[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 113-80]
DEFENSE HEALTH AGENCY
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON MILITARY PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
FEBRUARY 26, 2014
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SUBCOMMITTEE ON MILITARY PERSONNEL
JOE WILSON, South Carolina, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
JOSEPH J. HECK, Nevada ROBERT A. BRADY, Pennsylvania
AUSTIN SCOTT, Georgia MADELEINE Z. BORDALLO, Guam
BRAD R. WENSTRUP, Ohio DAVID LOEBSACK, Iowa
JACKIE WALORSKI, Indiana NIKI TSONGAS, Massachusetts
CHRISTOPHER P. GIBSON, New York CAROL SHEA-PORTER, New Hampshire
KRISTI L. NOEM, South Dakota
Jeanette James, Professional Staff Member
Debra Wada, Professional Staff Member
Colin Bosse, Clerk
C O N T E N T S
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CHRONOLOGICAL LIST OF HEARINGS
2014
Page
Hearing:
Wednesday, February 26, 2014, Defense Health Agency.............. 1
Appendix:
Wednesday, February 26, 2014..................................... 19
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WEDNESDAY, FEBRUARY 26, 2014
DEFENSE HEALTH AGENCY
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
Farrell, Brenda S., Director, Defense Capabilities and
Management, U.S. Government Accountability Office.............. 7
Robb, Lt Gen Douglas J., USAF, Director, Defense Health Agency... 5
Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for
Health Affairs, Department of Defense.......................... 3
APPENDIX
Prepared Statements:
Farrell, Brenda S............................................ 47
Wilson, Hon. Joe............................................. 23
Woodson, Hon. Jonathan, M.D., joint with Lt Gen Douglas J.
Robb....................................................... 25
Documents Submitted for the Record:
Statement of the American Clinical Laboratory Association.... 69
Witness Responses to Questions Asked During the Hearing:
Dr. Heck..................................................... 75
Mr. Wilson................................................... 75
Questions Submitted by Members Post Hearing:
Mr. Barber................................................... 84
Mr. Castro................................................... 85
Mr. Scott.................................................... 83
Ms. Tsongas.................................................. 83
Mr. Wilson................................................... 79
DEFENSE HEALTH AGENCY
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House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Wednesday, February 26, 2014.
The subcommittee met, pursuant to call, at 2:00 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, welcome to a meeting of
the House Armed Services Committee, Military Personnel
Subcommittee. Today the subcommittee meets to hear testimony on
the Defense Health Agency [DHA]. 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 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, Lieutenant Commander Addison Wilson,
Jr., who is a Navy orthopedic surgeon stationed in Naples,
Italy.
In June 2011, the House passed legislation establishing a
joint unified medical command as a method of making a
streamlined and efficient Military Health System [MHS], which
has been shown by multiple studies to be a potential source of
great cost savings. Ultimately, the Department of Defense [DOD]
rejected the option of a joint command, deciding instead to
establish the Defense Health Agency as part of an overall
restructure of governance of the Military Health System to
drive efficiencies and cost savings. This was done, despite
concerns raised by the Government Accountability Office [GAO]
about the Department's analyses of options for restructuring
the Military Health System.
I am anxious to hear from our witnesses how the Defense
Health Agency is progressing, including your forecast for
accomplishing the goals of increased efficiency and cost
reduction. To that end, I would like the witnesses to address
the following: First, the Government Accountability Office
offered several recommendations regarding implementation of the
Defense Health Agency. How has the Department addressed these
recommendations? Was a comprehensive cost analysis of the
Defense Health Agency conducted? And what were the results?
Second, in June of 2013, the Department estimated that the
Defense Health Agency staffing requirement would be 1,081. By
October 2013, that estimate nearly doubled to 1,941. What is
the current DHA staffing level? If it has been deviated from
the estimate, please explain why. Are further increases in
staffing required?
Pardon me. The phone has come to life.
Third, given that 7 of the 10 shared services were
implemented at the beginning of this fiscal year, are current
savings and spending levels on par with projections, especially
the pharmacy program, which was projected to attain early
savings?
Finally, I would like to hear how the military surgeons
general were involved in the implementation process.
I hope that 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 from California an opportunity to make opening
remarks.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 23.]
STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL
Mrs. Davis. Thank you, Mr. Chairman. I also want to welcome
Assistant Secretary Woodson, General Robb, and Ms. Farrell.
Given the recent budget released by the Secretary of
Defense on Monday, I am certainly looking forward to and I am
sure many people here are, to hearing from our DOD witnesses on
the state of the Defense Health Agency and its efforts to
consolidate functions, to better coordinate care, and reduce
resources.
As we all know, military healthcare budget is nearly $50
billion a year. And while we have a budget agreement for 2014,
sequestration still remains in effect for 2015 and future
years.
So difficult decisions will need to be made on how
reductions are going to be implemented and how the impact of
these reductions will be minimized as to not adversely impact
beneficiaries or their quality of care provided to them.
However, such achievements can only occur if there is
transparency and accountability of how the Department makes and
implements their decisions. The establishment and the
implementation of the Defense Health Agency is a case study
before us on where the Department can achieve transparency and
accountability within the Military Health System.
Ms. Farrell, thank you for coming. I look forward to
hearing GAO's assessment on the establishment of the DHA and
whether there are further areas of concern that the
subcommittee should continue to conduct oversight activities.
And I also look forward to hearing from Secretary Woodson,
of course, good to see you again, and General Robb on how the
DHA is moving forward, what efficiencies and savings have been
achieved to date, what is expected over the long term, and
where the DHA is in implementing all of the GAO's
recommendations.
So we thank you very much. Mr. Chairman, and look forward
to the discussion today.
Mr. Wilson. Thank you, Mrs. Davis.
We have three witnesses today. We would like 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 in 3 minutes. I assure you that your written comments
and statements will be made part of the hearing record.
I also want to announce that to ensure all Members have an
opportunity to question our witnesses we will use the 5-minute
rule when recognizing Members for questioning.
At this time, without objection, I ask unanimous consent
that an additional statement from the American Clinical
Laboratory Association be included in the record of this
hearing.
Without objection, so ordered.
[The information referred to can be found in the Appendix
on page 69.]
Mr. Wilson. Let me welcome the panel. Returning, the
Honorable Dr. Jonathan Woodson, M.D., Assistant Secretary of
Defense, Health Affairs, Department of Defense.
Thank you for being here.
Lieutenant General Doctor Douglas J. Robb, Director,
Defense Health Agency, U.S. Air Force, and Ms. Brenda S.
Farrell, Director Defense Capabilities and Management, U.S.
Government Accountability Office.
And before we begin, I would like to extend a special
welcome to General Robb, as this is his first appearance before
this subcommittee, and we appreciate your service to our
country.
As we begin, Dr. Woodson, and then we will shift over, and
then we will begin our questions. Thank you.
STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT SECRETARY
OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE
Dr. Woodson. Well, thank you very much, Chairman Wilson,
Ranking Member Davis, members of the committee. It is indeed a
privilege to be here today and update you on the Department's
implementation of an important reform in the Military Health
System, a needed reform in this era of significant challenges
for the Department and American health care at large.
Our national security and defense strategies must be
supported by a strong, relevant, agile, and forward-leaning
Military Health System. Our service members deserve and the
American people expect excellent care delivered reliably,
effectively, efficiently, and compassionately anywhere our
service members are stationed or deployed. We have good
evidence that joint integrated care improves results in combat.
Today, if a Marine unfortunately is wounded in combat, he
or she will be treated by a Navy corpsman immediately;
transported by an Army medevac unit to a level 2 or 3 facility,
staffed by Air Force, Army or Navy personnel working together;
further strategically evacuated, receiving critical care en
route by Air Force assets, to a level 4 or 5 facility where
again definitive advanced care will be given by a multiservice
healthcare team. This integrated, synchronized, coordinated
combat casualty care system transcends service and command
distinction and has resulted in the highest survival rates and
the lowest case fatality rates in recorded warfare.
This has come about not by chance but by designing a data-
driven integrated system focused on wounded warrior care and
improving outcomes. The system reduces variability and provides
for evidence-based common clinical and business processes
reform. Together with the surgeon generals, we have moved
forward to bring this design to all of our healthcare
operations.
Secretary Hagel has outlined his priorities for managing
the significant change needed in the coming years. These
include introducing institutional reforms, reevaluating our
military force planning construct, preparing for prolonged
readiness challenges, protecting investments in emerging
military capabilities, balancing forces between Active and
Reserves, and reforming personnel and compensation policies.
In order to meet our mission in these changing times, I
have outlined six lines of effort for the Military Health
System in support of the Secretary's priorities. These include
modernize the Military Health System's management with an
enterprise focus, define and deliver the medical capabilities
and manpower needed in the 21st century, invest in and expand
strategic partnerships, assess the balance of our medical force
structure, modernize the TRICARE health program, and define the
Military Health System's global health engagement requirements.
These strategic lines of effort will help us deliver on our
overwhelming--or our overarching quadruple aims of readiness,
improving the health of the populations we serve, improving the
experience of care in our system, and responsibly managing the
costs.
Today we will focus on the first priority, modernizing our
management structure. The establishment of the Defense Health
Agency represented a major milestone in the Department, and it
serves as a starting point for comprehensive enterprise-wide
reform.
In a few moments, General Robb will be sharing with you
steps we have taken and some early successes. But I also want
to provide additional context to our current situation. In
addition to the significant changes underway in our national
security posture, there is also dramatic change occurring in
American health care that will affect how we do business and
require us to refresh our thinking of health, health care, and
healthcare delivery systems. In addition to rising costs,
technology, subspecialization, information management, access,
and workforce issues are challenging the American healthcare
system. Health systems across the country, including ours, are
focused on ways to reduce variation in care, improve patient
safety, and more effectively use health information technology
to improve clinical decisionmaking and outcomes.
Within the military, there are additional imperatives for
designing an integrated health system, which includes more
joint basing, joint operations, and maintaining readiness. My
office, the service medical departments, and the Defense Health
Agency are partners in this process. We have created an agile
governance for policy and enterprise-wide operational
decisionmaking. We are holding ourselves accountable, using a
disciplined process for identifying opportunities and using
common enterprise-wide performance measures to see and check
what we are doing. We use the Government Accountability
Office's approach to conducting our business case analyses and
business process reengineering efforts. The GAO's reports to
Congress have been helpful, and we have taken continuous
corrective action to improve our analytic work and our project
management.
The Department is proud of its progress and the progress it
has made, but we need to be persistent in these efforts. I
thank you for the opportunity to speak today, and I look
forward to your questions.
[The joint prepared statement of Dr. Woodson and General
Robb can be found in the Appendix on page 25.]
Mr. Wilson. Thank you, Secretary Woodson.
And again, welcome, General Robb.
STATEMENT OF LT GEN DOUGLAS J. ROBB, USAF, DIRECTOR, DEFENSE
HEALTH AGENCY
General Robb. Chairman Wilson, Ranking Member Davis,
members of the committee. It is indeed an honor to be here for
the first time and to join Dr. Woodson in updating you on the
Defense Health Agency and our way forward over the coming
months and years. Dr. Woodson has already provided the
overarching strategy to make the MHS stronger, better, and more
relevant for our future. I am pleased to share with you how the
Defense Health Agency is going to contribute to that effort.
This agency came about after 18 studies over 50 years. The
vast majority of the 17 previous studies had recommended
greater integration of the Army, the Navy, and the Air Force
assets. However, little or no change occurred from those
earlier reports. However, we are proud that this, in the 18th
study, conducted in the summer of 2011, that I served as the
co-chair, the senior civilian military leaders in our
Department did indeed come together. And we analyzed almost
every possible organizational structure for the Department of
Defense. The Department then took action and selected the
Defense Health Agency as the best possible option to improve
the effectiveness and the efficiency without the cost and
disruption that would have accompanied other options.
In addition to providing the structure to create a more
integrated system of care, the Department also designated the
Defense Health Agency as a combat support agency. This is
important. It makes me accountable to the Chairman of the Joint
Chiefs of Staff, as well as Dr. Woodson, for ensuring that the
medical readiness needs of our combatant commanders are met.
And every 2 years, I will be graded by the chairman on how well
we are meeting that mission.
This is the central principle that I have conveyed to the
chairman, to the services, and to my own staff. The DHA stands
as a supporting organization, ensuring that the combatant
commanders and the service medical departments have the
resource support they require to meet their mission. Consistent
with the joint governance processes that Dr. Woodson outlined a
few minutes ago, the DHA's role as an integrator is to enhance
the ability of the services to accomplish their mission.
We have made significant progress in the first 150 days of
this reform effort. And we are on track with most of our major
milestones. Dr. Woodson mentioned the discipline and the rigor
of our approach in improving how we do business. This approach
has also provided all of us with insight into our most
challenging issues. In some instances, this process has allowed
us to rapidly introduce new processes, and we have accelerated
timelines for implementation and achieved savings, reduced
variation, and streamlined processes earlier than initially
projected. Our written testimony provided examples of the
status of all 10 of our shared services that comprise the
Defense Health Agency. I will not repeat that summary here,
but, rather, I want to highlight a few examples that illustrate
the value of the path that we are on and the reason for
optimism regarding the future.
In medical logistics, for example, we initially believed
fiscal year 2014 would require nominal investments or
additional costs to achieve the downstream savings in the
fiscal year 2015 through fiscal year 2019 period. However, the
DHA medical logistics community shared service implementation
effort identified opportunities to change the buying behaviors
even as we launched the agency in October. As a result, we are
on a path to cover our investment costs and save over $10
million when we previously projected no savings for this year.
Similarly, in the health information and technology shared
service, there are a number of initiatives to reduce redundancy
and consolidate IT contracts. The consolidation of the service
medical chief information officers into the DHA has allowed to
us move more quickly than we had anticipated, and we have
identified savings of almost $25 million in this fiscal year.
Of course, the most significant cost savings potential for
the Department still remains in the purchase healthcare sector.
Our efforts to improve the execution of the TRICARE health plan
are focused on long-term systemic challenges and how we better
integrate our direct care and private care health services
delivery and contracts for healthcare support. As this
generation of TRICARE contracts nears the end of its current
term, the Department is looking to reshape contracts in ways
that take advantage of strategic sourcing, improving
integration with military medical facilities, reduce
unnecessary overhead, and achieve greater simplicity and
flexibility for the beneficiary and for the government.
A final personal observation, after 5 months in this
position, as I work with my colleagues in the Army, the Navy,
and the Air Force, and with my own team in the Defense Health
Agency, we spend many hours studying how we can develop even
more common clinical and business efforts in support of our
warfighters. And at the end of each review, we can see progress
that we are making, the differences that we are making. And
more times than not and to a person, I hear the same thing:
this is the right way to go. In my personal experience
interacting with our partners, such as the Director of the
Defense Logistics Agency, is that they clearly see the benefit
of us operating as a single enterprise, and they are pleased
that we can present a single point of contact for Military
Health System issues. And the refrain from our internal team
and external partners is the same: we should have been doing
this sooner.
But we are not looking backwards, we are looking to the
future. Proud of the work we have accomplished, but even more
eager to identify ways that we can integrate our system on
behalf of the incredible people that we are privileged to
serve. Again, I appreciate the opportunity to be with you
today, and I look forward to your questions.
[The joint prepared statement of General Robb and Dr.
Woodson can be found in the Appendix on page 25.]
Mr. Wilson. Thank you, General.
Director Farrell.
STATEMENT OF BRENDA S. FARRELL, DIRECTOR, DEFENSE CAPABILITIES
AND MANAGEMENT, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Farrell. Thank you, Mr. Chairman.
Chairman Wilson, Ranking Member Davis, and members of the
subcommittee, thank you for the opportunity to be here today to
discuss whether the Defense Health Agency is positioned to
achieve the goals of DOD's effort to reform its Military Health
System. Let me briefly summarize my written statement.
DOD's Military Health System costs almost $50 billion
annually. The system's governance structure has been the
subject of many studies since 1949, some recommending major
changes to improve the cost efficiency of the system. GAO has
conducted a body of work reviewing efforts to reform the system
since 2006. In 2012, DOD announced the creation of the Defense
Health Agency by October 1, 2013. Congress required DOD to
provide its reform plans before the agency began initial
operations. Further, GAO was mandated to review DOD's reform
plans. My testimony today is based primarily on our report
issued in November 2013 that assessed DOD's plans. My main
message today is that DOD's senior leadership needs to take
additional actions to increase transparency and enhance
accountability of DOD's reform plans. These actions address
staffing, cost, and performance measures.
First, DOD has not determined its staffing requirements,
military, civilians, and contractors, for the new Defense
Health Agency. DOD did not have the data to determine how the
creation of the Defense Health Agency will affect the total
number of the system's headquarters staff because it does not
have a baseline assessment for current staff.
Notwithstanding, in 2011, using data that DOD later noted
was inaccurate, DOD identified estimated personnel savings as
part of the rationale for creating the new agency and
identified a resulting savings of almost $46 million. Our
previous work highlighted the need for Federal agencies to have
valid, reliable data, and to be aware of the size of their
workforce, its deployment across the organization, and the
knowledge, skills, and abilities needed for the agency to
accomplish its mission. A baseline assessment of a number of
current headquarters personnel is a crucial first step for
developing an estimate of the number of personnel that will be
required once the DHA is fully operational.
Second, DOD's cost savings estimates are unclear, as they
were missing key details, such as the sources for savings for
the various functions of its 10 shared services it is planning
as part of the reform effort. DOD aggregated the separate
business lines of its shared services, which obscures the size
and the cost of planned efficiencies for each business line. A
business case analysis requires detailed information to
convince customers and stakeholders that the selected business
process is the appropriate means for achieving performance.
In addition, DOD has not clarified its plans to monitor
implementation costs. In major reengineering efforts,
implementation costs can be the dominant cost element and the
area of greatest uncertainty. DOD's past experience with large-
scale projects, such as its initiative to acquire an electronic
health records system, demonstrates the difficulties in
controlling rising implementation costs. Greater clarity with
regard to the sources of cost savings is also needed to allow
senior leaders to monitor progress in achieving estimated
savings.
Third, DOD did not include critical details in performance
measures it developed to assess progress in achieving the seven
goals of the reform effort. Specifically, DOD did not develop
explanations for how each measure relates to the goals of the
reform effort, did not define the specific measure to be
developed, did not provide a baseline assessment of the current
performance that is to be measured and, most importantly, did
not identify quantifiable targets for assessing progress. Fully
developed performance measures are key to senior leaders'
ability to assess if DOD's reform effort is achieving the goals
or if corrective action is needed.
Let me conclude by noting that our November 2013 report
included recommendations in each of these areas to DOD, and DOD
concurred with our recommendations. DOD has taken action to
address these recommendations, but it has not completed them.
We continue to believe that it is imperative for DOD to
complete these actions so that decisionmakers will have
accurate and complete information to gauge reform progress
toward controlling costs versus adding to them.
Thank you, Mr. Chairman. I will be pleased to take
questions when you are ready.
[The prepared statement of Ms. Farrell can be found in the
Appendix on page 47.]
Mr. Wilson. Thank you very much, Ms. Farrell.
And we will begin now with each member of the subcommittee
asking questions for 5 minutes.
And a person above reproach, Jeanette James, is going to
keep the time.
And so this will be right on schedule. And we have votes
within the next possible 45 minutes. So that is why the time is
so important.
For each one of you, beginning with Secretary Woodson, when
the Department announced its decision to stand up the Defense
Health Agency as a more efficient governance structure, the
Government Accountability Office offered several
recommendations on improving the Department's decision process.
In response, the Department agreed to develop a comprehensive
cost analysis of the Defense Health Agency structure. What were
the results of the cost analysis?
Dr. Woodson. Thank you very much for that question.
And I want to reiterate that we have appreciated the GAO
review of our work. Some of the reports are a little out of
sequence in terms of the work that was actually done. And we
have clearly done a lot more work in terms of the analysis
relative to the questions that have been asked.
The issue about the cost investment is a significant one.
And one of the issues relative to that is that we are dealing
with a lot of shifting sets of program. We know what the base
cost and the base issues were relative to, let's say, TRICARE
Management Activity [TMA]. But, in fact, what we are doing is
we are layering on the shared services and bringing folks over
from the service headquarters.
I think the issue really is that, as we look at all of the
work that is done and we look at just fiscal year 2014, we
projected about $148 million in savings this year. And through
the first quarter, we have already achieved $80 million dollars
of that savings.
And so the issue is that we are ahead of schedule in terms
of the savings. And then, as we look at all of the areas,
particularly related to the shared services, again, we are
outpacing our projections. So, in the pharmacy area, of course,
we are projecting about $437 million in savings in fiscal year
2014. And we can submit for the record our estimation of these
savings.
So the bottom-line message that I am saying is that--giving
is that this is really, was complicated stuff in trying to
identify what was being done and what was the cost in each of
the headquarters, what was the baseline cost within the Defense
Health Agency. But the performance to date has been better than
projected.
And we can provide for you, again, a detailed assessment
for every shared service, what the estimate was and where we
are performing at this time. And, of course, to date, we have
incorporated a total for OIC [officer in charge] of six of the
shared services with four more to come on board.
[The information referred to can be found in the Appendix
on page 75.]
Mr. Wilson. Thank you, Dr. Woodson. Actually, complicated
but very impressive numbers.
General Robb.
General Robb. In regards to--I will cover specific
recommendations from the GAO report. And again, as Dr. Woodson
had mentioned, it only covered the first two reports to
Congress. In many of the issues that were raised by the GAO,
and appropriately so, were addressed in the third MHS report to
Congress. And what was good about their recommendations is it
allowed us to focus on what we needed to concentrate on.
So, in the first GAO recommendation, we have established
analytics function in the DHA. And that is key. We have never
done that in MHS. And that is key because that is going to
drive the standardization of the metrics across the enterprise.
So we are well down the, again, the road to standardizing,
again, an analytic function for our defense agency, which then
will drive, like you said, the measures, quantifiable,
objectable in a baseline assessment.
And then, just for some specific accomplishments, as far
the execution, our MHS enterprise core dashboard has been
developed. And, again, we are working its way through our new
governance structure to get buy-in from the services. And then
our multiservice market dashboard, where the rubber meets the
road, where those, again, the joint execution of health care is
going to occur, has also been approved and is currently being
used. And, again, we are using that to help drive and to
support our 5-year business plans.
On our second recommendation, we have--one of the
objectives is that, you know, our 10 shared services are well
on their way. Five of them stood up at IOC [initial operating
capability] when four were actually scheduled, and one of them
said, Hey, we are ready. And then, recently, we had budget and
accounting just came on board ahead of time, and we have three
more to go. So we have got that timeline, and we are staying on
track. And again, for the record, we would be glad to give that
to you.
And then more potential sources of cost savings. We had
projected the cost savings for the 10 shared services. Again,
2014, we are--again, we weren't--you know, we are 2015 to 2019,
we have predictions. We are looking at 2014. In fact, I review
that monthly, and so does our new governance system. Again, as
we are tracking the savings that are actually going to cover
many of our initial investments. Been a long time since I have
been in the military when we have been able to cover our costs
actually ahead of time. And so we are excited about that.
Because the folks out there, again, are dedicated to make this
happen. And then, again, we are going to--we can share again
the timelines for all our five shared services, actually the
four that remain and where we are going with that.
And then the--each of our shared services has--and we
talked about the specifics of it. Each one of them has started
out with a minimum of five business case analysis and five
businesses plus engineering. And again, the four that are
already on board, plus the fifth one--I gave logistics as an
example. You know, this isn't the future, this is already
executing and already getting a return on investment. So,
again, we track those monthly.
Our new governance system. We roll that up quarterly. We
just had the quarterly review. Again, we are 120 days, now 150
days into this. And again, they are very transparent on being
on target and on time and on glide slope to make sure that we
meet those recommended savings that we said that we were going
to do.
And then, number four, monitor implementations. Like I
talked about, these reviews, that the transparency is none like
I have ever seen it in my tenure in the MHS. One inside the
DHA, working its way up through the directors in the shared
services, and then, two, the new governance system that Dr.
Woodson had shared with you where our ones, you know, our
threes and fives, you know, our eights get together, almost
like a joint staff model, and again work out the issues. And
again transparency across the services, again, unheard of in my
tenure in the MHS.
And then, finally, develop and present to Congress baseline
assessment. So we--the staffing model for the DHA, again, is a
work in progress. But Dr. Woodson, and I will allow Dr. Woodson
to actually probably elaborate more on this. But we--there will
be no growth. I mean, my folks look at me, and I go, if you say
that you need something and where is it coming from. I mean, it
is clear there is no growth going to occur, especially in both
the military and civilian as we walk this through.
So our DHA, and all our folks understand this, is made up
of formerly known as TMA. But the shared services are the men
and women, again, who do the dedicated work inside each
service.
Mr. Wilson. Thank you, General.
My time is up.
General Robb. Yes.
Mr. Wilson. Ms. Farrell, if you could just provide for the
record later.
[The information referred to was not available at the time
of printing.]
Mr. Wilson. And we proceed to our ranking member, Susan
Davis.
Mrs. Davis. Thank you very much, Mr. Chairman.
I must say, I know that for a lot of people that are just
deep in the weeds of this in the audience, I think that they
have a good level of understanding. But if anybody else is
watching, they may be a little confused, because it is
difficult to sort of get a handle on this.
And I think one of the things that jumps out at me, I have
a sense, Ms. Farrell, that you are trying to get much more
detailed information, particularly in the staffing area. And
yet, you know, we are hearing that that is being provided. And
I am not exactly clear about that. So I am wondering, are you
satisfied with the sources of savings in that arena?
Ms. Farrell. It is true that our November 2013 report was
based on the first two submissions to Congress. But for this
testimony today we did obtain and review the third submission.
DOD noted in the comments to our 2013 report that many of
the--that they agreed with our findings, and many of the
actions would be taken and included in the third submission.
However, our review of that submission shows that it is still
lacking.
I do not want to take away from the very complex work under
the leadership of Dr. Woodson and Lieutenant General Robb. This
is a movement that we have seen much further than any of the
other reform efforts. But we still do not see a baseline
assessment, for example, that we were told would be in the
third submission. It is our understanding that that might be in
the 2014 strategic plan. Perhaps they can elaborate on that. We
do not believe that at this time DOD officials can determine
whether or not there will be an increase or a decrease in
staffing, since they do not have that baseline. And we
emphasize that the baseline should include not only military
and civilians, but the contractor workforce. We issued a report
last year that noted that the contractor services for DOD was
about 90 percent of the DOD Federal employees. The contractor
workforce is a significant part of the total workforce. DOD's
guidance even instructs them to consider all personnel
resources when making the manpower mix decisions, including
that of contractors. So we would encourage them to get that
inventory down.
Mrs. Davis. To include that. Because I guess, going to Dr.
Woodson and General Robb, if we are trying to get a 20 percent
savings and you don't have the baseline, how do we get there?
Dr. Woodson. So, you know, that is an excellent question.
And let me just give you sort of the idea of the complexity of
this. We have to map what is a new agency. Right. This has
never been done before.
Mrs. Davis. I want to say as well, I am delighted to see
the shift.
Dr. Woodson. Yes. It has, you know, got a core of, let's
say, TMA. And we can map those numbers, so we know we are on a
glide path to reducing those numbers down by 20 percent. We--
the reason being is that we were under a previous mandate to do
that under some Track Four Efficiencies and the like that the
Secretary had outlined some time ago.
But the issue really is, never before in the history of the
Military Health System have we had to map it back to the
headquarters of the individual service headquarters and some of
their sub-headquarters because of where the functions were
being performed.
And so that is a complicated process, and we do have better
fidelity on that now. But this will continue to be a work in
progress.
Anecdotally, though, what we are----
Mrs. Davis. Excuse me, Dr. Woodson.
Can I just interrupt for a second because we are almost out
of time. Because some of the information I have would suggest
that in the IT consolidated services alone that we have seen
the numbers really increase significantly there.
Dr. Woodson. Yes.
Mrs. Davis. So how is that?
Dr. Woodson. That is a great example. That is a great
example. Because one of the agreements between the services is
that the services wanted to get out of the health IT issue. And
so all of their folks transferred to DHA. So you are going to
see that swell. But what we found in the process is that we
immediately see duplications in positions. And so we are
working through what should be the glide path for reducing
those positions. So it is the first time really that we have
great--or understanding of this duplication that was occurring
within the service. So that is an absolute great example. So,
on the surface, it looks like a large bolus, and the reason is
that the service divested themselves of those people, but at
the same time, we immediately see where the duplications are.
Mrs. Davis. Okay. We will stop it there for now.
Thank you, Mr. Chairman.
Mr. Wilson. Thank you, Ms. Davis.
We now proceed to Congressman Dr. Joe Heck of Nevada.
Dr. Heck. Thank you, Mr. Chairman.
Thank you all for being here. I can just--can't even begin
to fathom the task. I mean, it is not like somebody handed you
a TDA [Table of Distribution and Allowances] and said, go build
Defense Health Agency. So I understand the numbers are going to
swing wide, like you just said. As you consolidate and people
come into your house, that is--the good side is now you have
increased visibility of where all these positions are. Now you
can start to right-size the force.
And I have no doubt, Dr. Woodson, that based on your
distinguished civilian and military career, that you are the
right guy to get this done.
And, General Robb, being a fellow D.O. [Doctor of
Osteopathy], I am sure you will be up to the task as well.
One of the shared lines of effort listed was medical
research and development. How will that, if it will at all,
impact, or what is the plan as it pertains to the
congressionally directed medical research program?
Dr. Woodson. I don't think that will negatively impact that
at all. But what it does do is it brings again great focus on
the research enterprise and allows us to set priorities more
effectively and achieve efficiencies in carrying it out. What
we have done, of course, is that in the old scheme, MRMC
[Medical Research and Materiel Command] was the basis on which
the services actually relied for many of its infrastructure
operations and carrying out research. Although, of course, Navy
had its assets and Air Force had its assets.
What we have done is we have linked the Defense Health
Agency to MRMC so the director of the Defense Health Agency is
now the deputy commander of MRMC. And it brings great clarity
and great unity in the issue of setting research priorities. It
actually allows us to leverage our dollars more effectively in
setting the priorities, get out the waste and the
infrastructure. Everything from, like, assurances to multiple
IRBs [independent review boards] will be dealt with and will
produce an efficiency in the research program that I don't
think has ever been seen before.
Dr. Heck. Great. That is very encouraging and I think long
overdue.
Now, I just want to ask, before I ask the question, were
you all aware of the statement from the Clinical Laboratory
Association that was going to be put into the record or what
the issue is that is contained herein?
Dr. Woodson. No.
Dr. Heck. Okay. So, evidently--there have been a lot of
questions, and this is probably going to be something that is
more at the tactical level than the strategic level, so if you
need to take it for the record, please do. Questions about the
TRICARE reimbursement on the laboratory-developed tests and the
lack of reimbursement for some of the molecular genetic tests.
And the question of why those tests were no longer being
covered if they were performed by an outside provider vice if
they were performed at an MTF [military treatment facility] and
whether or not they were or are not FDA-approved, how that all
came in. Some of the questions were, why was that decision
made? How was that decision made? And what are we going to do
to make sure that our beneficiaries have access to those tests
when needed?
Dr. Woodson. Thank you very much. I wasn't aware about the
submission for the record, but I do know about the subject. I
will take it and respond back to you fully. But let me give you
the bottom line up front. We have recognized sort of a
discrepancy. We have a program in place actually to fix it. And
none of the beneficiaries will be denied the tests that they
need to get great care.
[The information referred to can be found in the Appendix
on page 75.]
Dr. Heck. Regardless of whether it is done at an MTF or a
civilian location?
Dr. Woodson. Exactly. We are going to harmonize that whole
issue. It has to do with an issue of what we can pay for under
TRICARE care versus what can be done within the direct-care
system. It is a technical question that should never have come
into play with actually administration. It should be an
evidence-based decision about the test, not----
Dr. Heck. Great. I appreciate the quick response; look
forward to the full response for the record. Thanks.
Yield back, Mr. Chair.
Mr. Wilson. Thank you very much, Dr. Heck.
We really appreciate you being here today. And so we will--
I was conferring with the ranking member, Susan Davis. We will
continue for another round, and then we will recess and run
across the street.
For Dr. Woodson and General Robb, in June of 2013, the
Department estimated the Defense Health Agency staffing
requirement would be 1,081. By October 2013, that estimate
nearly doubled to 1,941. What is the current Defense Health
Agency staffing level? Please explain any deviation from the
estimate. Are further increases in staffing requirements
expected?
Secretary Woodson.
Dr. Woodson. Thank you, Chairman, for that question.
Again, this gets back to the issue of mapping individuals,
where they are coming from and what category they fall in. So
let me try and walk you through this. First of all, we need to
understand that the Defense Health Agency again is--was much
more than TMA. We are laying on shared service and bringing in
people from the services to do this work.
The baseline staffing for TMA had been estimated in
previous reports at over 2,800, basically. And this admittedly
took civilians and uniformed people and contractors.
Again, as it looks now, right with the six shared services
that are in, we are at 1,900. It looks like the core staffing,
though, is, again, at a glide slope of about 900, with a look
to reduce them to about 754. And what we are going to have to
do is map out all of these various categories and again matrix
it back to the headquarters to make sure that the headquarters
are not growing when they shift--even when they shift people
over. So it is a complicated process.
The data we have thus far suggests that we are on a glide
slope to reduce. We do understand, as mentioned before, that we
have gotten in duplications, if you will. So health IT is again
that issue where we are going to have to sort these individuals
out. But never before has anyone attempted to look at the grand
scheme of the MHS and map the FTEs [full-time equivalents] and
the duplication. And we are in that process. But I really feel
very sure that we are going to produce the efficiencies just
simply because they are showing up almost every day in terms of
the duplications.
Mr. Wilson. That is encouraging.
General Robb.
General Robb. Again, I will support Dr. Woodson in the
sense of we are building this. And as you see, an agency isn't
headquarters. An agency is an institution that provides a
service that we are supporting our organization. So when you
look at it from that perspective, for example, HIT [healthcare
information technology] was a prime example. And it depends on
the shared service. Some of it would be just executive
oversight and management. But the rest, like HIT, they are the
ones doing the work. They are the ones that are the CIO [chief
information officer] shops for the services. So, before, they
used to be in the service; now they are in our agency. And so--
and there has been no--there is no growth in the sense that the
numbers.
Now, Dr. Woodson talks about once we bring all those CIOs
together, they have already identified redundancies, and they
have already--again, as they do the business case analysis and
the business process reengineering, this is realtime; in other
words, this wasn't all done last summer, much less at IOC. And
again, there is work to be done in R&D [research and
development] and education training. But HIT is a great
example. So we have identified civilians for reduction. We have
identified military members for a reduction because of the
duplication. And again, as you can imagine--and, ma'am, to your
point, contracts. And so there is--that area there is ripe for,
one, inventory, and, two, reset.
Dr. Woodson. If I might add just one other example to give
sort of clarity on these numbers and how we have moved in a
positive direction. If you were to take, let's say, just the
movement of the NCR [National Capital Region] Directorate into
the DHA, JTF CAPMED [Joint Task Force National Capital Region
Medical] had probably about 130, 140-plus individuals with a
manning document that was probably about 176 or so. We have
reduced that to 42.
Mr. Wilson. My goodness.
Dr. Woodson. Forty-two. And this is the power of the
construct and the shared entity.
Mr. Wilson. We appreciate your oversight.
And we now proceed to Ranking Member Susan Davis.
Mrs. Davis. Thank you. I know we have talked about those
shared services. Could you share a little bit more about the
consolidation of education and training services as well, and
how is that figuring in with these cost savings? Where can we
go with that?
Dr. Woodson. So, thank you, again, for that question.
So one of the I think enabling factors in standing up the
DHA was the fact that we had begun in certain isolated pockets
to go to joint entities. The Medical Education and Training
Center in San Antonio is one of those issues. In my opening
statement, where I talked about that medic who first attended
to the wounded Marine, although he was a Navy corpsman, he
probably was trained at the Medical Education Training Center
next to the Air Force buddy and an Army buddy, basically. So it
was an easy move for that entity to come into education and
training.
But beyond that, we educate all the time medical personnel.
And so the money we spend on continuing medical education and
e-learning, graduate medical education, and the like, are all
opportunities to harmonize, synergize, and produce efficiencies
in that area.
Mrs. Davis. And you feel that--where--because--in some
ways, we want to be sure that we are--we are really allowing
the kinds of, I guess, creativity to come forward. And do you
think that is going to be better served?
Dr. Woodson. That is an excellent question. And I think
that is probably the most pertinent question we can ask.
We have been talking about standardization, efficiencies,
reducing variability. And sometimes that is considered counter
to innovation and, you know, really moving, advancing ahead.
The truth of the matter is that if you manage the processes
correctly, one helps the other. So reducing variability is
about identifying the best standard and then making sure we
create wisdom without--in the system so everybody operates at
that best standard.
But at the same time, I have stood up an innovation cell to
ensure that we are linking the appropriate communities of
interest so that we can find new ideas, whether it is advances
in strategies for education or strategies for care, we can feed
it and resource those appropriately, see if they are validated
by measuring, putting metrics against them, and then, at the
earliest opportunity, spreading it across the enterprise. So we
have not neglected the issue of innovation.
Mrs. Davis. Can you overlay employee satisfaction on that?
Because it is my understanding, again, that as we look at that
right now that the Defense Health Agency is kind of ranked
fairly low. And I don't know whether that is just because we
are in a transition. I mean, this is a difficult time for
everybody. But how are you evaluating morale? And where you see
that it is low, to what do you attribute that?
Dr. Woodson. So another great question.
I think, you know, our experience is that when you talk to
folks in the field, they are excited about the change. They
recognize that they have been working with their brothers and
sisters in the other services for some time. And they recognize
the opportunities of working in fellow service institutions.
I think the issues--we have to be careful at this time in
our history. We have been at war for 13-plus years. We have got
all of these budget issues in the news. Everybody is talking
about downsizing and the like. And it gets to be a very
confusing picture about what is driving morale.
I think in the medical community, what we are hearing when
you talk to the individual, everybody is nervous about change.
We are human beings; we get nervous about change. But the issue
is they are excited about the possibilities I think that this
new endeavor creates. So I have a different take on it. I think
there is some general anxiety out there about all that is going
on. I don't see the morale within the medical community as
having suffered.
Mrs. Davis. Director Farrell, do you pick up that also when
you are doing your gathering information? Is that something you
could weigh in on?
Ms. Farrell. We have ongoing work that is driven by this
committee specifically looking at the integration of medical
education in San Antonio. I would note that that is an effort
that actually started with BRAC in 2005, for consolidation of
facilities, not necessarily the education itself, that being
the courses. So we are currently looking at what integration
has actually taken place. What is the morale of the students?
What are the strengths? Are there any issues that are
developing? And we will be reporting that back to this
committee next month.
Mrs. Davis. All right. Thank you very much.
Thank you, Mr. Chairman.
Mr. Wilson. Thank you, Ms. Davis.
Now Congressman Dr. Joe Heck.
Dr. Heck. Thanks, Mr. Chair, for the second round of
questioning. Actually, my questions are in response to some of
the other answers to the other questions.
On medical education, is USUHS [Uniformed Services
University of Health Science] going to be within your wiring
diagram now?
Dr. Woodson. So USUHS is--yes, it is a report to me.
Dr. Heck. And as you move these other entities now, like
using IT from the services into DHA, who is the bill payer? Do
they stay on the services' books or are you picking up the tab?
Dr. Woodson. So a lot of that we have been picking up the
tab for, anyway. That is DHP [Defense Health Program] money.
And so it is very interesting. This project is just fascinating
in some sense.
So one of the things we had to figure out is, you know,
where the money goes. And so one of the initiatives, of course,
is we have developed a common cost accounting system. Never
been done before. So that we can track.
The bottom-line answer to your question, though, is that it
is DHP money, so we have been the bill payer. It is just that
we are now being able to centralize the portfolios, clean up
the portfolios so that we don't have duplicate IT programs and
the like. And it is just much more efficient. But we are the
bill payer.
Dr. Heck. And then, lastly, the whole concept for this was
put into place or developed prior to sequestration passing.
With the advent of sequestration, how do you see that, or does
it impact your ability to move forward on what you need to do
with DHA?
Dr. Woodson. Thank you, again, for another good question.
I hope everyone realizes that last year was a very
challenging year for us, right? We had the program cuts for the
Budget Control Act. We had sequestration. We had furloughs. We
had--this agency stood up in the middle of a government
shutdown. And yet it has delivered on the promise of the
savings and is getting the job done.
In direct answer to your question, though, thank God we
started down this path. Because if we had not and we had these
budgetary concerns and all of the issues in forced management,
forced reduction and the coming concerns, it would have spelled
disaster, I think, for the Military Health System. So we
started with vision in mind about what we need to do, because
it was right. It turns out it serves a purpose of efficiency
and meeting the budgetary issues as well.
Dr. Heck. Great. Again, thank you all for what you are
doing.
Yield back.
Mr. Wilson. Thank you very much, Dr. Heck.
And thank you all for being here today.
And indeed, we appreciate your promoting efficiencies, as
you indicated, in an extraordinarily disruptive environment.
That is very impressive.
If there is no further comment, we shall be adjourned.
[Whereupon, at 3:31 p.m., the subcommittee was adjourned.]
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
February 26, 2014
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RESPONSES TO QUESTIONS SUBMITTED BY MR. WILSON
Dr. Woodson and General Robb. GAO recommended that DOD develop (1)
a comprehensive cost analysis for its potential MHS governance options,
(2) a business case analysis and strategy for implementing its shared
services concept, and (3) more complete analyses of the options'
strengths and weaknesses. DOD concurred with developing a business case
analysis for its shared services concept. DOD did not concur with the
other 2 recommendations, stating that further analysis would not alter
its conclusions. Section 731 of the FY 2013 required that the
Department report to Congress on the progress achieved in standing up
the Defense Health Agency and Shared Services. In our first report to
the congressional defense committees, dated March 15, 2013, we
identified our reform efforts and provided detailed goals, milestones
and schedules for implementing the Defense Health Agency (DHA), the
enhanced multi-Service markets (eMSMs), and the National Capital Region
(NCR) Directorate. In our second report, dated June 27, 2013, we
provided our strategic objectives, success measures, and business case
analyses for four of the initial ten identified shared services. In the
third report, dated October 25, 2013, we provide specific information
for each shared service, including our assessments for the remaining
six shared services, to be implemented in FY 2014. [See page 9.]
______
RESPONSES TO QUESTIONS SUBMITTED BY DR. HECK
Dr. Woodson and General Robb. Providing safe and effective care for
our beneficiaries is our top priority. The DOD is committed to ensuring
that our beneficiaries have access to the full array of proven health
services, technologies, and products available in the United States.
Title 32, Code of Federal Regulations (CFR), Section 199.4(g)(15)(i),
provides that TRICARE cannot cost-share unproven drugs, devices,
medical treatments, or procedures, and that a drug, device, or medical
treatment or procedure is unproven if the drug or device cannot be
lawfully marketed without the approval or clearance of the United
States Food and Drug Administration (FDA). The Federal Food, Drug, and
Cosmetic Act (FFDCA) provides for the regulation of medical devices.
These medical devices are defined broadly in Title 21, United States
Code, Section 321, to include: ``an instrument, apparatus, implement,
machine, contrivance, implant, in vitro reagent, or other similar or
related articles, including any component, part or accessory which is .
. . intended for use in the diagnosis of disease or other conditions,
or in the cure, mitigation, treatment or prevention of disease.'' A
laboratory developed test (LDT) is a test developed by a single
clinical laboratory that provides testing to the public, but does not
sell the lab kit or its technological processes to other labs. LDTs are
considered to be medical devices by the FDA and the Defense Health
Agency (DHA).
The FDA has stated that clinical laboratories developing LDTs are
acting as manufacturers of medical devices and are subject to FDA
jurisdiction under the FFDCA, thus requiring either a Premarket
Notification 510(k) or Premarket Approval. However, the FDA has chosen
to exercise ``enforcement discretion'' regarding regulatory oversight
of LDTs, meaning the FDA has not required the removal of these tests
from the market. As a result, LDTs are available in the market without
FDA approval or clearance. However, when the FDA elects to exercise
enforcement discretion, this choice does not change the fact that the
law applies to those products. Consequently, and in accordance with the
federal regulations governing the TRICARE program, medical devices,
including LDTs, that require FDA approval or clearance for marketing
when such approval or clearance has not been given may not be cost-
shared by TRICARE.
As stated above, there has not been a change in TRICARE's
underlying coverage policies regarding non-FDA approved LDTs. Our
managed care support contractors (MCSCs) and beneficiaries are aware of
TRICARE's existing coverage policies, including the exclusion for
devices that are not FDA cleared/approved. The adoption of new Current
Procedural Terminology (CPT) codes, effective January 1, 2013, provided
payers, including the DOD, with greater transparency in billing for
laboratory tests. These coding changes allowed the DHA to identify
specific LDTs that: (1) have not been approved or cleared by the FDA,
and/or (2) failed to meet TRICARE criteria for coverage (e.g. demand
genetic testing that is not medically necessary and does not assist in
the medical management of the patient). While the revised codes allowed
TRICARE to accurately determine TRICARE coverage for specific tests,
there was no change in TRICARE's underlying coverage policies.
Consistent with the change in CPT coding, the DHA moved LDTs that were
not FDA approved or otherwise failed to meet TRICARE coverage criteria
to the Government's No Pay Procedure Code List.
The DHA recognizes that some non-FDA approved LDTs may be useful to
providers and patients with certain treatment decisions. This is due,
in part, to the on-going development of new medical tests and
technologies. In the absence of FDA approval/clearance of LDTs, we need
to establish an alternative process to ensure safety and efficacy. As a
result of beneficiary and provider input, TRICARE has chosen to
initiate a new demonstration project to review the safety and efficacy
of a broad range of non-FDA approved LDTs with potential high
utilization and potential high clinical impact for our beneficiaries.
This demonstration project will collect data to support potential
future regulatory revisions and enhance the flexibility of the MHS in
responding to emerging technologies. This new effort will expand upon
our existing demonstration project, which provides coverage for certain
LDTs that inform clinical decision making in cancer diagnosis and
treatment. Under the new demonstration project, we will assess the
safety and efficacy of a broader range of LDTs with potential high
utilization and potential high clinical impact on our TRICARE
beneficiaries. This demonstration project will also collect the
additional and necessary data to support future regulatory revisions.
In keeping with other demonstration projects, LDTs approved under the
new demonstration project will be covered by TRICARE during the
demonstration period and will also be available in Military Treatment
Facilities (MTFs). Once formalized, details of the demonstration
project will be published in the Federal Register.
We recognize there are differences between the purchased care
sectors and direct care sectors (MTFs) in the ability to obtain certain
LDTs; however, this is due to differing functions and specific federal
regulatory requirements for the purchased care sector. The new
demonstration project is an important first step in ensuring patients
seen in either the direct or purchased care sectors have the same
access to non-FDA approved LDTs that are determined to be safe and
effective. LDTs approved under the new demonstration for our purchased
care sector will be integrated into the direct care sector providing
more consistency between both systems. [See page 14.]
?
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
February 26, 2014
=======================================================================
QUESTIONS SUBMITTED BY MR. WILSON
Mr. Wilson. Families report significant barriers and delays to
enroll in the ABA Pilot and that care is often delayed by months. Can
you please tell me how many beneficiaries are currently receiving
services under the ABA Pilot? Please provide explanation for treatment
delays.
Dr. Woodson. Based on contractor feedback (TRICARE purchased-care
claims can be submitted up to one year after the service is provided
and, therefore, claims data incomplete and not a reliable indicator of
current ABA Pilot participation), as of January 31, 2014 there were 94
beneficiaries approved to receive Applied Behavior Analysis (ABA) for
treatment of Autism Spectrum Disorder (ASD) under the ABA Pilot and
another 168 pending approval. Completion of psychometric testing and
assessment is required for approval. Obtaining the required
psychometric testing--Autism Diagnostic Observation Schedule, Second
Edition (ADOS-2) and/or Vineland Adaptive Behavior Scale II (Vineland-
II), is the primary reason for reported delays. There have been several
meetings between the Managed Care Support Contractors and the Director,
TRICARE Health Plan to address this issue. Also, individual outreach
has been conducted to families in the approval process to assist them
in completing any needed actions to include completion of psychometric
testing.
Mr. Wilson. Why are the enrollment and authorization requirements
for the ABA Pilot more burdensome than authorizations under the Autism
Demonstration and the TRICARE Basic program?
Dr. Woodson. In sum, the enrollment and authorization requirements
for the Applied Behavior Analysis (ABA) Pilot are more burdensome than
authorizations under the Autism Demonstration as the ABA Pilot will
evaluate the feasibility of using standardized measures, not currently
a requirement under the ECHO Autism Demonstration, to assess ABA
treatment progress and report its findings to Congress concerning the
ABA Pilot for Non-Active Duty family members (NADFMs).
One objective of the ABA Pilot is to evaluate the use of
standardized measures to assess ABA treatment progress based on the
Behavior Analyst Certification Board (BACB) Guidelines for Health Plan
Coverage of Applied Behavior Analysis Treatment of Autism Spectrum
Disorders (2012). The guidelines recommend that data from standardized
tests are helpful to ``inform issues related to selection and
prioritization of treatment goals and determining a response to
treatment.'' This standardized psychological testing requirement
applies only to beneficiaries who choose to participate in the ABA
Pilot. There is no change for any other TRICARE beneficiaries--whether
Active Duty family members (ADFMs) or NADFMs--receiving ABA under the
TRICARE Basic Program, or for ADFMs receiving autism-related services
under the Extended Care Health Option Autism Demonstration.
An on-going series of focus groups is being held to solicit
feedback in hopes of using this information to optimally meet the needs
of beneficiaries.
Mr. Wilson. Families report that dollar caps under the Autism
Demonstration and the ABA Pilot prevent them from accessing recommended
treatment services. Can you please explain why so many families cannot
obtain coverage for treatment services that have been medically
prescribed?
Dr. Woodson. The National Defense Authorization Act for FY 2009
section 732, established the limit of Government liability for Extended
Care Health Option (ECHO) benefits at $36,000 per year. This change was
implemented on April 1, 2009. In FY 2013, 4.2 percent of Active Duty
Family Members using only ECHO program services (218 of 5,131 users)
had annual expenditures at or near the $36,000 annual cap (we define
this as those with more than $35,000 annually). The $36,000 annual cap
for ABA services under the ABA Pilot mirrors the Extended Care Health
Option (ECHO) cap.
Under the TRICARE program, all necessary medical care is provided
without a cap or dollar limit. This medical or behavioral health care
is provided through the basic TRICARE program whether the beneficiary
has chosen TRICARE Prime or TRICARE Standard. These medical and
behavioral therapies include those which are provided for ABA services.
The tutor services which are a part of some ABA approaches are provided
through the ECHO.
Mr. Wilson. Based on the testimony of Dr. Woodson and General Robb
savings from the consolidation of Medical Logistics is projected to be
$10 million. What is the amount of savings at this time?
Dr. Woodson. Defense Health Agency Medical Logistics initiatives
have resulted in $8.2M in FY14 savings to date.
Mr. Wilson. Based on the testimony of Dr. Woodson and General Robb
$24.7 million is the projected savings from consolidation of Health
Information Technology. In what fiscal year will this savings be
attained? Please provide a detailed explanation of where these savings
come from.
Dr. Woodson. As of February 26, 2014, the Defense Health Agency has
achieved $24.7M in Health Information Technology (IT) savings for FY
2014.
These savings are attributable to efficiencies implemented in FY14
in the following areas:
Reengineering IT Management: $3.8M is attributed to reductions in
the operations and consultant contracts
Infrastructure Consolidation: $12.2M is attributed to contract
efficiencies in Service medical software licenses, help desk
operations, and information assurance activities
Portfolio Rationalization: $8.7M is attributed to contract
efficiencies in Service medical systems trainers and systems support
Mr. Wilson. The Department has outlined how closing walk-in
customer service centers in favor of call center based customer service
will provide savings. How does the Department plan to gauge customer
satisfaction with the new process? What method will the Department use
to survey, including how the survey will be conducted and what
population of customers will be queried.
Dr. Woodson. The Department uses a survey to monitor how well our
contractors' Customer Service Call Centers are performing. Monthly a
random survey of recent TRICARE users (those with a claim within the
past 30 days) is conducted. The beneficiaries selected are called and
asked if they used the Call Center in the past month and, if so, to
please rate the services provided on a scale of 1-6. Since December
2013, 86% to 98% of those surveyed each month rated services provided
by the call centers as ``completely satisfied, very satisfied or
somewhat satisfied.''
Additionally, the Department has made several changes to the
tricare.mil website and the online enrollment portal to ensure the
other ``self-service'' options are user-friendly. The website usage has
increased each month since December 2013 (27,000 daily users to 32,000
users) and the online enrollment and enrollment change application from
36,000 to 55,000 monthly users.
The survey results and feedback received from our military
treatment facilities, military associations, and beneficiary inquiries
are closely monitored by the Defense Health Agency leadership to ensure
TRICARE beneficiaries continue to receive prompt, quality customer
services.
Mr. Wilson. Please discuss, in detail, the cost savings to date
from changes in purchased care accounts
Dr. Woodson. Prior Year Initiatives: The following savings
initiatives were implemented in previous years to slow the growth in
DOD's health care costs.
Federal Ceiling Price: Beginning in 2008, the Department
implemented regulations and extensive administrative procedures to
implement a change in law (known as Federal Ceiling Price) that
required pharmaceutical manufacturers to provide discounts for drugs
for TRICARE beneficiaries through retail network pharmacies.
-- Federal Ceiling Price discounts for drugs are at least 24%
less than the average manufacturer's price for its non-Federal
customers.
-- Discounts are achieved through quarterly collection of
refunds from pharmaceutical manufacturers based on the quantity
of their brand name drug utilized in the TRICARE retail network
pharmacies.
TRICARE Home Delivery: The Department implemented a
comprehensive pharmaceutical Home Delivery (mail order) marketing
program in 2010, which has contributed to an overall increase in Home
Delivery of pharmaceuticals and a decline at retail locations. FY 2013
results continued to build on FY 2012 positive trends:
-- In FY 2013, mail order use increased by 15.6% compared to
FY 2012. The monthly volume of over 1.5M prescriptions
continued the upward trend from 2012 for TRICARE Home Delivery.
-- Retail prescription volume fell 6% in FY 2013 as compared
to FY 2012.
TRICARE For Life Pilot: A FY 2013 NDAA-directed TRICARE
For Life Pharmacy Pilot will start mid-February 2014. This pilot will
require TRICARE For Life beneficiaries who fill prescriptions for
select maintenance medications at a retail network pharmacy to switch
to either home delivery or a military pharmacy.
Outpatient Prospective Payment System: In 2009, by
aligning its payments with Medicare rates (known as the Outpatient
Prospective Payment System), the Department instituted changes in the
way it reimburses private hospitals for outpatient services provided to
TRICARE.
-- Over a four-year transition period that commenced in mid-
2009, TRICARE pays hospitals on a prospective payment basis for
hospital outpatient services, which allows for a reasonable
profit and eliminates excessive facility charges.
TRICARE Prime Enrollment Fees: In FY 2012, the Department
was allowed to implement a modest increase in Prime enrollment fee
($30/$60 per year increase for individual/family coverage), indexed to
annual retiree COLA starting in FY 2013.
Pharmacy co-pay adjustment: The Department implemented
pharmacy co-pay changes in FY 2012 and the FY 2013 National Defense
Authorization Act included some additional adjustments to the TRICARE
pharmacy co-pay structure.
U.S. Family Health Plan (USFHP): In FY 2013, we
implemented a lower and more accurate capitation rate to reimburse
USFHP plans for health care delivery. As part of the FY 2012
President's Budget Request, the Department submitted a legislative
proposal requiring new USFHP enrollees to move to the TRICARE for Life
(TFL) Program upon becoming eligible for Medicare like all other
military retirees. This proposal was enacted as part of the FY 2012
National Defense Authorization Act. This change is reducing demand on
the Medicare Eligible Retiree Health Care Fund (MERHCF) because,
previously, TRICARE was the primary payer for TFL-eligible retirees
enrolled in USFHP instead of the second payer to Medicare as is the
case for all other TFL retirees not residing overseas.
Managed Care Support Contract (MCSC) Specific Initiatives
and Demos
-- The third generation of TRICARE contracts (known as T3)
requires network discount guarantees and other utilization
management strategies which show significant positive results
and are holding the rate of purchased sector health care cost
growth below the national average.
-- Two demonstration projects (in the North Region and South
Region) were initiated to enroll beneficiaries in network
Primary Care Medical Homes to discover if this will increase
quality and coordination of care and decrease costs as per the
literature.
-- Managed Care Support Contractors each instituted care
coordination systems/initiatives and utilization management
initiatives as enhancements in the contracts that drive cost
savings through better care coordination and management.
-- A demonstration project was initiated to reduce emergency
room costs by allowing U.S. Coast Guard beneficiaries in the
South region to access urgent care center visits without
authorization where medically appropriate.
-- A comprehensive model to assist MTFs to identify healthcare
recapture opportunities was developed. The model is now in use
in all three regions.
-- An initiative that places reasonable limits on services,
such as physical therapy, has resulted in significant savings
without diminishing the outcome of the care provided.
-- The implementation of improved use of information, coupled
with outreach to both patients and providers, has demonstrated
initial results of a decrease of over ten percent in inpatient
hospital care. Inpatient hospital care is the most expensive
form of care provided.
Current Year Initiatives: The following savings initiatives have
started or are planned to start in FY 2014 to slow the growth in DOD's
health care costs.
Sole Community Hospital: The Department has revised its
payment rules to reimburse inpatient care claims at sole community
hospitals by complying with federal law and aligning its reimbursement
more closely with Medicare rates.
-- Previously, we reimbursed at rates that were, on average,
75-85% higher than rates used by Medicare.
-- New payment rules went into effect on January 1, 2014.
Reimbursement changes will phase-in over multiple years that
will help hospital's reduce potential impacts, reducing the
Department's health care costs and leading to significant cost
savings for the agency. There is also an adjustment available
to qualifying network hospitals serving a disproportionate
number of Active Duty Service members and Active Duty family
members, and deemed essential for readiness.
Electronic Prescribing: TRICARE's focus is on
implementing electronic prescribing from civilian providers to MTF
pharmacies. Implementing e-prescribing at MTFs will result in an
increase in MTF filled prescriptions, which is the least expensive
point of service, and a decrease in retail pharmacy-filled
prescriptions which is the most expensive point of service. A 1% shift
in non-specialty maintenance medications (270,000 prescriptions) to
MTFs from retail pharmacies has substantial cost-avoidance to the MHS.
The electronic prescribing is currently in a test phase with a
projected roll out date of mid-2014.
Other Health Insurance: Beneficiaries do not always
provide their Other Health Insurance (OHI) information to ensure
TRICARE pays second on any civilian claims or to allow MTFs to bill for
care rendered. The Defense Health Agency (DHA) will contract with a
commercial vendor to identify missing OHI policy information to
decrease the cost of purchased care claims and increase the MTF's
revenues.
Prime Service Area Reduction: On October 1, 2013, the
Department reduced the number of TRICARE Prime Service Areas (PSAs) in
the Unites States. PSAs are now being maintained only around MTFs and
base realignment and closure (BRAC) sites. This initiative has been
planned since 2007.
-- No beneficiary lost TRICARE health care benefits. The
retirees and their family members living in an affected area
could re-enroll to a more distant PSA, if one was available
within 100 miles from their residence, or they had immediate
access to TRICARE Standard. TRICARE Standard is the basic
entitlement by law.
-- Fiscal Year 2014 NDAA also allows each affected eligible
beneficiary who was enrolled in TRICARE Prime as of September
30, 2013, to may make a one-time election to continue such
enrollment in TRICARE Prime contingent upon certain provisions.
TRICARE Service Center (TSC) Initiative: The TSCs will no
longer provide walk-in customer service at the 189 TSCs in all 50
States, as of April 1, 2014.
-- TSCs were established 20 years ago to assist beneficiaries
with questions concerning enrollment, billing benefits, etc.,
when TRICARE replaced CHAMPUS. They are regional contractor-
operated offices, with a limited number of staff providing
face-to-face customer services.
-- With more and more beneficiaries now using electronic
communications for assistance (internet, mobile applications,
telephone, etc.), walk-in customer service is no longer deemed
necessary or cost effective. It is the most expensive customer
service option available.
-- Few, if any, commercial health plans offer a similar walk-
in customer service. Due to the unique nature of the overseas
environment, all overseas TSCs will continue providing walk-in
customer services.
-- All TSC walk-in services can be provided by long-standing
and well tested toll-free call centers or multiple internet and
mobile sites.
Health Plan Headquarters Initiatives:
-- Consolidation of the MCSC under a single TRICARE Regional
Office Director has resulted in increased consistency in the
award fee process and savings in awards.
-- Initiatives to decrease print materials and the move to
increased electronic communications have resulted in
substantial savings over previous years.
Mr. Wilson. Based on the testimony of Dr. Woodson and General Robb
savings from the consolidation of Medical Logistics is projected to be
$10 million. What is the amount of savings at this time?
General Robb. Defense Health Agency Medical Logistics initiatives
have resulted in $8.2M in FY14 savings to date.
Mr. Wilson. Based on the testimony of Dr. Woodson and General Robb
$24.7 million is the projected savings from consolidation of Health
Information Technology. In what fiscal year will this savings be
attained? Please provide a detailed explanation of where these savings
come from.
General Robb. These savings are attributable to efficiencies
implemented in FY14 in the following areas:
Reengineering IT Management: $3.8M is attributed to reductions in
the operations and consultant contracts
Infrastructure Consolidation: $12.2M is attributed to contract
efficiencies in Service medical software licenses, help desk
operations, and information assurance activities
Portfolio Rationalization: $8.7M is attributed to contract
efficiencies in Service medical systems trainers and systems support
______
QUESTIONS SUBMITTED BY MS. TSONGAS
Ms. Tsongas. What can TRICARE do to help address the issue of obese
and overweight DOD dependents and obese or overweight Active Duty
personnel?
Dr. Woodson. The Department is addressing the issue of obese and
overweight DOD dependents and obese or overweight Active Duty personnel
by actively screening weight as part of the Military Health System
(MHS) strategy to provide improved patient-centered delivery of
healthcare services in place within our Patient Centered Medical Homes.
Adults with a Body Mass Index (BMI) of 25 or adolescents and children
with a BMI greater than the 85th percentile are typically encouraged to
receive nutritional and physical activity counseling as part of the
primary care visit. Additionally, as part of the National Prevention
Strategy, we are working to shape the physical and nutritional
environment on installations making the healthy choice the easy choice.
Specifically, a demonstration project called The Healthy Base
Initiative (HBI), is designed to test pilot initiatives to inform a
strategic way ahead to improve the health of the community. For
example, the Military Nutrition Environment Assessment Tool (m-NEAT)
built in collaboration with the Services will assist individuals with
evaluating the nutritional quality of foods provided at all military
and commercial dining environments on installations. This approach will
pay dividends in both readiness and in better health for our
beneficiaries.
Ms. Tsongas. What are TRICARE's processes and procedures for the
review of new medical treatments including new categories of FDA-
approved pharmaceutical products not currently covered by TRICARE?
Dr. Woodson. TRICARE only covers medically necessary services and
supplies for which the safety and efficacy have been proven. In order
to ensure our beneficiaries are receiving safe and effective care,
TRICARE uses a ``hierarchy of reliable evidence'' to determine when a
drug, device, or medical procedure is safe and effective. This also
prevents our beneficiaries from being exposed to less than fully
developed and tested medical procedures and to avoid the associated
risk of unnecessary or unproven treatment. The below list shows the
documentation TRICARE utilizes during coverage reviews.
TRICARE uses the following hierarchy of reliable evidence:
1. Well controlled studies of clinically meaningful endpoints,
published in refereed medical literature. 2. Published formal
technology assessments. 3. Published reports of national professional
medical associations. 4. Published national medical policy organization
positions; and 5. Published reports of national expert opinion
organizations.
Specifically not included in the meaning of reliable evidence are
reports, articles or statements by providers or groups of providers
containing only abstracts, anecdotal evidence or personal-professional
opinions.
Ms. Tsongas. What is the medical cost to TRICARE for conditions and
diseases associated with obesity?
Dr. Woodson. Regarding the medical cost to TRICARE, a cost of
disease model published in 2010 of the cost of overweight and obesity
for TRICARE estimated a charge to TRICARE of approximately $1.1 billion
annually. This analysis incorporated the role of excess weight in the
development of a range of chronic medical conditions such as type 2
diabetes, cardiovascular disease, stroke and some types of cancers, all
of which increase medical costs, impact quality of life, and contribute
to premature mortality. This estimate, which focused on TRICARE prime
beneficiaries, represents a significant proportion of cost but likely
underestimates the total annual medical costs to the DOD.
______
QUESTIONS SUBMITTED BY MR. SCOTT
Mr. Scott. In response to a recent Congressional inquiry, the DOD
stated they were only immunizing military personnel stationed in Asia
against Japanese encephalitis (JE) ``based on Service guidance, unit
mission or other occupational requirements (for example those who
operationally deploy to a high-risk field environment)'', which is
resulting in extremely low vaccine coverage rates except for the
Marines and a few other special operations units. Why is the DOD Not
following the recommendations issued by the CDC and Dr. Woodson to
immunize all ``Service members, Department of Defense civilians, and
beneficiaries who are, or will be, stationed or visiting for more than
30 days in JE endemic areas''?
Dr. Woodson. The Department of Defense follows the Centers for
Disease Control and Prevention (CDC) recommendations and the Health
Affairs guidance. The Health Affairs guidance mirrors the
recommendations from the CDC. Individuals deploying to endemic or rural
areas in the U.S. Pacific Command (PACOM) should be administered the JE
vaccine in accordance with the latest PACOM Force Health Protection
guidance. The Services and PACOM may issue more specific requirements
based on a medical threat within the area of operations and have done
so for certain Marine and special operations units.
______
QUESTIONS SUBMITTED BY MR. BARBER
Mr. Barber. Numerous newspaper articles indicate an adversarial
relationship between the TRICARE contractor, beneficiaries and local
providers in the Philippines. Constituents complain about a lack of
reliable information on the benefit and a lack of responsiveness to
customer support. Major national pharmacy firms and the Red Cross and
all of its field offices have refused to work with the contractor
denying beneficiary access to numerous pharmacies and a major source of
blood. One of four internationally accredited hospitals and the only
one in the southern Philippines cannot be used by beneficiaries for
what appears to be nothing more than a paperwork exercise as it is
obviously a licensed and legitimate hospital with better quality than
many currently certified and hospitals.
In 2008 the beneficiaries were promised an onsite employee that
would listen to their issues and learn the nuances of the local health
care industry so access to care could be restored. In 2011 the DODIG,
as the result of a multi-year investigation of the contractor,
recommended to the TRICARE Management Activity, ``Consider establishing
a TRICARE presence in the Philippines to service military retirees and
their dependents.'' Their response was ``TMA is in the process of
selecting a location for a TRICARE Satellite Office in Manila,
Philippines to provide assistance to military retirees and their
dependents residing there. The office will be staffed by a TMA
Government employee, and TMA is currently in the process of advertising
that position.'' Yet in 2014 there is no such position and my
constituents indicate DHA is now silent when questioned about the
promised position.
Given the adversarial relationship that has developed between the
contractor, beneficiaries and the local health care industry and the
current ongoing Demonstration, that also appears to be in trouble,
wouldn't it be prudent to take immediate action to place the promised
employee on the ground so they can work with beneficiaries and the
local health care industry to finally insure good access to care to
these beneficiaries?
General Robb. All three of the major national pharmacy firms
operating in the Republic of the Philippines are TRICARE certified.
Mercury Drug was certified in September 2010; Rose Pharmacy in April
2012; and Watsons Pharmacy in July 2013. Certification of these
pharmaceutical companies at the corporate level allow TRICARE
beneficiaries to access any of these pharmacies' stores, regardless of
where in the country they are located. The Philippine National Red
Cross is TRICARE certified effective February 19, 2014. Similar to the
certification of the pharmacy companies, certification of the Red Cross
at the national level allows TRICARE beneficiaries to access any of the
80 Red Cross Chapters in the Philippines to obtain the necessary
testing and blood supplies they may need. Due to the delay in
certifying the Philippine National Red Cross, the Defense Health Agency
has directed the TRICARE Overseas Program contractor to reprocess all
previously submitted claims since September 2010 and provide the
appropriate reimbursement to the beneficiaries for their out of pocket
expenses for testing and blood supplies obtained from any Philippine
Red Cross chapter.
In 2008, the Deputy Director, TRICARE Management Activity (TMA),
visited the Republic of the Philippines. Based on what he saw and heard
from the retired beneficiaries, as well as his awareness of significant
fraud issues in the Philippines, the Deputy Director directed
establishment of a satellite office in the Philippines to enable the
TRICARE Area Office-Pacific to better support beneficiaries living
there. At that time, office space was identified at the old Clark Air
Force Base, and coordination was completed to have a U.S. citizen who
would staff the office fall under the protection of the U.S. Embassy.
Since that time, the space at the old Clark Air Force Base is no longer
available.
In 2012, the Deputy Director, TMA reversed the previous decision to
establish a satellite office in the Philippines in light of several
factors. These factors included the award of the TRICARE Overseas
Program (TOP) contract in 2009 to International SOS Assistance
(International SOS). This contract requires the operation of a 24/7
Regional Call Center, staffed with customer service representatives
trained to assist beneficiaries and host nation providers with
questions about claims, locating a provider, benefit determinations,
and authorizations for care. Additionally, the agency had decided to
implement the Philippine Demonstration Project which is designed to
increase access to quality health care, eliminate the need for
beneficiaries to file their own claims, and control costs. The
Demonstration Project began in January 2013. Nowhere else do we have a
TRICARE office specifically to support the retiree population in any
other overseas location and establishing one in the Philippines would
be potentially precedent-setting, resulting in retirees living in other
overseas locations expecting to have a satellite office established
specifically to support them. And finally, in this resource constrained
environment, establishing a satellite office in the Philippines was not
a fiscally sound decision.
The purpose of the Philippine Demonstration is to test an
alternative method for the delivery of health care in the Philippines
to continue to control costs, reduce aberrant billing activity, and
eliminate balance-billing issues while providing quality health care to
TRICARE Standard beneficiaries residing in the Philippines and
receiving care in designated demonstration area(s). This will be
accomplished by using approved demonstration providers who have agreed
to accept TRICARE reimbursement as payment in full, file the claim on
behalf of the beneficiary, collect only the applicable cost-share and
deductible, and agree to on-site verification and provider
certification.
Selection of Approved Demonstration Providers was based on a
thorough review of claims history over the past two years with the
objective to recruit and retain a sufficient number and mix of Approved
Providers in designated demonstration areas. Criteria for the selection
of approved providers consisted (1) the number of claims submitted by
the providers/facilities and (2) whether or not the providers/
facilities were under any type of pre-payment review. As of March 2014,
there are 11 approved institutional facilities that provide inpatient
services and 323 approved individual providers in designated
demonstration areas. Additionally, throughout the Philippines there are
301 certified institutional facilities that provide inpatient services
and 4,335 individual certified providers.
______
QUESTIONS SUBMITTED BY MR. CASTRO
Mr. Castro. DOD has had great success with the creation of the
Armed Forces Institute of Regenerative Medicine (AFIRM), a medical
research consortium established to bring the best minds across military
and civilian research communities to focus on a high priority area for
the military. DOD has recently joined with the Department of Veteran's
Affairs to create consortiums in Traumatic Brain Injury and Post
Traumatic Stress which are also high priority areas for the military.
What are the next priority areas of research where these civilian/
military consortiums should take place, especially in looking to
maintain advances in military medicine and translating the lessons
learned from Iraq and Afghanistan into civilian medicine?
Dr. Woodson and General Robb. The DOD is exploring the feasibility
of research collaborations or research consortia for a systems approach
to all transport, equipment, and clinical aspects of en-route trauma
care, hearing loss, prosthetics, and artificial vision.
Civilian-military consortia would focus on medical (e.g.,
medications, blood products, oxygen-carrying substitutes) and
procedural (e.g., devices to control pain and hemorrhage and to promote
perfusion to the brain and heart) strategies in the pre-hospital and
en-route care setting. These consortia would synergize the development
of new monitoring and triage devices (e.g., predicting those in the
early stages of shock) as well as expand data gathering and
telemedicine capabilities.
Mr. Castro. In this era of declining budgets what steps is the
Defense Health Agency taking to assure that its medical research and
development remains focused on the high priority gaps defined in the
2008 Guidance for the Development of the Force? Have these gaps been
resolved and if not, how are we resolving them and are they properly
resourced?
Dr. Woodson. The Office of the Assistant Secretary of Defense for
Health Affairs (OASD(HA)) conducts regular reviews and analyses of the
medical research and development (R&D) portfolio to assure that
investments are aligned to capability gaps, to assess the current state
of science in a gap area, and to identify R&D gaps and needs that
inform future resource strategies.
The Military Health System strategic priorities that drive R&D
investments are based on the Joint Capabilities Integration and
Development System (JCIDS) that informed the 2008 Guidance for the
Development of the Force gaps. Using the JCIDS, the DOD re-validates
and re-evaluates joint force health protection and readiness
capabilities through the Capabilities Based Assessments (CBA) process.
A CBA, sponsored by the OASD(HA), will re-validate, revise, or
establish new capability requirements and associated capability gaps
based upon operational lessons learned, changing needs, and gap
assessment. Gap resolution is an on-going process. Over the last five
years, considerable progress has been made in specific gap resolution
for the 2008 guidance but the CBA will revise existing gaps or create
new gaps.
Mr. Castro. In this era of declining budgets what steps is the
Defense Health Agency taking to assure that its medical research and
development remains focused on the high priority gaps defined in the
2008 Guidance for the Development of the Force? Have these gaps been
resolved and if not, how are we resolving them and are they properly
resourced?
General Robb. The Office of the Assistant Secretary of Defense for
Health Affairs (OASD(HA)) conducts regular reviews and analyses of the
medical research and development (R&D) portfolio to assure that
investments are aligned to capability gaps, to assess the current state
of science in a gap area, and to identify R&D gaps and needs that
inform future resource strategies. During this fiscal year, the Defense
Health Agency will begin to assume management responsibility for
medical R&D.
The Military Health System strategic priorities that drive R&D
investments are based on the Joint Capabilities Integration and
Development System (JCIDS) that informed the 2008 Guidance for the
Development of the Force gaps. Using the JCIDS, the DOD re-validates
and re-evaluates joint force health protection and readiness
capabilities through the Capabilities Based Assessments (CBA) process.
A CBA, sponsored by the OASD(HA), will re-validate, revise, or
establish new capability requirements and associated capability gaps
based upon operational lessons learned, changing needs, and gap
assessment. Gap resolution is an on-going process. Over the last five
years, considerable progress has been made in specific gap resolution
for the 2008 guidance but the CBA will revise existing gaps or create
new gaps.