but I am telling you,
that is the message that is getting out there and to friends of
mine that are still in uniform. So, you know, I know my time
has run out, but I have to tell you something. You have to tell
Secretary Panetta this is FUBAR [fouled up beyond all
recognition].
I yield back.
Mr. Wilson. Thank you very much.
We proceed to Colonel--Congressman Mike Coffman of
Colorado.
Mr. Coffman. Thank you, Mr. Chairman. I was a sergeant in
the Army, a major in the Marines, so I didn't get to that rank.
Let me first say that, in visiting the wounded in Bethesda,
how impressed I am with the care that they are receiving. And I
want to commend you for that.
I come from a military family. My father was in military
medicine for the second half of his career. And I volunteered
at Fitzsimons Army Medical Center in Aurora, Colorado, when I
was a young person, 14, in 1969. And, you know, obviously, the
technology, we have learned a lot about how to take care of
particularly amputees, but I remember the morale just being
terrible for those wounded.
And I think as America became divided about the war in
Vietnam, they became divided about support for our veterans.
And they felt--that was an Army installation, and they felt
completely disconnected once they were wounded, that they were
no longer really soldiers, where the wounded that I see in
Bethesda are connected to their units. They feel that they are
still a part of the military. And I like it that their
rehabilitation is done in the military and they are not
shuttered off to VA facilities. And that is a separate
discussion, in terms of improving those.
And I have tracked a double amputee coming out of my
district, a lance corporal in the Marine Corps, who is able to
not just walk but run on his prosthetics. He is competing in
athletic events. He is at Balboa now, naval medical center. And
I talked to him on the phone last week. He said he is in the
best shape that he has ever been in. And so I am impressed with
that.
One thing, there is one gap that I want to ask you about in
military medicine that I am concerned about, and that is post-
traumatic stress disorder. And the reason why I am concerned
about it is because I think that our approach is that we seem
to have a disability-centric approach and not a treatment-
centric approach. And I think that it would cost us more money
in the short run but save money in the long run if we would
shift to more of a treatment-centric approach.
Those in the mental health profession that I talk to all
feel that it could be brought--that the symptoms could be
brought down to where they are not debilitating if given the
proper modalities of treatment. So I wondered if any of you
could respond to that issue.
General Horoho. Sure. I will take that first, if that is
okay.
Mr. Coffman. Yes.
General Horoho. What we have looked at is really shifting
more toward prevention, and I believe that is what you are
talking about.
And so we have, over the last couple years, we have a
comprehensive behavioral health system of care, where we have
five touchpoints where our soldiers see a behavioral health
specialist prior to deployment. In theater, we have increased
our behavioral health assets. We are using tele-behavioral
health, so that instead of waiting until they redeploy back to
deal with some of the stressors and the symptoms associated
with deployment, they are able to do that through tele-
behavioral health in some of the remote areas in Afghanistan.
And then we are also--we have over-hired across each of our
regions, using tele-behavioral health so we can shift that
capability where the demand is.
We are also looking, when you look at not just behavioral
health, but it is looking at stress reduction, anger
management, alcohol use. So the approach now is more toward
that prevention and looking at incorporating mindfulness, yoga,
acupressure, acupuncture, so that we really help with
decreasing some of that stress.
Because we agree with you. We have focused more on
treatment, and over the last couple years it has been more
toward prevention. And we have a ways to go, though.
General Green. Sir, if I could add to that, the most recent
of statistics is--we just went and looked at it. There was a
perception that, because of the wounded warriors going through
the IDES [Integrated Disability Evaluation System] system that
so many of them, as high as 80, 85 percent, also had PTSD, that
we were putting a lot of people out because they had PTSD. But
the reality is, of those diagnosed with PTSD, 75 percent are
returned to duty. So our focus is on treatment.
Obviously, I agree with General Horoho in terms of what we
are doing to try and prevent this in the first place. But I do
think that it is a bit of a misperception to think that we are
not focused on treatment when we are bringing 75 percent back
to duty.
Mr. Coffman. Admiral.
Admiral Nathan. And if I may just add one caveat, sir,
which is, my previous command role to this was the commander at
Walter Reed Bethesda. And you talked about the two signature
injuries in your question, one was amputations and limb loss,
and the other is traumatic brain injury and post-traumatic
stress.
And what we have learned in PTS and PTSD is that it not
only takes the individual or the patient with it, it takes the
family along, too. In other words, it is a family illness and,
basically, can be devastating not only to a single patient,
such as loss of limb, but to family. And so we provide a much
more holistic approach now across the military, engaging family
care at the same time that we engage the patient.
We actually created the national center of excellence for
TBI at Bethesda, the National Intrepid Center of Excellence,
NICoE, which is this avant-garde building there which is
basically designed to be a prototypical facility to create and
try innovative and new procedures, garnering the best academic,
private, and military specialists available to look at new
diagnostic and therapeutic techniques.
And as they treat their cohorts of patients, they treat
them at the same time as the families. The families are flown
in, brought in. And the entire family, including children, are
taken through diagnostic and therapeutic trials along with the
patient.
We are seeing some marvelous results from that. It is
labor-intensive, it is personnel-intensive, and so it is going
to be hard to replicate that across the entire spectrum. But we
are starting to create satellite NICoEs in places like Camp
Lejeune and Belvoir, and I think we will see more of those
grow.
Mr. Coffman. Thank you, Mr. Chairman. Just to say that I
think that is a much cheaper approach than sending somebody a
disability check for the rest of their life.
With that, Mr. Chairman, I yield back.
Mr. Wilson. Thank you all very much.
And if there are no further questions--and Congressman
Walter Jones of North Carolina had an appointment at the
office, and so I have questions that he wanted submitted for
the record for Dr. Woodson. And so, with unanimous consent,
they shall be included.
As we conclude, again, thank you for your sincere and
genuine concern for our military personnel, military families,
and veterans. And we look forward to working with you to
provide the world-class health care that you are providing.
Thank you, and we shall now be adjourned.
[Whereupon, at 4:20 p.m., the subcommittee was adjourned.]
?

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A P P E N D I X

March 21, 2012

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PREPARED STATEMENTS SUBMITTED FOR THE RECORD

March 21, 2012

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Statement of Hon. Joe Wilson

Chairman, House Subcommittee on Military Personnel

Hearing on

Defense Health Program Budget Overview

March 21, 2012

Even in this tight fiscal environment, the Military Health
System must continue to provide world-class health care to
beneficiaries and remain strong and viable and fully funded in
order to maintain that commitment. The Department of Defense
has proposed several measures aimed at reducing the cost of the
Defense Health Program. Unfortunately, all of the proposals
simply shift the cost burden to TRICARE fee and cost-share
increases to not only our working-age retirees but, for the
first time, to our most senior military retirees.
The subcommittee has a number of concerns about the
Department's initiatives. To that end, we would expect the
Department's witnesses to address our concerns, including that
the proposed TRICARE Prime fee increases, which have been
characterized by military leaders as modest, will raise fees in
fiscal year 2013 by 30 to 78 percent over the current rate.
Over 5 years, the fees would increase by 94 to 345 percent.
The proposed increases may be designed to cause military
retirees to opt out of TRICARE, choose a TRICARE option that is
less costly to DOD, or decrease their use of TRICARE. The
proposal would establish an annual enrollment fee for retirees
who use TRICARE Standard and Extra and, for the first time,
would require our most senior retirees to pay an enrollment fee
for TRICARE For Life.
What is not clear to me is why, aside from the revenue
being generated from the fees, DOD believes enrolling these
participants is necessary. What benefit can these individuals
expect to receive from enrolling? Sixty percent of the
estimated cost savings from TRICARE proposals is based on
military retirees opting out of TRICARE or using it less.
Frankly, I think this plan is wrongheaded.
Finally, I would like to hear from the military surgeons
about efforts they are taking within the military departments
to increase the efficiency of the military healthcare system
and reduce cost. I would also like the military surgeons' views
on areas where additional efficiencies can be gained across the
DOD health system.

Statement of Hon. Susan A. Davis

Ranking Member, House Subcommittee on Military Personnel

Hearing on

Defense Health Program Budget Overview

March 21, 2012

The last decade of conflict has been weathered on the backs
of our remarkable forces, in particular, those who serve in our
military healthcare system. The constant demands borne by those
in uniform and those in support of them have yielded incredible
successes on our battlefields abroad and at home here in the
States. While I suspect that much of this hearing will focus on
the healthcare proposals of the Department of Defense, this
hearing will also provide the members of this subcommittee an
opportunity to understand and examine some of the difficult
challenges facing the military healthcare system--from
reductions in resources to meeting the ever-increasing demand
for mental health services.
Our military personnel and their families consistently
exceed expectations under tremendous strains and pressures, and
their access to quality health care should not be added to
their plight.
I look forward to your testimony on how we are caring for
our service members and their families, particularly our
injured, ill, and wounded, and how we can continue to improve
our military healthcare system in the new fiscal environment we
will be facing.

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DOCUMENTS SUBMITTED FOR THE RECORD

March 21, 2012

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WITNESS RESPONSES TO QUESTIONS ASKED DURING

THE HEARING

March 21, 2012

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RESPONSE TO QUESTION SUBMITTED BY DR. HECK

Secretary Woodson. DOD considers Doctors of Osteopathy and Doctors
of Medicine as equivalent. I am not aware of any effort or interest
that would not recognize the American Osteopathic Association
accredited osteopathic residency programs. [See page 17.]
?

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QUESTIONS SUBMITTED BY MEMBERS POST HEARING

March 21, 2012

=======================================================================

QUESTIONS SUBMITTED BY MRS. DAVIS

Mrs. Davis. This year, the Department of Defense has proposed yet
another change to its governance structure. In 2006, the Department
approved a change to its medical governance structure. Of the seven
governance initiatives that were supposed to achieve economies of scale
and operational efficiencies to the tune of $200 million, to date, how
many have actually achieved any savings?
Secretary Woodson. The GAO has conducted a study to address this
question. The findings from that study are poised for release in late
April 2012. In the report, the GAO specifically assessed each of the
seven governance initiatives with regard to savings achieved. The
Department has reviewed the report and has concurred with the findings;
however, the GAO has asked the department to refrain from quoting from
the study entitled ``Applying Key Management Practices Should Help
Achieve Efficiencies within the Military Health System'' until the
formal release of the report. If additional changes to MHS governance
are implemented, the Department is committed to a rigorous approach for
measuring and monitoring costs and benefits of change.
Mrs. Davis. Last year, this Congress directed the Comptroller
General to conduct a review of women-specific health services and
treatment. What is the Department and the Services doing to address the
healthcare needs of female service members and dependents?
Secretary Woodson. The National Defense Authorization Act of 2012,
Section 725 directed the Comptroller General, as head of the Government
Accountability Office (GAO), to conduct a review of women-specific
health services and treatment for female members of the Armed Forces.
This report is to be submitted by the Comptroller General to the
congressional defense committees no later than December 31, 2012. GAO
has initiated two new engagements which are to be conducted by its
Defense Capabilities and Management and Health Care teams. One
engagement addresses DOD-wide, women-specific healthcare services `at
home,' while the other engagement pertains to deployment issues, and
care for female sexual assault victims domestically and abroad. A May
2002 GAO Report of the adequacy and quality of the health care provided
to women in DOD found that a full range of healthcare services for
women are offered, and that members' satisfaction with care was well
above average. Some concern was noted in areas regarding healthcare
services or availability of gender-specific supplies in austere
environments.
The provision of health care for women in the Armed Forces
represents not only a clinical concern, but a tactical imperative in
keeping DOD's forces fit to fight. The Department provides a continuum
of care ranging from preventive services (including contraception) to
robust access to primary care; assessment and treatment of medical
emergencies; referral to specialty care as indicated; care for chronic
conditions; and rehabilitation and support for transition and
disability for those whose illnesses or injuries do not permit return
to full duty. Some medical services, such as Obstetrics and Gynecology,
are focused on the medical needs of women, but most other adult medical
services are designed and capable of assessing and treating medical
conditions regardless of age or sex. When medical needs of any Service
member exceed capabilities in their duty location, we also have the
capacity to use medical evacuation to move the Service member to a
location capable of meeting the specific medical need. The continuum of
care includes both military and civilian treatment facilities, and we
work especially closely with our VA colleagues when needs include
transition from active to veteran status.
Recent policy initiatives, research, and leadership focus have
addressed some specific needs and illustrate our commitment to Service
women. It is important to note that policies on management of sexual
assault are equally applicable to both male and female victims.
In FY11, the three new DOD policies augmented efforts to improve
access to quality healthcare services for the victims of sexual assault
and ensure continuity of medical care in both deployed and non-deployed
environments:

In December 2011, a policy ``Expedited Transfer of
Military Service Members Who File Unrestricted Reports of
Sexual Assault'' was generated to affect expedited transfer of
Service members who file an unrestricted report of sexual
assault.
Also in December 2011, Document Retention in Cases of
Restricted and Unrestricted Reports of Sexual Assault,
established comprehensive policy for the retention of sexual
assault records.
The DOD Sexual Assault Prevention and Response (SAPR)
Program policy was revised for reissuance and published in
March 2012. Better policies for prevention, response and
oversight of the SAPR program were promulgated.

In 2008 and 2009, significant advances were made to evaluate and
meet the medical needs of deploying and returning female Service
members:

The Deputy Secretary of Defense convened a Scientific
Oversight Committee meeting which specifically addressed Women
Wounded Warrior Issues, appraised gender-specific foci in
clinical and research studies, and reviewed compliance with the
NDAA FY 2008 mandates.
In October 2009, the Armed Forces Health Surveillance
Center published a monograph that focused on the unique health
issues of women in combat environments and identified
conditions with consistently high incidence rates among
females, which served to highlight treatment essentials and
inform clinicians' diagnostic sensibilities and medical system
requirements in theater.
Mrs. Davis. There continues to be concern that diagnosis and
treatment for PTS and TBI are still not at the levels needed to ensure
that service members are getting the proper diagnosis and treatment for
either PTS or TBI. Where is the Department and the individual Services
on this issue?
Secretary Woodson. The Defense Department (DOD) and Military
Healthcare System (MHS) remain committed to the delivery of high
quality care by appropriately diagnosing and treating Service members
(SMs) with posttraumatic stress disorder (PTSD) or traumatic brain
injury (TBI). To address PTSD, the DOD has added over 2,000 behavioral
health providers to military hospitals and clinics, and 10,000 more to
the care networks since 2009. There are currently many collaborative
programs in the MHS, to include the Army Re-Engineering Systems of
Primary Care Treatment in the Military (RESPECT-Mil) and the USAF
Behavioral Health Optimization Project (BHOP), that systematically
coordinate care for SMs with psychological health (PH), TBI and other
co-occurring conditions. The DOD is also highly invested in efforts to
enhance psychological resilience/prevention, stigma reduction, and
improved access to PH and TBI services.
Further, the DOD has placed increased emphasis on PTSD and TBI
screening in all individual Services to ensure that SMs are getting
proper and timely diagnoses and treatment. The DOD has established
enterprise wide screening and assessment procedures to identify both PH
and TBI in SM at the earliest opportunity. For example, the Directive-
Type Memorandum (DTM) 09-033: ``Policy Guidance for the Management of
Concussion/Mild Traumatic Brain Injury in the Deployed Setting,''
requires the assessment of all SMs involved in potentially concussive
events. Events requiring mandatory screening include any SM within 50
meters of a blast, involved in a vehicle collision or rollover, any SM
who sustained a direct blow to the head or had loss of consciousness.
All personnel with potentially concussive events are evaluated through
evidence based clinical algorithms utilizing a mandatory standardized
screening. Results are recorded for each screened individual, and
submitted as part of the significant activities (SIGACT) report
required for blast-related events. The DTM also outlines four clinical
practice algorithms used by medical personnel. These were recently
revised in 2012 by a DOD working group that included representatives
from all Services. Additional efforts are underway at Military
Treatment Facilities (MTFs) to identify SMs who are medically evacuated
for any illness or injury, or are otherwise redeployed from theater for
signs or symptoms of TBI. These additional screenings help to identify
those SMs with a prior history of TBI or concussion exposure, are newly
symptomatic, or those with poly-trauma whose injuries may have
precluded an earlier evaluation for mild TBI. Receiving CONUS MTFs also
rescreen wounded or ill SMs that are evacuated.
Additional screening of all SMs for TBI and PTSD also occurs
through DOD Post-Deployment Health Assessments (PDHA) and Post-
Deployment Health Reassessments (PDHRA). SMs who respond positively are
referred for further clinical evaluation for mild TBI/concussion and/or
PTSD. The DOD's focus on TBI screening, diagnosis, and treatment has
resulted in the development of over 60 TBI programs in MTFs in the non-
deployed setting with varying levels of capabilities, and the
establishment of 11 Concussion Restoration Care Centers in the deployed
setting. There are over 377 programs available to help SMs with PH
problems (including PTSD), in addition to clinical treatment available
at MTF's and locally through Tricare providers stateside, and through
deployed providers in-theater.
Other initiatives to strengthen diagnosis and treatment efforts for
PTSD and TBI involve the Joint Clinical Practice Guidelines (CPGs),
which have been created by the DOD and VA to identify and promote
effective PH and TBI care practices within and between the departments.
Companion Clinical Support Tools for PTSD are in development and
scheduled to be released in late summer of 2012. DOD has also developed
Clinical Recommendations for managing neuroendocrine, visual and
vestibular disturbances following mild TBI, scheduled to be released in
2012. Another cooperative effort between the DOD and VA, known as the
``Integrated Mental Health Strategies'' (IMHS), was developed to
identify specific mutual goals that improve the quality, consistency,
and continuity of PH and TBI health care for SMs, Veterans, and their
families. All individual Services have representatives working on these
initiatives.
Finally, the DOD has made a strong financial commitment to continue
to support research related to factors that inform the development of
evidence based treatment for both PTSD and TBI. The DOD's neurotrauma
research portfolio through MRMC includes more than 600 clinical
research studies encompassing novel treatment modalities to include
nutraceuticals, complementary and alternative medicine, hyperbaric
oxygen and other pharmacotherapies. The DOD also currently funds nine
on-going additional studies to investigate the use of cognitive
rehabilitation therapies in TBI. The DOD has made cognitive
rehabilitation techniques available to SMs with cognitive and
behavioral deficits subsequent to TBI. MRMC also supports DOD efforts
to sustain a robust PTSD research program. The PTSD portfolio
represents broad areas of study to include epidemiology, basic science,
prevention and education, early screening and interventions,
assessment, treatment, and recovery/return to duty. There are now over
300 PTSD studies funded and in progress. PTSD and TBI research results
are used to inform and guide new clinical practices and these
interventions are systematically taught to providers who treat SM's
with PTSD and TBI. DOD research efforts will continue to ensure that
our SMs receive the greatest benefit, via accurate diagnosis and
effective treatment derived from the most current scientific knowledge
in the field.
Mrs. Davis. What are the strategic issues that the subcommittee
should be considering to ensure the success of the military healthcare
system?
Secretary Woodson. The Military Health System has adopted the
Quadruple Aim to describe our high level goals: improved readiness,
better health, better care and lower costs. We have grouped the high
level strategic issues according to the aim they most affect.

Readiness:

Understanding and meeting the long term needs for
medical care generated by 10 years of war
Integrating and optimizing psychological health
programs to improve outcomes
Maintaining the skills and capabilities of the all-
volunteer medical force that has performed so well in serving
the warfighter

Population Health:

Addressing the behaviors that influence the majority
of health outcomes starting with obesity and tobacco use

Experience of Care:

Improving safety and quality by implementing evidence
based practices across the enterprise and making the MHS the
safest health system in the world
Implementing the integrated Electronic Health Record
(iEHR) with the VA to support better decisions, integrate
patients into the care process and reduce waste

Per Capita Cost:

Optimizing market management to bring care back to
our Military Treatment Facilities to support readiness,
strengthen Graduate Medical Education and reduce costs
Aligning incentives to pay for value
Rebalancing government and beneficiary cost shares
Mrs. Davis. The Department of Defense has proposed cost increases
for the health care of our military retirees. Why is the Department
proposing such large fee increases for our military retirees? What was
the rationale to begin a means testing for healthcare fees?
Secretary Woodson. Our proposed changes in the cost-sharing formula
for health care will mostly affect retirees and, especially, retirees
who are under the age of 65 and are still in their working years. Since
2001, the cost of military pay and benefits has grown by over 87
percent (30 percent more than inflation), while Active Duty end
strength has grown by about three percent. We felt we had to review pay
and benefits to avoid overly large reductions in forces and
investments.
The military and civilian leadership considered changes in pay and
benefits based on several guiding principles. To begin with, the
military compensation system must take into account the unique stress
of military life. It should not simply be a copy of civilian systems.
The system must also enable us to recruit and retain needed personnel.
And we must keep faith with our military personnel.
Changes affecting pay and compensation were designed to be
disproportionately small when compared to the changes in forces and
investments. While pay and benefits account for about one-third of the
Defense budget, savings from the initiatives we are proposing will
amount to about $29 billion over the FYDP, which is slightly more than
10 percent of our savings target.
It is important to note that the proposed cost-sharing changes are
still modest compared to the cost-shares, as a percentage of total
healthcare costs, borne by beneficiaries as recently as 1996. In that
year, we estimate that retiree beneficiaries were responsible for out-
of-pocket costs representing 27 percent of the total healthcare costs.
Due to the fact that virtually all beneficiary cost-shares were either
frozen (or dropped further) since 1996, these out-of-pocket costs
dropped to 10 percent of the total healthcare costs. While cost-sharing
is increasing, it is still well below 1996 levels, and will stabilize
at approximately 14 percent of total health costs under this proposal.
Where feasible, the proposed fee increases were tiered by military
retirement pay, based on the principles of the FY 2007 Task Force on
the Future of Military Medicine. In its deliberations, the Task Force
recognized that military retirement is not like most civilian
retirement systems and that the entire military compensation system
differs from the typical civilian ``salary'' system because much of the
compensation is ``in-kind'' or ``deferred.'' Thus, changes in the
healthcare benefit were examined in the context of this unique system
and its compensation laws, policies, and programs. The Task Force
believes that, for equity reasons, military retirees who earn more
military retired pay should pay a higher enrollment fee than those who
earn less. While this ``tiering'' approach is not commonly used in the
private sector for enrollment fees, the Task Force believed that it
made sense in a military environment.
Mrs. Davis. With your statements supporting the proposed changes to
TRICARE, what is the impact to the DHP if Congress does not authorize
the TRICARE fee increases? Even if Congress was to approve the fees,
how will the Department cover unanticipated costs if the savings
estimated from beneficiaries opting out of TRICARE do not materialize
to the estimated levels?
Secretary Woodson. If Congress does not provide us with needed
support for the health reform proposals, the Department will have to
find about $12.9 billion, the projected savings from these proposals,
from other Defense programs to meet its healthcare obligations. Such
action would place the new defense strategy at risk. Without needed
authority, the Department will face further cuts in forces and
investment to be consistent with the Budget Control Act. The
Department's budget proposal already makes substantial reductions in
the investment accounts so further cuts might fall mostly on forces.
This could mean cutting additional Active Duty and Reserve Forces by
FY17 at a magnitude that could jeopardize the Department's ability to
pursue the new defense strategy.
If the assumptions on the behavioral changes projected in the
Budget are overstated, savings will be reduced and the Department would
have to review all requirements and resources available at that point
in time. However, it is important to note that, if the behavior effect
is not seen as modeled, the Department would still capture savings
because those beneficiaries will still be subject to the higher fees.
For example, if a beneficiary does not switch a prescription from
retail to mail order, which results in some savings, they would still
be subject to the higher copay in retail which would still result in
some savings. However, since the proposals provide some incentive to
motivate beneficiaries to use more cost-effective healthcare options,
some behavioral effects will be inevitable. The Department will be able
to refine its projections over time, based on actual experience.
Mrs. Davis. Vision injuries have impacted 58,000 OIF and OEF
service members according to DOD, hearing loss has been diagnosed in
over 189,000 veterans from OIF and OEF according to VA, and male
urological injuries from blasts have exceeded 1,670 and yet these
battlefield wounds have not received the research funding that other
types of defense medical research programs have in past budgets. Should
additional funding be provided for these types of injuries given their
traumatic impact on service members?
Secretary Woodson. Research in vision injuries, hearing loss, and
genitourinary injury are included in the Clinical and Rehabilitative
Medicine Research Program (CRMRP). The CRMRP focuses on definitive and
rehabilitative care innovations required to reset our wounded warriors,
both in terms of duty performance and quality of life. Due to advances
in trauma care, increasing numbers of service members are surviving
with extreme trauma to the extremities and head. The program has
multiple initiatives to achieve its goals, including improving
prosthetic function, enhancing self-regenerative capacity, improving
limb/organ transplant success, creating full functioning limbs/organs,
repairing damaged eyes, treating visual dysfunction following injury,
improving pain management, and enhancing rehabilitative care. These
initiatives leverage research across the CRMRP to address dismounted
complex blast injuries that include genitourinary injuries.

Mrs. Davis. Where is the Army in implementing a confidential
alcohol program? A pilot program was established in three bases. What
is the current status of those programs, and what is the Army's plan to
address the increasing concern of alcohol abuse among soldiers?
General Horoho. In July 2009, the Army Center for Substance Abuse
Programs (ACSAP) initiated the Confidential Alcohol Treatment and
Education Pilot (CATEP) program at Fort Lewis, Fort Richardson, and
Schofield Barracks. After conducting initial evaluations of the pilot,
the Army expanded its implementation to Fort Carson, Fort Riley and
Fort Leonard Wood in August 2010. In July 2011 the Army approved
testing of CATEP procedural improvements, which included an enrollment
contract in an effort to decrease the voluntary dropout rate and to
ensure Soldiers with alcohol disorders receive the treatment their
conditions require. As of August 2012, CATEP participation at the six
pilot sites is as follows: a total of 1310 Soldiers self-referred; of
which 924 were screened and enrolled and 386 were screened, but not
enrolled. A total of 253 Soldiers have successfully completed CATEP and
another 127 are currently enrolled. In August 2012, the Deputy Chief of
Staff, G-1 will provide the Vice Chief of the Army with results of
CATEP and recommendations for the way ahead on the expansion of CATEP
Army-wide by Fiscal Year 2013.
In addition to its efforts with CATEP, the Army recognizes the
increasing role substance abuse plays in many high-risk behaviors,
including suicide, and therefore is responding with comprehensive
prevention resources, increased counselor hiring, and anti-stigma
campaign efforts.
To deliver substance abuse prevention services to Soldiers, the
Army adopted Prime For Life (PFL) as its Alcohol and Drug Abuse
Prevention Training (ADAPT). PFL, a classroom training platform
developed over a 25-year time span, is delivered by certified
Prevention Coordinator instructors. In April 2012, the Army began
fielding a 4-hour standardized universal prevention training package
for Soldiers. The Army will continue to define, develop and field
leader-centric training for substance abuse, leveraging squad and
platoon leaders.
As of 25 July 2012, the Army has 481 substance abuse counselors, an
increase of 57 since September 2011, providing education and treatment
for Soldiers. We continue recruiting efforts to fill vacancies and put
several initiatives in place to create a pipeline of resources that
will be available to fill vacancies.
The ACSAP completed a comprehensive study of stigma associated with
substance abuse treatment and found stigma to be prevalent. As a
result, the Army initiated a new campaign focusing on a more
comprehensive view of stigma and developed messaging on a broader range
of issues to encourage Soldiers to seek help for substance abuse,
behavioral health, sexual assault and other personal challenges.
ACSAP is currently rewriting Army Regulation 600-85, The Army
Substance Abuse Program, to codify ASAP policies related to the fitness
and combat readiness of Soldiers.
Mrs. Davis. Last year, this Congress directed the Comptroller
General to conduct a review of women-specific health services and
treatment. What is the Department and the Services doing to address the
healthcare needs of female service members and dependents?
General Horoho. The Women's Health Campaign Plan focuses on
standardized women's health education and training, logistical support
for women's health items, fit and functionality of the Army uniform and
protective gear for females, research and development into gynecologic
issues during deployment, sexual assault case management, and the
psychosocial effects of combat on women.
Mrs. Davis. There continues to be concern that diagnosis and
treatment for PTS and TBI are still not at the levels needed to ensure
that service members are getting the proper diagnosis and treatment for
either PTS or TBI. Where is the Department and the individual Services
on this issue?
General Horoho. The Army provides behavioral health care for all
recognized behavioral health conditions as defined by the Diagnostic
and Statistical Manual of Mental Disorders, 4th Edition, Text Revision.
In February 2010 the Army launched the Behavioral Health System of Care
Campaign Plan to standardize, synchronize, and coordinate behavioral
health care, including PTSD, across the Army and throughout the Army
Force Generation cycle. The Army has implemented a comprehensive TBI
Action Plan based on the 2007 TBI Task Force Report and has hired over
460 providers since 2007 to evaluate and treat Soldiers with TBI.
Providers at Army treatment facilities utilize the 2008 VA-DOD Clinical
Practice Guidelines (CPGs) for the medical management of Service
Members with concussion/mTBI. This set of CPGs was recently rated as
the best of 8 CPGs for concussion/mTBI management and represent the
highest level of scientific evidence. TBI care policy and medical
algorithms in the deployed environment include special provisions for
recurrent concussions within the previous 12 months. This proactive
policy promotes early detection, medical management, and helps prevent
subsequent concussion while the brain is still healing. In order to
assist with the medical evaluation and advance TBI research, the
Department of Defense deployed 3 MRI machines to Afghanistan in October
2011.
The U.S. Army Medical Research and Material Command has invested
over $633 Million since 2007 to advance the science of TBI detection/
screening, diagnosis, and treatment. While a definitive diagnostic
biomarker for TBI is not available, Army Medicine is collaborating with
academic and civilian scientists to evaluate tests that help identify
TBI. The scientific community is also researching promising treatments
to ensure that they are both safe and effective for TBI rehabilitation.
Mrs. Davis. The Department of Defense has proposed cost increases
for health care that not only will impact retirees, but they could also
impact military dependents. Has your Service looked at the potential
impact of these fee increases and its impact on retention of the force?
General Horoho. The Army Medical Department has not studied any
impact of TRICARE fee proposals on retention of the force.
Mrs. Davis. With your statements supporting the proposed changes to
TRICARE, what is the impact to the DHP if Congress does not authorize
the TRICARE fee increases? Even if Congress was to approve the fees,
how will the Department cover unanticipated costs if the savings
estimated from beneficiaries opting out of TRICARE do not materialize
to the estimated levels?
General Horoho. If Congress does not support proposed reform,
ASD(HA) has projected a Department deficit of $12.9 billion which will
impact other Defense programs in order to meet healthcare obligations.
Without needed authority, ASD(HA) states the Department will face
further cuts to important programs and investments. If the assumptions
on the behavioral changes projected in the Budget are overstated,
savings will be reduced and the Department would have to review all
requirements and resources available at that point in time.

Mrs. Davis. There are anecdotal stories that service members are
self-medicating themselves through alcohol consumption. What are your
Services doing as well to address alcohol abuse among airmen, sailors,
and marines as well?
Admiral Nathan. Navy Medicine has launched the MORE program (My
Online Recovery Experience), a web- and phone-based recovery support
program for Service members recovering from alcohol dependence. MORE
offers individually tailored patient education and support over a
secure web-based system with world-wide access, 24 hour-day, seven-days
a week.
Additionally, the Navy has a long-standing and extensive Substance
Abuse & Rehabilitation Program (SARP):

--SARP has transitioned from an addiction-only treatment program to
a dual diagnosis program that identifies and treats mental health
illnesses in addition to identifying and treating substance use
disorders. SARPs located at Naval Medical Center Portsmouth and Naval
Medical Center San Diego also treat patients with dual diagnoses
(substance use disorder and mental health illness).
--SARP has established screening and treatment protocols for
substance abuse and dependence, providing necessary treatment and
rehabilitation with pre- and continuing after-care where appropriate.
--All program activities comply with established DOD, DON, and Navy
Medicine guidance or governance.
--SARPs screen over 10,000 individuals a year, with an estimated
7,000 to 8,000 enrolling as patients annually.
--Fifty-two SARPs exist throughout the Navy Medicine enterprise,
with a mix of Active Duty and civilians who provide screening,
evaluation, and treatment. Treatments range from education with early
intervention, to outpatient and intensive outpatient therapies, up to
the highest level of inpatient care.
Mrs. Davis. Last year, this Congress directed the Comptroller
General to conduct a review of women-specific health services and
treatment. What is the Department and the Services doing to address the
healthcare needs of female service members and dependents?
Admiral Nathan. Navy Medicine is committed to delivering
outstanding, patient-centered healthcare services to our female Sailors
and Marines wherever and whenever needed. This support includes access
to care in both operational settings and at our medical treatment
facilities (MTFs). Navy Medicine continues to offer a full spectrum of
services to address the unique healthcare needs of female service
members and their family members. Referral processes are in place to
provide services not available at local MTFs.
In addition, Navy Medicine has Clinical Advisory Boards that
provide current evidence-based practice guidance from subject matter
experts throughout the Navy Medicine enterprise. Specifically, they
recommend policy, evaluate clinical practice guidelines and provide an
endorsement to support Navy-wide integration. At 18 MTFs, there are
peri-natal clinical advisory boards to guide the practice of maternal-
child health. Town hall meetings, local forums and patient satisfaction
surveys are used to gather feedback to ensure our patients have the
required access to services.
Mrs. Davis. There continues to be concern that diagnosis and
treatment for PTS and TBI are still not at the levels needed to ensure
that service members are getting the proper diagnosis and treatment for
either PTS or TBI. Where is the Department and the individual Services
on this issue?
Admiral Nathan. Post-Traumatic Stress Disorder (PTSD) is one of
many psychological health conditions that adversely impacts operational
readiness and quality of life. Navy Medicine has an umbrella of
psychological health programs that target multiple, often co-occurring,
mental health conditions including PTSD. These programs support
prevention, diagnosis, mitigation, treatment, and rehabilitation of
PTSD. Our efforts are also focused on appropriate staffing, meeting
access standards, implementing recommended and standardized evidence-
based practices, as well as reducing stigma and barriers to care.
Priorities include:

Embedding psychological health providers in Navy and
Marine Corps units, ensuring primary and secondary prevention
efforts and appropriate mental health care are readily
accessible for Sailors and Marines.
Embedding psychological health providers in the
primary care setting where most service members and their
families first seek assistance for mental health issues
enhancing integrated treatment, early recognition and access to
the appropriate level of psychological health care. The
Behavioral Health Integration Program in the Medical Home Port
is a new program that is actively being implemented across 69
Navy and Marine Corps sites.
Maintaining support to 17 Deployment Health Centers
(DHCs) as non-stigmatizing portals of care for service members
outside the traditional mental health setting.
Implementing innovative programs like Overcoming
Adversity and Stress Injury Support (OASIS) at the Naval
Medical Center San Diego is providing intensive mental health
care for service members with combat-related mental health
symptoms from posttraumatic stress disorder, as well as major
depressive disorders, anxiety disorders and substance abuse
problems. Care is provided seven days a week for 10-12 weeks,
and service members reside within the facility while they
receive treatment.
Providing active consultative subject matter
expertise to Line Leaders, focusing on preventive measures,
early pre-clinical recognition and intervention, as well as
recommended treatment management.

In addition, TBI care on the battlefield has improved significantly
since 2007 when it was labeled as a ``signature injury'' of the current
conflicts. Most improvements have targeted early screening and
diagnosis followed by definitive treatment. In 2010, Directive-type
Memorandum 09-033 resulted in improved diagnosis and treatment of
battlefield concussion. Policy highlights include mandatory screening
by line commanders for any service member in a potentially concussive
event, standardized medical screening with a 24 hour rest/recovery
period regardless of diagnosis, rest and education (the only proven
clinically effective treatments) for diagnosed concussion, and
guidelines for evaluation, treatment and return to duty for symptom-
free service members with 1, 2 or 3 concussions in a 12-month period.
From 1 AUG 2010 to 30 AUG 2011 this policy resulted in the enhanced
screening for 187 Sailors and 4684 Marines, resulting in diagnoses of
concussion in 27 Sailors and 803 Marines from that group. For the Navy
and Marine Corps, the primary treatment site for concussed service
members is the Concussion Care Restoration Center in Camp Leatherneck.
Since opening in 2010, the Camp Leatherneck has treated over 930
service members with first-time concussions, resulting in a greater
than 98% return to duty (RTD) rate, and an average of 10.1 days of duty
lost from point of injury to symptom-free RTD. There is also a
concussion clinic at the NATO Role III Hospital in Kandahar. Upon
return from deployment, enhanced screening methods for TBI and mental
health conditions are being piloted at several Navy and Marine Corps
sites. This includes increasing use of the National Intrepid Center of
Excellence (NICoE) along with development of NICoE satellite sites to
provide state-of-the-art screening and treatment for those patients
that do not improve with routine clinical care.
We are also heavily engaged in active and expansive partnerships
with the other Services, our Centers of Excellence, the VA, and leading
academic medical and research centers to make the best care available
to our warriors afflicted with PTSD and TBI.
Mrs. Davis. The Department of Defense has proposed cost increases
for health care that not only will impact retirees, but they could also
impact military dependents. Has your Service looked at the potential
impact of these fee increases and its impact on retention of the force?
Admiral Nathan. The Department of Navy supports these proposals and
believes they are important for ensuring a sustainable and equitable
benefit for all our beneficiaries. While the proposed increases will
primarily impact our retired beneficiaries, military medicine provides
one of the most comprehensive health benefits available. These changes
will help us better manage costs, provide quality, accessible care and
keep faith with our beneficiaries.
Mrs. Davis. With your statements supporting the proposed changes to
TRICARE, what is the impact to the DHP if Congress does not authorize
the TRICARE fee increases? Even if Congress was to approve the fees,
how will the Department cover unanticipated costs if the savings
estimated from beneficiaries opting out of TRICARE do not materialize
to the estimated levels?
Admiral Nathan. Based on information provided by the Assistant
Secretary of Defense for Health Affairs, if Congress does not provide
the needed support for the health reform proposals, the Department of
Defense will have to find about $12.9 billion, the projected five year
savings from these proposals, from other Defense programs to meet its
healthcare obligations. If the assumptions on the behavioral changes
projected in the Budget are overstated, savings will be reduced and the
Department of Defense would have to review all requirements and
resources available at that point in time.

Mrs. Davis. There are anecdotal stories that service members are
self-medicating themselves through alcohol consumption. What are your
Services doing as well to address alcohol abuse among airmen, sailors,
and marines as well?
General Green. As with any community, there are members of the Air
Force who will use alcohol to self-medicate. Therefore, the Air Force
has implemented processes to educate service members about the dangers
of alcohol misuse, to recognize this when self-medication and other
forms of alcohol misuse occurs, and to provide services when needed to
treat both substance abuse and other problems that individuals may use
alcohol to address.
One means of addressing alcohol misuse is that Air Force medical
professionals provide alcohol abuse prevention briefings to our first-
term Airmen, at base Newcomers' events, and annually to commanders,
first sergeants, other senior enlisted personnel and medical
professionals. Airmen involved with alcohol-related misconduct are
provided individualized, focused education to prevent recurrence or
worsening of alcohol related problems.
Additionally, Air Force medical providers also provide screenings
and treatment for alcohol abuse. Our medical providers screen patients
from all Services for alcohol misuse at each visit to primary care
medical home, and screen Air Force members during their annual health
assessment. Service members are also screened for depression and Post
Traumatic Stress Disorder and are provided effective mental health
treatment when necessary so there is no need to self-medicate with
alcohol. We also screen Airmen four different times as part of the pre-
and post-deployment health assessments. Healthcare providers address
concerns regarding a service member's drinking behaviors as they arise.
When further evaluation or treatment is necessary, a referral is made
to an integrated behavioral health provider in the primary care clinic
or to the specialty substance abuse providers. Our staff in the
Specialty Substance Abuse Programs at each Air Force installation will
assess service members and provide the appropriate education or
treatment, including a referral to a civilian program if a higher level
of care is needed than can be provided on the installation.
Mrs. Davis. Last year, this Congress directed the Comptroller
General to conduct a review of women-specific health services and
treatment. What is the Department and the Services doing to address the
healthcare needs of female service members and dependents?
General Green. The Air Force maintains a robust women's healthcare
program and provides women's health services at all Air Force bases in
the United States and overseas by either direct provision of care or
through timely referral. Most of our 75 medical treatment facilities
provide women's healthcare services through separately established
women's health clinics. These clinics provide comprehensive women's
health services, including well exams, health teaching and screening,
gynecological services, colposcopy, loop electrosurgical excision
procedure (LEEP), birth control services, and hormone replacement
therapy, to active duty, retired and dependent females. In addition to
primary care physicians and obstetrician/gynecologists, the Air Force
employs approximately 70 active duty Women's Health Nurse Practitioners
(WHNPs) and 14 civilian WHNPs.
In 2008, the Air Force began promoting full-time clinical WHNPs to
the rank of colonel with the specific goal of keeping these women's
health ``master clinicians'' at the bedside caring for women and
running the women's health clinics. Many of our WHNPs are trained as
sexual assault forensic examiners and providers and in this capacity
they perform the forensic/legal exams for victims of sexual assault. In
addition, our WHNPS are deployed around the world to provide care for
female airman, sailors, marines, and soldiers.
Air Force Surgeon General obstetric modernization funds have been
used to: establish an Obstetric Quality Forum to promote patient
safety, quality outcomes and process improvement; provide lactation
consultants for each Air Force site that delivers babies; create a
prenatal care counseling and education video; host a national Patient
Safety and Critical Care Obstetric conference; and lead a tri-service
effort to create an evidence-based practice guideline for the
management of pregnancy across the DOD and VA.
The Air Force Medical Service is also involved in a number of
ongoing women's health research projects. The San Antonio Military
Medical Health System (SAMMHS) Outcomes Coordinator and Pregnancy
Coordinator completed a prospective randomized trial of 1800 women
comparing routine one-on-one visits to a group prenatal care model.
Preliminary results published as part of a collaborative non-randomized
study with the March of Dimes showed a 60% reduction in the risk of
preterm birth. The results are being further analyzed and if sustained
have the potential to change the format of prenatal care around the
world. The Patient and Physician Radiotherapy Schedule Preferences for
Breast Cancer treated with Breast Conservation Therapy study seeks to
align of physician practice patterns with best evidence and patient
preferences in order to enhance patient autonomy and improve cancer
care. Recognizing that the pregnant spouses of deployed service members
face unique challenges, the Air Force Medical Service is engaged in the
Mentors Offering Maternal Support (M.O.M.S.) study to test the
effectiveness specialized support services for pregnant spouses of
deployed service members with the goal of promoting prenatal maternal
adaptation. Other ongoing studies include a research collaboration on a
FDA-promoted, multinational study involving 17-OH progesterone use for
the reduction of preterm birth, a randomized controlled trial
evaluating the use of lavender aromatherapy to reduce pain and anxiety
during cervical colposcopy, and a study of post-breast lumpectomy
reconstruction using cell-enriched fat grafting.
Mrs. Davis. There continues to be concern that diagnosis and
treatment for PTS and TBI are still not at the levels needed to ensure
that service members are getting the proper diagnosis and treatment for
either PTS or TBI. Where is the Department and the individual Services
on this issue?
General Green. Thank you for the opportunity to explain the Air
Force's approach for treating Service members who suffer from Traumatic
Brain Injury (TBI) or Post-Traumatic Stress Disorder (PTSD).
The Air Force's goal is to identify and address PTSD and TBI
symptoms as early as possible, before problems develop and to allow for
full return to duty. This goal is pursued through a combination of
programs aimed at screening, awareness education, and evidence-based
treatment.
Fortunately, despite Airmen deploying in roles involving combat or
being involved in the rescue or treatment of those with severe
injuries, the rate of both PTSD and TBI in Airmen has remained low. Per
our recent report to Congress, for example, the average PTSD rate of
new cases for active duty Airmen for 2003 through 2010 was 2.0 per
thousand (0.2%). The rate of TBI is about 10 per thousand (1%), nearly
90% of which are mild in severity. In mild TBI full recovery can be
expected by the majority within weeks.
The Air Force proactively screens for TBI, PTSD, and other mental
health concerns on a recurrent basis. This is accomplished via annual
Preventive Health Assessments and via Post-Deployment Health
Assessments and Post-Deployment Health Re-Assessments. Additionally,
Airmen are screened with the Automated Neuropsychological Assessment
Metrics (ANAM) prior to deployment in order to establish a baseline
measure of cognitive functioning. Deployed Service members who are
involved in an event which may cause a TBI are screened for TBI and
referred for further medical evaluation and treatment if the screening
is positive. In addition to history and examination, the ANAM may be
used post-injury in theater and compared to baseline pre-deployment
ANAM results to aid in the medical evaluation.
Airmen are provided with awareness education on PTSD and TBI and
are offered multiple opportunities to identify symptoms and concerns.
To ease access to mental health providers, many medical treatment
facilities have one or more mental health providers working directly in
the primary care clinics.
Formal training has significantly increased for providers on
assessment, diagnosis, and treatment of PTSD and TBI. The majority of
Air Force mental health providers have attended formal training in
evidence-based treatment of PTSD, and it is included in Air Force
social work and psychology training programs to ensure providers
appropriately recognize and treat affected individuals. Education on
the causes, signs, and symptoms of TBI and PTSD are provided through
new training modules in Self Aid and Buddy Care, an annually required
computer based training for all Airmen. More advanced education on TBI
and PTSD is provided in pre-deployment courses including Expeditionary
Medical Support course and Combat Casualty Care Course, to include use
of the Military Acute Concussion Evaluation and the Clinical Practice
Guidelines for TBI in the Deployed Setting. VA/DOD clinical practice
guidelines are also taught and used for the management of PTSD and TBI
in post-deployment health throughout the Air Force. There has been
increased emphasis on these topics during mental health and neurology
internship and residency programs. Finally, the Defense and Veterans
Brain Injury Center hosts an annual TBI Training Program to educate DOD
and VA healthcare providers. The formal training emphasizes the use of
evidence-based practices for the treatment of PTSD and/or TBI, to
include exposure-based therapies (with or without virtual reality
enhancement), medication management, and combinations of treatments.
Mrs. Davis. The Department of Defense has proposed cost increases
for health care that not only will impact retirees, but they could also
impact military dependents. Has your Service looked at the potential
impact of these fee increases and its impact on retention of the force?
General Green. Our retiree population actively shapes perceptions
of the value of military service. Any action that discourages our
retiree population can adversely impact recruiting activities.
Healthcare benefits for active duty military personnel are not impacted
under the current proposal. TRICARE standard caps affect the small
number of active duty family members not enrolled in Prime. The
pharmacy co-pay increases only affect those who do not get their
prescription filled at an Military Treatment Facility. Although
increases in healthcare fees may be perceived as a loss of benefit to
our retiree population, the increases are not expected to negatively
influence retention of active duty military personnel.
Mrs. Davis. With your statements supporting the proposed changes to
TRICARE, what is the impact to the DHP if Congress does not authorize
the TRICARE fee increases? Even if Congress was to approve the fees,
how will the Department cover unanticipated costs if the savings
estimated from beneficiaries opting out of TRICARE do not materialize
to the estimated levels?
General Green. If Congress does not provide us with needed support
for these proposals, the Department will have to find about $12.9
billion, the projected five year savings from these proposals, from
other Defense programs to meet its healthcare obligations. Without
needed authority, we will face further cuts in forces and investment to
be consistent with the Budget Control Act. Because our budget proposal
already makes substantial reductions in the investment accounts,
further cuts may impact end strength. If, for example, Congress did not
support any of our proposed TRICARE changes, the Department would have
to make very difficult choices between further cuts to weapons systems
or reducing end strength to cover the $12B hole in the budget. Cuts of
this magnitude would jeopardize our ability to pursue some priorities
as planned the new defense strategy and force potential cutbacks in
both direct and private sector care.
______

QUESTIONS SUBMITTED BY MR. JONES

Mr. Jones. Medicare pays about 60% and DOD pays 40% of the overall
TRICARE For Life (TFL) beneficiary costs, does your office have any
ideas on how to reduce the cost? Have you considered looking at a
management option for TFL beneficiaries?
Secretary Woodson. TRICARE for Life provides Medicare wrap-around
coverage when health care is a benefit under both programs, as long as
the beneficiary is enrolled in Medicare Part B. Medicare pays 80
percent of their allowed amount, and claims automatically cross over to
TRICARE where TRICARE processes the remainder for payment.
Recently, TRICARE Management Activity staff met with
representatives from the Centers for Medicare and Medicaid Services'
(CMS) Innovation Center to discuss the Comprehensive Primary Care
Initiative that CMS is developing. This initiative will use a managed
care approach to providing preventive care and disease management for
Medicare and other patients. It will reward providers when costs are
reduced as participants in the initiative achieve desired health
outcomes. Many TFL beneficiaries are likely participants in the
initiative, and TRICARE intends to monitor progress and results of the
initiative to assess how and whether to apply the care approach to a
broader segment of our TFL population.
We have also instituted new management controls that are applicable
when TRICARE becomes primary payer for a TFL beneficiary's stay in a
skilled nursing facility (SNF). This occurs after exhaustion of the
100-day SNF care coverage provided by Medicare. We have found that
bills for SNF care are among the largest of any that TFL must cover.
Now we require that SNF care beyond 100 days be preauthorized, and base
the decision upon review of medical records to ensure (a) that skilled
care truly is required and (b) if skilled care is required, that it is
of such intensity that it cannot be safely provided at a lower, less
expensive level, than in a SNF.
Mr. Jones. It is my understanding that DOD proposes to tie the cost
that the military retiree will pay to a ``means test'' system, meaning
the greater the annuity that a retiree receives, the more they will pay
for their health care. As you know, no other Federal retired employee
healthcare cost is ``means tested.'' Don't you think that this proposed
system is unfair to our service members and their families who have
sacrificed so much, especially this last decade?
Secretary Woodson. Where feasible, the proposed fee increases were
tiered by military retirement pay, based on the principles of the FY
2007 Task Force on the Future of Military Medicine. In its
deliberations, the Task Force recognized that military retirement is
not like most civilian retirement systems and that the entire military
compensation system differs from the typical civilian ``salary'' system
because much of the compensation is ``in-kind'' or ``deferred.'' Thus,
changes in the healthcare benefit were examined in the context of this
unique system and its compensation laws, policies, and programs. The
Task Force believed that, for equity reasons, military retirees who
earn more military retired pay should pay a higher enrollment fee than
those who earn less. While this ``tiering'' approach is not commonly
used in the private sector for enrollment fees, the Task Force believed
that it made sense in a military environment.
______

QUESTIONS SUBMITTED BY MS. BORDALLO

Ms. Bordallo. Do you believe that in this era of declining budgets
and military end-strength, that the prohibition on converting medical
military personnel to civilian personnel should be continued?
Secretary Woodson. No, I do not believe that the prohibition should
be continued. Given the fiscal and budgetary pressures facing the
Department and nation, the Department can achieve savings from pursuing
such conversions. Additionally, with declining end-strengths and
changing force structures, the Department must do everything it can to
minimize the utilization of uniformed military personnel in positions
that are not military essential, or do not require military unique
knowledge and skills to support readiness or career progression. A
significant portion of the current medical positions filled by military
personnel do not meet these criteria and could, and should, be
considered for conversion to civilian performance (or in certain
circumstances, private sector performance if appropriate and in
accordance with statutes). Doing so will not only achieve savings
associated with lower civilian personnel costs but also free military
personnel for more pressing needs of the Services and Combatant
Commanders.
Ms. Bordallo. How many military medical positions does the
Department currently have that could potentially be converted to
civilian performance because military incumbency is not essential?
Secretary Woodson. The Military Readiness Review (MRR) mandates the
number of uniformed men and women necessary to deliver military medical
and health care, and is established to meet service wartime
requirements and to provide adequate rotational and training
opportunities in order to maintain required skill levels for
deployment. The number of military providers above the level dictated
by the MRR could, and should, be converted to civilian positions (or
contract if appropriate and in accordance with policies and statutes)
without degrading either unit readiness or the training and
deployability of the military member. Prior to the prohibition on
conversion of such billets, the Department had estimated nearly 17,000
positions for conversion. Current data points to at least 6,000 medical
military positions that could potentially be converted to civilian
performance, at significant savings to the Department and in support of
the end-strength reductions.
Ms. Bordallo. Given the opportunity, could the Department save
money by converting medical military positions to civilian positions?
Secretary Woodson. Yes, the Department can save money by converting
medical military positions to civilian performance, or, in certain
circumstances, private sector performance (if appropriate and in
accordance with statutes). The Department estimates it could
potentially save in excess of $1.5 billion over a five year period
(with savings continuing annually beyond that) by converting military
medical positions to civilian performance, with no degradation to
quality of care. This is based on approximately 16,000 military medical
positions that were slated to be converted prior to the prohibition and
annual savings of approximately $22,000 per position. In addition to
these direct savings to the Department, additional government and
taxpayer savings would be realized by the Departments of Veterans
Affairs and Treasury by avoiding long-term deferred costs associated
with military incumbency.
Ms. Bordallo. Notwithstanding the current congressionally imposed
prohibition, how could the Department convert medical military
personnel to civilians given the current mandate across DOD to maintain
FY10 civilian levels?
Secretary Woodson. Absent the congressionally mandated prohibition,
medical military personnel could be converted to civilian personnel by
absorbing work into existing government positions by refining duties or
requirements; establishing new positions to perform these medical
duties by eliminating or shifting equivalent existing manpower
resources (personnel) from lower priority activities; or requesting an
exception. Any large-scale conversion of medical military manpower to
civilian, as originally programmed prior to the congressional
prohibition on such conversions, would require deviation and an
exception from the fiscal year 2010 civilian personnel levels the
Services have been directed to maintain.
Ms. Bordallo. What instances and requirements would justify
military incumbency for medical requirements instead of civilian
performance?
Secretary Woodson. The primary instance or requirement for military
incumbency is predicated on the fact that military members have an
obligation to deploy and medical personnel are a key element of the
operating forces. They are responsible for providing world class
medical and health care on the battlefield, referred to as ``Service
Wartime Requirements''. Additionally, career progression, overseas
rotation, and military unique skills/knowledge requirements necessitate
military incumbency outside of these ``Service Wartime Requirements''.
In order to maintain the necessary level of skills to meet operational,
mobilization, and wartime requirements, it is critical that military
medical professionals receive the training and patient load necessary
to provide experience with current medical scenarios, diagnoses and
treatments. Maintaining training and rotational practice opportunities
for military providers is critical to the continued health of the
Military Health System.
Ms. Bordallo. How many medical military positions were originally
slated to be converted to civilian positions prior to the prohibition
on such?
Secretary Woodson. The number of medical military positions
originally slated to be converted, prior to the implementation of the
congressional mandated prohibition, between fiscal years 2005 and 2013
was 16,876.
Ms. Bordallo. Do you believe that medical care for our uniformed
men and women and unit readiness would suffer if delivered by civilian
personnel instead of military personnel?
Secretary Woodson. The Military Readiness Review (MRR) mandates the
number of uniformed men and women necessary to deliver military medical
and health care. This number is established to meet service wartime
requirements and to provide adequate rotational and training
opportunities in order to maintain required skill levels for
deployment. I believe that any military medical billets above the level
dictated by the MRR could, and should, be converted to civilian
positions (or contract if appropriate and in accordance with policies
and statutes) without degrading medical care, unit readiness, or the
training and deployability of the military medical providers.
Ms. Bordallo. What impact has the civilian cap had on the Defense
Health Program and ability to deliver care?
Secretary Woodson. The Military Health System (MHS) draws
healthcare providers from three different labor sources: active and
reserve military, government civilian employees, and contracted
support. Any arbitrary personnel ceiling that limits the Department's
potential ability to hire civilian employees forces the MHS to increase
contracted support, both within the military treatment facilities and
in the local economy. The Department is committed to providing world
class healthcare to Service members, and that level of healthcare will
continue regardless of any constrants, but will come a significantly
higher cost if the MHS is forced to utilize contracted support in lieu
of government civilians. Such increased costs will impact availability
of care and the patient share of the cost, and take funding away from
other pressing medical and health needs of the force, as well as
reducing available funding for other compelling needs across the
Department.

Ms. Bordallo. Do you believe that in this era of declining budgets
and Army end-strength, that the prohibition on converting medical
military personnel to civilian personnel should be continued?
General Horoho. The current congressional prohibition has
effectively reduced programmatic and operational turmoil to our complex
medical workforce. Previous rounds of medical military to civilian
conversion directly impacted Army Medical Department mission
capabilities to the detriment of medical support to our Soldiers and
their Families. The inability to backfill military conversions with
qualified civilians in a timely basis generated shortfalls in the
delivery of health care, especially in the ancillary workforce required
to support our physicians and nurses. The Army restored military
billets converted between FY07-FY11, recognizing the negative effects
of reduced support staff and resulting decreased clinician efficiency
and effectiveness which directly impacted quality and access to care.
Ms. Bordallo. How many military medical positions does the Army
currently have that could potentially be converted to civilian
performance because military incumbency is not essential?
General Horoho. An assessment of military medical billets,
potential readiness impact, cost, and local market availability is
necessary to determine if any medical positions could be converted to
civilian performance. Military to civilian conversion would require the
programming of additional funding for the required civilian medical
workforce.
Ms. Bordallo. Do you believe that medical care for your soldiers
and unit readiness would suffer if delivered by civilian personnel
instead of military personnel?
General Horoho. The Army Medicine Team is composed of a symbiotic
core of military, civilian and contract healthcare personnel. As an
Army in persistent conflict for over a decade, we stand shoulder-to-
shoulder with the Warfighter, both on the battlefield and at home. Our
military healthcare personnel are the critical link between care in the
garrison environment and on remote battlefields. The combined Army
Medicine team leverages the strengths, competencies, Duty and Selfless
Service necessary to ensure a fit and medically ready force.

Ms. Bordallo. Do you believe that in this era of declining budgets
and Navy/Marine Corps end-strength, that the prohibition on converting
medical military personnel to civilian personnel should be continued?
Admiral Nathan. Military to civilian conversions in the Medical
Department are often independent of declining budgets and end strength
reductions. The ideal mix of personnel; active duty, civilians,
contractors, is established first and foremost to meet operational
requirements, and then to appropriately augment the team with civilian
and contractor staff; as is currently done. Uniformed staffing
requirements are directly linked to the operational needs of the Fleet
and Fleet Marine Forces. Active duty personnel directly support and
mobilize, when needed, to meet Combatant Commanders' requirements.
Civilian and contract staff augment and complete the staffing at our
fixed military treatment facilities, providing much needed continuity
of care delivery. As was learned during the last effort of Military-to-
Civilian conversions, ending the prohibition on converting military
personnel to civilian personnel will not necessarily lead to lower
costs.
Ms. Bordallo. How many military medical positions does the Navy/
Marine Corps currently have that could potentially be converted to
civilian performance because military incumbency is not essential?
Admiral Nathan. Navy Medicine uses an operational requirements
model, based on the Combatant Commanders' needs, to determine the
appropriate, number of uniformed medical department personnel needed to
ensure that the Navy and Marine Corps missions are met. The total
number of uniformed personnel within Navy Medicine today is adequate to
meet currently identified operational requirements. Uniformed personnel
are allocated to operational units and, when not deployed, are assigned
to our fixed military treatment facilities. There they hone and sustain
their needed clinical and ancillary skills in order to prepare for
their mobilization assignments. The number of medical professionals
needed to staff these Medical Treatment Facilities, in excess of active
duty requirements, may be supported by any personnel category
(military, civilian, or contractor). Navy Medicine's complement of
total staff, comprising all of these categories is approximately 63,000
men and women supporting Navy's healthcare missions.
Ms. Bordallo. Do you believe that medical care for sailors and
marines, and unit readiness would suffer if delivered by civilian
personnel instead of military personnel?
Admiral Nathan. Navy maintains one high standard of health care,
whether that care is delivered by military or civilian providers.
Military or civilian providers maintain the same qualifications and
credentialing standards. Navy Medicine meets the unit readiness and the
beneficiary peacetime missions while in-garrison, by employing
available uniformed staff, augmented by civilian and contract providers
and support staff at our fixed facilities. Civilians delivering care to
our deployable forces in our fixed Medical Treatment Facilities would
not degrade unit readiness, so long as a uniformed force is maintained
at the appropriate levels required to support our operational missions.

Ms. Bordallo. Do you believe that in this era of declining budgets
and Air Force end-strength, that the prohibition on converting medical
military personnel to civilian personnel should be continued?
General Green. In certain locations, and for certain Air Force
Specialty Codes, military-to-civilian conversions provide an effective
option to the Air Force Medical Service for managing costs while
continuing to deliver outstanding healthcare. The NDAA prohibition
inhibits the ability to optimize force structure for emerging and
changing missions and operations tempo by eliminating military to
civilian/contract conversion options when conversion is deemed the most
effective and efficient funding source. However, we need to ensure that
the conversions are in the appropriate market due to the availability
of civilians with the required skills/training and the potential
competition and pay disparities with the civilian sector.
Ms. Bordallo. How many military medical positions does the Air
Force currently have that could potentially be converted to civilian
performance because military incumbency is not essential?
General Green. The Air Force Defense Health Program current
Critical Operational Readiness Requirement is 25,284 and current active
duty Defense Health Program end-strength is 31,544. In theory, the Air
Force could potentially convert approximately 6,200 positions from
Military to Civilian across the Future Year Defense Plan (Fiscal Year
14-18) at an estimated rate of 1,240 positions per year.
Three very important issues that would impact the number of
conversions would be: 1. In theory, we could covert 6,200 Military to
Civilian positions; however, we may not be able to execute because of
the availability of civilians with the required skills/training and the
potential competition and pay disparities with the civilian sector. 2.
Currently there are ongoing discussions with Health Affairs and the
Service Surgeon Generals to develop strategies for determining medical
requirements and medical force sizing for future contingencies. 3.
There needs to be consistent civilian pay categories across all
government pay systems (e.g. DOD, VA, Public Health Service) to
simplify recruiting and retention of civilians.
Ms. Bordallo. Do you believe that medical care for airmen and unit
readiness would suffer if delivered by civilian personnel instead of
military personnel?
General Green. The Air Force does not believe that medical care for
Airmen would suffer if delivered by civilian personnel. The Air Force
has successfully utilized Active Duty, civilian and contract personnel
to provide medical care to our active duty population in our Medical
Treatment Facilities. Unit readiness requires a health system to assist
commanders' track and resolve health related readiness concerns. Any
Shift that eliminated the health system from assisting commanders could
impact readiness.
______

QUESTION SUBMITTED BY MR. LOEBSACK

Mr. Loebsack. My understanding is that an announcement was recently
made about the TRICARE program in the TRICARE West Region. Can you tell
me what the Department has done to ensure that there will be no
disruption in care for my constituents or for any TRICARE beneficiaries
in the region? What has been done to ensure that any changes in the
TRICARE West Region will not result in a reduction of healthcare
services available in rural states like Iowa for our service members
(including in the Reserve Component), retirees, and military families?
Secretary Woodson. The West contract is under protest and services
will continue under the old contract until the protest is resolved.
However, all TRICARE Regional contracts have transition periods as
required by statute and those transition periods address the transfer
of responsibility in a timely and orderly fashion. The contracts also
contain required access standards and networks of adequate size and
composition to cover all needed services in the Regions. While it
cannot be guaranteed that all providers currently in the TRIWEST
network will continue as providers under the new contractor, most will
be likely retained and beneficiaries will not be without services nor
should they experience any disruption of service as a result of the
transition, regardless of the area they live in.