[Senate Hearing 110-198]
[From the U.S. Government Printing Office]
S. Hrg. 110-198
CARE, LIVING CONDITIONS, AND ADMINISTRATION OF OUTPATIENTS AT WALTER
REED ARMY MEDICAL CENTER
=======================================================================
HEARING
before the
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MARCH 6, 2007
__________
Printed for the use of the Committee on Armed Services
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COMMITTEE ON ARMED SERVICES
CARL LEVIN, Michigan, Chairman
EDWARD M. KENNEDY, Massachusetts JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia JOHN WARNER, Virginia,
JOSEPH I. LIEBERMAN, Connecticut JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii SUSAN M. COLLINS, Maine
BILL NELSON, Florida JOHN ENSIGN, Nevada
E. BENJAMIN NELSON, Nebraska SAXBY CHAMBLISS, Georgia
EVAN BAYH, Indiana LINDSEY O. GRAHAM, South Carolina
HILLARY RODHAM CLINTON, New York ELIZABETH DOLE, North Carolina
MARK L. PRYOR, Arkansas JOHN CORNYN, Texas
JIM WEBB, Virginia JOHN THUNE, South Dakota
CLAIRE McCASKILL, Missouri MEL MARTINEZ, Florida
Richard D. DeBobes, Staff Director
Michael V. Kostiw, Replublican Staff Director
(ii)
C O N T E N T S
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CHRONOLOGICAL LIST OF WITNESSES
Care, Living Conditions, and Administration of Outpatients at Walter
Reed Army Medical Center
march 6, 2007
Page
Chu, Hon. David S.C., Under Secretary of Defense for Personnel
and Readiness.................................................. 6
Schoomaker, GEN Peter J., USA, Chief of Staff, United States Army 11
Winkenwerder, William, Jr., M.D., Assistant Secretary of Defense
for Health Affairs............................................. 14
Kiley, LTG Kevin C., USA, Surgeon General, United States Army.... 19
(iii)
CARE, LIVING CONDITIONS, AND ADMINISTRATION OF OUTPATIENTS AT WALTER
REED ARMY MEDICAL CENTER
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TUESDAY, MARCH 6, 2007
U.S. Senate,
Committee on Armed Services,
Washington, DC.
The committee met, pursuant to notice, at 9:34 a.m. in room
SD-106, Dirksen Senate Office Building, Senator Carl Levin
(chairman) presiding.
Committee members present: Senators Levin, Kennedy,
Lieberman, Reed, Akaka, Bill Nelson, E. Benjamin Nelson, Bayh,
Clinton, Pryor, Webb, McCaskill, McCain, Warner, Inhofe,
Sessions, Collins, Ensign, Chambliss, Graham, Dole, Cornyn,
Thune, and Martinez.
Committee staff members present: Richard D. DeBobes, staff
director; Leah C. Brewer, nominations and hearings clerk; and
Gary J. Howard, systems administrator.
Majority staff members present: Jonathan D. Clark, counsel;
Gabriella Eisen, professional staff member; Gerald J. Leeling,
counsel; and Michael J. McCord, professional staff member.
Minority staff members present: Michael V. Kostiw,
Republican staff director; David M. Morriss, minority counsel;
Lucian L. Niemeyer, professional staff member; Diana G. Tabler,
professional staff member; and Richard F. Walsh, minority
counsel.
Staff assistants present: David G. Collins, Kevin A.
Cronin, and Jessica L. Kingston.
Committee members' assistants present: Frederick M. Downey,
assistant to Senator Lieberman; Elizabeth King, assistant to
Senator Reed; Darcie Tokioka, assistant to Senator Akaka;
Benjamin Rinaker, assistant to Senator Ben Nelson; Andrew
Shapiro, assistant to Senator Clinton; Lauren Henry, assistant
to Senator Pryor; Jason D. Rauch, assistant to Senator
McCaskill; Richard H. Fontaine, Jr., assistant to Senator
McCain; Sandra Luff, assistant to Senator Warner; D'Arcy
Grisier, assistant to Senator Ensign; Bridges Sinyard and Clyde
A. Taylor IV, assistants to Senator Chambliss; and Adam G.
Brake, assistant to Senator Graham.
OPENING STATEMENT OF SENATOR CARL LEVIN, CHAIRMAN
Chairman Levin. Good morning, everybody. This committee
meets this morning to address reports of substandard living
conditions, poor outpatient care, and bureaucratic roadblocks
and delays for injured soldiers at Walter Reed Army Medical
Center. We welcome our witnesses here today: Dr. David S.C.
Chu, Under Secretary of Defense for Personnel and Readiness;
Dr. William Winkenwerder, Assistant Secretary of Defense for
Health Affairs; General Peter Schoomaker, Chief of Staff of the
Army; and Lieutenant General Kevin Kiley, Surgeon General of
the Army.
This committee is determined to understand what went wrong
at Walter Reed Army Medical Center and what we need to do to
make sure it does not happen again there, or anywhere else. Our
Nation has a moral obligation to provide quality health care to
the men and women who put on our Nation's uniform and are
injured and wounded fighting our Nation's wars. This obligation
extends from the point of injury through evacuation from the
battlefield, to first class medical facilities in the United
States, and ends only when the wounds are healed. Where the
wounds will never heal, we have an obligation to provide
quality care throughout the lifetime of the veteran. I am sad
to say that we are not meeting this obligation, although it is
an obligation which all Americans accept and insist be met to
the fullest.
Today's hearing is about another example of the lack of
planning for a war that was premised on the assumption that
combat operations would be swift, casualties would be minimal,
and that we would be welcomed as liberators instead of being
attacked by the people we liberated.
I am proud of the fact that our military doctors, nurses,
and medics have provided outstanding medical care to those who
were wounded. Many servicemembers who would have died in
earlier conflicts survived in Iraq and Afghanistan because of
the advances in battlefield medical care, and the skill and
bravery of our combat medical teams. Seriously injured troops
are rapidly evacuated to world-class medical facilities like
Walter Reed and Bethesda, where they continue to receive state-
of-the-art care as inpatients.
It is when they leave inpatient status that the system has
failed them. A recent series of Washington Post articles
described deplorable living conditions, failure to account for,
and bungled administrative processing of injured troops in
outpatient status at the Walter Reed Army Medical Center. New
reports indicate that these problems are not confined to Walter
Reed. They exist elsewhere in the military and Department of
Veterans Affairs (VA) medical systems. Washington Post
reporters Dana Priest and Anne Hull are to be commended for
bringing this tragic situation to light.
The Army now has acted to move soldiers out of a worn,
aging facility that should never have been used to house
wounded soldiers. These heros deserve far better than that.
They all volunteered for service in our military forces, with
great hopes and dreams for their futures. Now they are faced
with the daunting task of figuring out how to live with
lifetime disability, a condition they incurred in service to
our Nation.
It appears that the Army, especially the leadership at
Walter Reed, was slow to recognize the need to increase the
number of caseworkers and experienced noncommissioned officers
(NCOs) to keep pace with the increased number of outpatients
under their care. These NCOs and case managers are critical for
assisting injured soldiers in making and keeping medical
appointments, for accounting for and tracking of these soldiers
during rehabilitation and recuperation, and assisting them as
they process through the disability evaluation system.
The Army is now hiring more case managers and bringing in
additional NCOs to help these injured soldiers and their
families navigate the health care system, and to ensure that
these soldiers have a decent quality-of-life while they
continue to recover from their injuries. The Army is also
establishing a new command structure at Walter Reed that will
be focused on taking care of wounded soldiers in an outpatient
status. Good leadership should have taken those steps long ago,
without prompting by a series of embarrassing news articles.
Senior officers are being held accountable for failures of
leadership that led to these conditions. Unlike his
predecessor, who fired only those who disagreed with him,
Secretary of Defense Robert Gates has moved quickly to remove
senior officials when he lost confidence in them because their
actions did not measure up. Our soldiers will benefit as a
result of Secretary Gates's decisive action to insist on
accountability.
While the Army appears to be taking the necessary steps to
repair and evacuate substandard buildings and hire additional
staff to assist wounded soldiers, the more daunting task is to
change an overly complex, bureaucratic, adversarial system used
to evaluate and rate disabilities of injured servicemembers,
and we are going to hear more about that this morning.
Last Friday, four colleagues and I visited Walter Reed and
talked with a number of these wounded soldiers and their
families. By and large, they had praise for the inpatient
health care that they received and, despite our personal
observation of substandard living conditions for the
outpatients, they did not complain. What they were most
concerned about is the military's disability evaluation system.
Many of these soldiers have extremely complex injuries that
take many operations and a long time to heal. For some this
process takes more than a year. Once they get to the point
where their doctors tell them that further medical care will
not improve their condition and it is determined that they are
not fit for duty, most of these wounded soldiers just want to
go home and get on with their lives.
It is at this point in their treatment that they encounter
the Department of Defense (DOD) disability evaluation system.
This system places these soldiers in the position of having to
fight for a disability rating that entitles them to medical
treatment. After all they have been through, these injured
soldiers should not feel that they have to fight for what we as
a Nation have a moral obligation to provide.
One soldier with whom I talked had been injured by an
improvised explosive device (IED) blast while on his second
tour of duty in Iraq. He is continuing to receive care for his
injuries in an outpatient status. He understands that he is no
longer physically fit for military duty because of the
seriousness of his injuries. He told me that he is ``scared to
death'' that the physical disability evaluation system will
rate his disability at less than 30 percent and therefore he
would not receive a medical retirement, although he is going to
be discharged, and that he would be ``put on the street,'' in
his words, without the ability to take care of his family and
their medical needs, including his four children.
How can we as a Nation ask our young men and women to
serve, and when they are wounded while serving put them in a
position where they are scared to death that we will not take
proper care of them and their families? Surely we must change
such a system.
The problems are not over for these disabled veterans when
they leave the military. After a servicemember is medically
discharged or separated, he or she can apply for disability
compensation and health care through the VA. The VA conducts
its own assessment of the degree of disability of the veteran.
Although the VA and DOD use the same standard for evaluating
disabilities, their disability ratings often vary significantly
and in most cases the VA disability rating is higher than the
military disability rating. Unfortunately, only the military
disability rating counts when determining whether the member is
medically retired with family health care benefits or medically
discharged with no benefits for his or her family, and that is
extremely frustrating and confusing for our wounded
servicemembers and their families, who then have to fight the
system to get the best rating that they can.
I commend Secretary Gates for quickly recognizing that we
are falling short in our obligation to our wounded
servicemembers and, in a unique statement that he made of
gratitude to the reporters who broke the story, said that he
was very disappointed that we did not identify it ourselves. He
added very accurately that our servicemembers ``battled our
foreign enemies; they should not have to battle an American
bureaucracy.''
Senator Akaka, the chairman of the Committee on Veterans
Affairs, and I and our ranking members, Senator McCain and
Senator Craig, are determined that our committees will work
together to improve the care of our veterans throughout their
continuum of care. We will hold a joint hearing of our two
committees in the near future to identify the remedies to the
problems that our wounded soldiers are facing.
The American people are deeply angry about the shortfalls
in care. The war in Iraq has divided our Nation, but the cause
of supporting our troops unites us. We will do everything we
possibly can do, not as Democrats or Republicans, but as
grateful Americans, to care for those who have served our
Nation with such honor and distinction.
Senator McCain.
STATEMENT OF SENATOR JOHN McCAIN
Senator McCain. Mr. Chairman, I want to thank you for
calling this very important hearing. The revelations over the
past week have been distressing to the Nation. I am dismayed
this ever occurred. It was a failure in the most basic tenets
of command responsibility, to take care of our troops.
This is even more troubling because we have reason to
believe that the Army learned from the headlines of poor
conditions, inadequate medical treatment, and bureaucratic
delays for the wounded at Fort Stewart 3 years ago. You will
recall that Acting Secretary of the Army Les Brownlee
immediately visited Fort Stewart and initiated remedial action
within the Army. By 2004, hundreds of additional medical and
administrative personnel had been mobilized and new regional
centers established throughout the country to accommodate
soldiers in medical holdover status.
In 2006, my colleague, Senator Graham, then chairman of the
Subcommittee on Personnel, sought assurance from two of our
witnesses today, Doctors Chu and Winkenwerder, that our
Government was doing everything possible to ensure that
wounded, once they get off the battlefield with the best
medicine known in the history of warfare, do not fall through
the cracks. Today I hope we will hear from Dr. Chu and Dr.
Winkenwerder where we have failed.
Our Nation is blessed with a magnificent team of military
and civilian doctors and nurses who care for our wounded. I
think it is very important that we recognize and support their
efforts. At the same time, we must demand accountability for
the failure to take appropriate actions and move aggressively
to take corrective action.
Senior Army leaders were defensive in the face of these
revelations at Walter Reed, and were quick to lay blame for
these failures on NCOs. Frankly, I find that appalling.
To the soldiers who spoke out and their families, you have
our gratitude for your service and your courage. We should also
be grateful to the Washington Post reporters who brought this
to our attention.
Mr. Chairman, there are more questions to be answered. Is
Walter Reed just the tip of the iceberg? How many other
Building 18s are in the Army, the Navy, the Marine Corps, and
the Air Force? What improvement projects at Walter Reed had a
higher priority than basic life and safety improvements for
wounded soldiers? What complaints were received by the Army and
DOD inspectors general relative to conditions at Walter Reed,
and what actions were taken? How did the base realignment and
closure (BRAC) impact the decisions leaders in the Army and at
Walter Reed made with regard to outpatient facilities?
We also have a responsibility to ensure that there is a
future for our wounded that is better than the past. If
legislation is necessary, we will pursue it. Systems and
institutions must change. We utilize 21st century medical
technology to save lives at a rate far greater than at any time
in our Nation's history, yet Cold War processes to determine
compensation and the ability to continue to serve. There have
to be better ways to address the medical and disability
evaluation systems for those who cannot continue on Active Duty
due to their disabling conditions.
The Army leadership must continue to do what it has just
begun, bring more resources to bear on helping wounded warriors
and their families. They deserve nothing less.
Secretary Gates has introduced welcome change to the DOD.
It is my sincere hope that through his leadership we will build
on the quality and strength in our system today, but we must
make right the wrongs that our wounded have endured in what has
occurred and ensure accountability at all levels, all levels.
There is no more important responsibility than to act on
our moral obligation as a Nation to those who are willing to
give their blood for its freedom. Let us be guided by the words
of President George Washington in 1789, who said: ``The
willingness with which our young people are likely to serve in
any war, no matter how justified, shall be directly
proportional as to how they perceive that veterans of earlier
wars were treated and appreciated by their country.''
Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator McCain.
Secretary Chu.
STATEMENT OF HON. DAVID S.C. CHU, UNDER SECRETARY OF DEFENSE
FOR PERSONNEL AND READINESS
Dr. Chu. My colleagues and I have prepared statements that
I hope you would accept for the record.
Chairman Levin. We will.
Dr. Chu. Thank you, sir.
Mr. Chairman and Senator McCain, I am deeply chagrined by
the events that bring us to this hearing this morning.
We set high standards for personnel actions in the DOD, and
as you have celebrated in the quality of clinical care,
starting on the battlefield and coming all the way back to our
inpatient facilities here in the United States. Thanks to that
care, as you reported, the United States enjoys the lowest
disease and non-battle injury rate in the history of military
actions by this Republic, and the highest rate of survival by
the wounded that we have ever achieved. Indeed, the overall
TRICARE health program enjoys high positive ratings from its
beneficiaries and those have led Congress to add additional
groups to the coverage under that program.
Where we have fallen short in administration, in billeting,
in the processing of disability evaluation claims, I want to
apologize this morning on behalf of DOD to the individuals
concerned and to the American public. We need to maintain the
same high standards in these areas that we have achieved in
others.
If I may, Mr. Chairman, I would like to defer to my
colleagues to testify to the medical issues and then return to
the long-term issue at the conclusion of their opening
statements that you have raised, and that is the disability
evaluation system. You and Senator McCain have both spoken to
this important subject. I think General Schoomaker would be
next.
[The prepared statement of Dr. Chu follows:]
Prepared Statement by Hon. David S.C. Chu
Mr. Chairman and distinguished members of this committee, thank you
for this opportunity to discuss care for injured servicemembers and the
administrative processes for restoration to duty or separation from
military service.
We provide extraordinary medical services, on the battlefield, in
transport to facilities outside of the theater, and in clinical centers
here in the United States. With the advent of operations in Afghanistan
and Iraq, our medical care systems mounted an enormously effective
trauma treatment response. More of those suffering traumatic injuries
were saved; in years past they might have succumbed to their wounds
instead.
I will defer to Dr. Winkenwerder's discussion of the specifics of
medical care, but I wish to underscore that I share his distress with
the significant administrative problems at Walter Reed. On behalf of
the Department, I apologize to the servicemembers and to the American
public.
We did not meet our standards as we should. The various review
panels now being organized will help establish what occurred and the
adequacy of remedial actions. Permit me to turn to the other issues of
interest to the committee, starting with the Department's disability
system.
department of defense disability system
The Right Paradigm
Does this Nation have the right paradigm in place military
disability compensation? We have diverse approaches in the public
sector to problems that have much in common. Social Security's
disability payments, the Department of Labor, Workmen's Compensation,
the Department of Veterans Affairs' (VA) and the Department of
Defense's (DOD) disability evaluation system (DES) are carried out in
different ways, against different standards, to achieve different ends.
Perhaps foreseeing this issue, Congress in 2003 directed the
establishment of the VA Disability Benefits Commission. Its report is
expected October 2007, and it may help us understand how to achieve
unity of effort and purpose.
Department of Defense Disability Evaluation System
The citizens of the United States have a long and proud history of
compensating servicemembers whose opportunity to complete a military
career has been cut short as the result of injuries or illnesses
incurred in the line of duty. Congress mandated the development of a
system of rating military disabilities in 1917 and over time that
system has been further refined to the benefit of servicemembers and
their families. The Career Compensation Act of 1949 formalized the code
the military departments utilize today. In addition to DOD disability
compensation, former servicemembers may be eligible for disability
compensation benefits through the VA. A key difference between the DOD
and VA disability systems is that the Services only award disability
ratings for medical conditions that make the individual unfit for
continued military service, whereas the VA may rate any change in
health status that can be linked to the time the member was in Service
regardless of whether it was disabling enough to preclude continued
service. Military disability ratings are fixed upon final disposition,
while VA ratings can increase over time when the condition worsens.
Now, as in the past, the DOD remains committed to providing a
comprehensive, fair, and timely medical and administrative processing
system to evaluate our injured or ill servicemembers' fitness for
continued service using the DES. The overarching legislative guidance
for the DOD DES is set forth in statute in chapter 61 of title 10 of
the U.S.C. Since the inception of chapter 61 in 1949, the Department
has provided additional policy guidance. Ultimately, Secretaries of the
military departments have exercised this title 10 authority consistent
with their roles and missions. However, the Department does mandate
military department DES include four elements: medical/physical
evaluation, appellate review, counseling, and final disposition.
Title 10 mandates that each servicemember determined to be unfit be
afforded the right to a full and fair personal appearance and hearing.
To ensure due process, Department policy requires Secretaries concerned
to utilize a series of medical and administrative boards.
The evaluation process begins with the medical evaluation board
(MEB). The MEB is typically generated by a physician when a
servicemember has an unresolved medical condition or injury which
precludes him or her from being classified as fit for full duty. The
MEB documents the medical diagnosis(es), course of treatment, prognosis
and any duty limitations of the servicemember. The MEB process serves
to protect the health of the servicemember. But it may be the basis for
referral to the physical evaluation board (PEB) process if the MEB
calls into question the individual's fitness for continued military
service. The PEB is a performance-based process composed of two board
types referred to as informal and formal PEBs. Formal PEBs typically
consist of three board members but board composition and membership is
established by the individual Service Secretaries. The PEBs review a
variety of medical evidence and performance information to adjudicate
the impact of the servicemember's medical condition his ability to
reasonably perform the duties of his or her office, grade, rank, or
rating. The informal board is a record review process without
representation whereas the formal board provides a personal appearance
opportunity with legal representation. If the servicemember's case
proceeds to a formal hearing, he or she is encouraged to utilize legal
assistance, provided by the Service or retained by the servicemember at
personal expense. The formal hearing is a non-adversarial proceeding
designed to ensure fairness, equity, and due process.
Physical Evaluation Board Adjudication
On the basis of a preponderance of the evidence, the PEB determines
whether the individual is fit or unfit (i.e., does not meet medical
retention standards) for continued military service with one of four
possible disposition recommendations: return to duty, separate from the
Service, placement on the temporary disability retired list, or
permanent disability retirement. As a product of the PEB process and
according to title 10, servicemembers found unfit for continued
military service will be awarded a disability rating percentage, for
the military unfitting condition, in accordance with the rating
guidance established in the VA Schedule for Rating Disabilities. This
disability rating determines entitlement to separation or retirement
benefits.
Timely Disability Evaluation System Adjudication
The Department's DES timeliness standards were established in 1996
based on a 1992 DOD Inspector General recommendation. When a physician
initiates a MEB, the processing time should normally not exceed 30 days
from the date the MEB report is dictated to the date it is received by
the PEB. Upon receipt of the MEB or physical examination report by the
PEB, the processing time to the date of the determination of the final
reviewing authority as prescribed by the Secretary of the Military
Department should normally be no more than 40 days. One can easily see
that the timeliness of the adjudication of each DES case is dependent
upon a myriad of factors, e.g. the severity of the injury, the recovery
process, administrative documentation, and due process concerns.
According to the military departments, the average adjudication
period for MEB/PEB cases is now longer because the cases are more
complicated as a result of the types of injuries servicemembers are
sustaining in current combat operations. In 2004, in order to mitigate
this formal board phenomenon, the Army Physical Disability Agency
established a mobile PEB to augment its capacity to conduct formal
boards at their three fixed PEB sites. This has helped the Army
accommodate its increased case load. Reserve component servicemembers'
cases occasionally take longer because private practitioners are
involved in documenting the cases. The Army reports that its overall
timeliness rates are above the DOD goal; this is attributed to the
complexity of injuries and the challenges in collating case files for
Reserve component soldiers.
It may be difficult for the individual servicemember to
differentiate between the medical inpatient/outpatient recovery phase
and the administrative MEB/PEB processes. This creates the impression
of long processing times caused by MEBs/PEBs when, actually, the
servicemembers could still be receiving medical and convalescing care
for their injuries.
Let me also emphasize that during this process of health care,
convalescent care, rehabilitation, and MEB/PEB review, servicemembers
are in receipt of full pay and allowances. The system is designed not
to rush a decision. I assure you our servicemembers' best interests are
at the heart of the system. But we need to communicate better the
purposeful and deliberate intent of the DES to our servicemembers and
their families.
Update on the Government Accountability Office findings
The 2006 Government Accountability Office (GAO) report, ``Military
Disability System: Improved Oversight Needed to Ensure Consistent and
Timely Outcomes for Reserve and Active Duty Servicemembers'' concluded
that disability ratings are consistent between Active and Reserve
components. The report could not determine if dispositions were
consistent, and lacking data on preexisting conditions, it called for
stronger oversight. In response, the Department revitalized its
Disability Advisory Council (DAC) so that it plays an active and
strengthened role in molding Department DES policy.
Revitalization Efforts
In a self-policing effort, the Military Departments' Personnel
Chiefs and Surgeons General recommended we charge the DAC with updating
the set of DOD directives/instructions that promulgate disability
policies. The Department has also tasked this group with strengthening
oversight processes and making recommendations on program effectiveness
measures. The Department has established working groups, under the
Disability Advisory Council, consisting of senior human resource and
medical subject matter experts from the military departments and OSD
agencies to address the GAO recommendations on training, oversight and
consistency of application. We anticipate revised DOD instructions will
be completed in May 2007.
In addition to our DOD-level initiatives, the military departments
are also continually reviewing their processes to make them more
effective. For example, Army leadership recently established a Physical
DES Transformation Initiative which integrates multiple major commands
and the VA. This combined effort targets improving process efficiency
and timeliness in areas such as: MEB and PEB processes, automation of
disability data, counseling and training, and transition assistance.
Additionally, in November 2006, the Army directed an internal Inspector
General review of its DES process. I understand that the report is due
out this fall.
quality-of-life programs for severely injured
Military Severely Injured Center
The Department is committed to providing the assistance and support
required to meet the challenges that confront our severely injured and
wounded servicemembers and their families during the difficult time of
transition. Each Service has programs to serve severely wounded from
the war: the Army Wounded Warrior Program (AW2), the Navy Safe Harbor
program, the Air Force Helping Airmen Recover Together (Palace HART)
program, and the Marine4Life (M4L) Injured Support Program. DOD's
Military Severely Injured Center augments the support provided by the
Services. It reaches beyond the DOD to coordinate with other agencies,
to the nonprofit world, and to corporate America. It serves as a fusion
point for four Federal agencies--DOD, the VA, the Department of
Homeland Security's Transportation Security Administration (TSA), and
the Department of Labor.
Federal Partners
The Military Severely Injured (MSI) Center unites Federal agencies
through a common mission: to assist the severely injured and their
families.
The VA Office of Seamless Transition has a full-time liaison
assigned to the center to address VA benefits issues ranging
from expediting claims, facilitating VA ratings, connecting
servicemembers to local VA offices, and coordinating the
transition between the Military and the VA systems.
The Department of Labor has assigned three liaisons from its
REALifelines program which offers personalized employment
assistance to injured servicemembers to find careers in the
field and geographic area of their choice. REALifelines works
closely with the VA's Vocational Rehabilitation program to
ensure servicemembers have the skills, training, and education
required to pursue their desired career field.
The Department of Homeland Security's TSA has a
transportation specialist assigned to the center to facilitate
travel of severely injured members and their families through
our Nation's airports. The Center's TSA liaison coordinates
with local airport TSA officials to ensure that each member is
assisted throughout the airport and given a facilitated (or
private) security screening that takes into account the
member's individual injuries.
Nonprofit Coordination
The MSI Center has coordinated with over 40 nonprofit
organizations, all of which have a mission is to assist injured
servicemembers and their families. These nonprofits offer assistance in
a number of areas from financial to employment to transportation to
goods and services. Many are national organizations, but some are
local, serving Service men and women in a specific region or at a
specific Military Treatment Facility. Some of the many organizations
that are providing assistance are the Wounded Warrior Project, the
Injured Marine Semper Fi Fund, the Veterans of Foreign Wars, the
American Legion, Disabled American Veterans, the Coalition to Salute
America's Heroes, and, of course, the Service Relief Societies. There
are hundreds of other non-profits who offer assistance to military
families in general that are part of the America Supports You network
(www.americasupportsyou.mil).
Operation Warfighter
DOD sponsors Operation Warfighter (OWF), a temporary assignment or
internship program for servicemembers who are convalescing at military
treatment facilities in the National Capital Region. This program is
designed to provide recuperating servicemembers with meaningful
activity outside of the hospital environment that assists in their
wellness and offers a formal means of transition back to the military
or civilian workforce. The program's goal is to match servicemembers
with opportunities that consider their interests and utilize both their
military and non-military skills, thereby creating productive
assignments that are beneficial to the recuperation of the
servicemember and their views of the future. Servicemembers must be
medically cleared to participate in OWF, and work schedules need to be
flexible and considerate of the candidate's medical appointments. Under
no circumstance will any OWF assignment interfere with a
servicemember's medical treatment or adversely affect the well-being
and recuperation of OWF participants.
In 2006, 140 participants were successfully placed in OWF. Through
this program, these servicemembers were able to build their resumes,
explore employment interests, develop job skills, and gain valuable
Federal Government work experience to help prepare them for the future.
The 80 Federal agencies and sub-components acting as employers in the
program were able to benefit from the considerable talent and
dedication of these recuperating servicemembers. Approximately 20
permanent job placements resulted from OWF assignments upon the
servicemember's medical retirement and separation from military
service.
The core of OWF is not about employment, however; placing
servicemembers in supportive work settings that positively assist their
recuperation is the underlying purpose of the program.
Heroes to Hometowns
The American public's strong support for our troops shows
especially in their willingness to help servicemembers who are severely
injured in the war and their ever-supportive families, as they
transition from the hospital environment and return to civilian life.
Heroes to Hometowns' focus is on reintegration back home, with networks
established at the national and State levels to better identify the
extraordinary needs of returning families before they return home. They
work with local communities to coordinate government and nongovernment
resources necessary for long-term success.
The Department has partnered with the National Guard Bureau and the
American Legion, and most recently the National Association of State
Directors of Veterans Affairs, to tap into their national, state, and
local support systems to provide essential links to government,
corporate, and nonprofit resources at all levels and to garner
community support. Support has included help with paying the bills,
adapting homes, finding jobs, arranging welcome home celebrations, help
working through bureaucracy, holiday dinners, entertainment options,
mentoring, and very importantly, coordinated hometown support.
Currently, Heroes to Hometowns assistance has been provided to 156
families in 37 States and 2 territories.
Many private and nonprofit organizations have set their primary
mission to support severely injured veterans. The Sentinels of Freedom
in San Ramon, California, for example, recruits qualifying severely
injured to their community with ``scholarships'' that include free
housing for 4 years, an adaptive vehicle, a career enhancing job,
educational opportunities, and comprehensive community mentoring.
Through a coordinated effort among local governments, corporations,
businesses, nonprofits, and the general public, six scholarships have
already been provided in the San Ramon Valley and plans are to expand
the program nationwide.
Paralympics
The ability of injured servicemembers to engage in recreational
activities is a very important component of recovery. We continue to
work with the United States Paralympics Committee and other
organizations so that our severely injured have opportunities to
participate in adaptive sports programs, whether those are skiing,
running, hiking, horseback riding, rafting, or kayaking. We are also
mindful of the need to ensure installation morale, welfare, and
recreation (MWR) fitness and sports programs can accommodate the
recreational needs of our severely injured servicemembers. At
congressional request, we are studying current capabilities of MWR
programs to provide access and accommodate eligible disabled personnel.
The United States Olympic Committee Paralympics organization is
also coordinating with key Military Treatment Facilities to see how
severely injured sports and recreational opportunities can be expanded
and incorporated into all aspects of the recovery, rehabilitation, and
reintegration process. The Department is coordinating with other
organizations such as the Armed Forces Recreation Society to provide
similar opportunities to severely injured veterans on the municipal and
local levels, even possibly partnering with colleges and universities
to take advantage of those facilities and recreational programs.
the way ahead
Earlier I requested the DOD Inspector General (IG) perform an
independent review, evaluating our policies and processes for injured
Operations Enduring Freedom/Iraqi Freedom servicemembers. The objective
is to ensure they are provided effective, transparent, and expeditious
access to health care and other benefits when identified for separation
or retirement due to their injuries. I expect to receive the IG report
by July 2007.
In compliance with the National Defense Authorization Act for
Fiscal Year 2005, the Joint Medical Readiness Oversight Committee
(JMROC) was established to improve medical readiness throughout the DOD
and enhance servicemember health status tracking before, during, and
after military operations. The JMROC oversees medical readiness issues
by using a Comprehensive Medical Readiness Plan. Initially consisting
of the 22 actions required by the National Defense Authorization Act
for Fiscal Year 2005, the Department is expanding that list to include
readiness initiatives emanating from the National Defense Authorization
Acts for Fiscal Years 2006 and 2007. I believe the JMROC can assist the
Department in implementing improvements to support our injured
servicemembers.
As the various reviews reach their conclusions, I hope that we can
reach a national consensus on the integration of Federal disability
systems affecting our Nation's veterans and how they can be improved. I
look forward to working with you to develop the best way to provide for
the men and women who stepped forward to defend this Nation and were
injured in its service.
Chairman Levin. General Schoomaker.
STATEMENT OF GEN PETER J. SCHOOMAKER, USA, CHIEF OF STAFF,
UNITED STATES ARMY
General Schoomaker. Mr. Chairman and distinguished members
of the committee, I cannot tell you how disappointed and how
absolutely angry I am to have to sit before you today and to
stand accountable for what has occurred in the United States
Army. I agree with your statement and the statement of the
ranking member. I think that the military health care system,
particularly the Army, one I am very familiar with, is full of
the most professional, most caring medical professionals in the
world, and I hope that we make sure that as we address the
shortcomings here that we recognize the heroic work that is
taking place by all of the men and women who are taking care of
our wounded warriors and their families throughout this
process.
Now, we have discovered shortcomings that were brought to
our attention by the media. We should have known about these
things ourselves and we are finding out why we did not. But I
will tell you that I accept full responsibility and
accountability for these shortcomings because I am the senior
uniformed officer in the Army, just like I accept
responsibility for everything that happens in the Army and
fails to happen. That is the tradition of military service and
accountability, and I stand before you accountable for what has
occurred.
I will tell you that we all run in a bureaucratic morass.
Life every day in this system is like running in hip boots in a
swamp. It sucks the energy out of you every day, and not just
in the medical system, but in everything else that we do. I
hope that as we take a look at this that we look broadly at the
kinds of things that we can do to bring all of this into the
21st century, because that is the challenge that I believe we
all face and I believe it is a national security issue.
I would like to describe very quickly the things that we
have done and are doing immediately to rectify and bring into
standards and tolerance the situation that we find not only at
Walter Reed, but across the United States Army system. First of
all, we put a new leader in command at Walter Reed, Major
General Eric Schoomaker. He took command last Friday and was on
the ground within hours of taking charge. His deputy commander
will be announced. He is being selected as I speak, and will be
announced this week. He will be a combat arms brigadier general
that will work for Major General Schoomaker and will assist in
making sure that the proper care is being taken in an
administrative and military way for our soldiers.
The Wounded Warrior Transition Brigade commander and
command sergeant major, both combat arms soldiers-leaders, have
been selected and are on the ground, and are taking charge of
accountability for health and welfare issues. The new brigade
structure that we have approved out there is being manned.
A one-stop soldier and family assistance center has been
established at Walter Reed and this brings together in one
place the case managers, family coordinators, personnel and
finance experts, Army Wounded Warrior Program representatives,
Red Cross, Army community services, Army emergency relief, and
VA representatives.
Additionally, we are establishing a hot line from across
the Army directly into the Army operations center, which means
that anybody can call in on a toll-free number and report
directly into our operations center problems that they are
having within the system so that the leadership will have
direct access and immediate knowledge of what is occurring.
We have launched a tiger team of medical installation
professionals to our major medical treatment facilities Army-
wide to assess the outpatient care and to report back to the
Army leadership within 30 days. We will launch a similar team
early next week to assess outpatient care at our eight
community-based health care organizations, which are locations
where our Reserve component soldiers are given the opportunity
to recover and rehabilitate closer to their families and their
homes.
The Vice Chief of Staff of the Army will host a video
teleconference this Friday with hospital commanders of those
treatment facilities with major outpatient populations to get
an assessment of their programs and need for resources.
All wounded soldiers, save those on leave or that are
departing within the next few days, have been moved to Building
14, which was renovated in July 2005, on the Walter Reed
campus. This will put all wounded soldiers on the Walter Reed
compound. State-of-the-art Internet capability computers,
television, and phones are being added to each room in Building
14 and those same accessories will be provided to all wounded
soldiers out there.
We are pursuing a patient advocate, an ombudsman, program
at Walter Reed and other major installations for soldiers.
Additionally, for the soldiers we have a central issue point
for uniforms for all wounded soldiers, centralized distribution
system for all donated goods, have made improvements to the
dining facility so that wounded soldiers can more easily access
it, and are ensuring that awards that have been earned are
expeditiously presented and as rapidly as possible.
There are many other things that we are doing outside
Walter Reed specifically and for the purposes of brevity I will
stop here. Again I want to recount that I stand accountable for
what has occurred in the Army and all of our energy is going
into make sure that the proper actions are being taken to
correct it.
Thank you very much.
[The prepared statement of General Schoomaker follows:]
Prepared Statement by GEN Peter J. Schoomaker, USA
Mr. Chairman, Senator McCain, and distinguished members of the
committee, thank you for this opportunity to discuss the outpatient
care of our Nation's wounded warriors at Walter Reed Army Medical
Center, and throughout our Army. Every leader in our force is committed
to ensuring that Army health care for America's soldiers is the best
this Nation can provide. From the battlefield through a soldier's
return home, our priority is the expedient delivery of compassionate
and comprehensive world class medical care.
I am here today as the Chief of Staff of the U.S. Army. I can tell
you, I have never been prouder than I am today to serve with our
incredible soldiers, who motivate me every day and who remain the focus
of everything we do as an Army.
As Americans, we treasure the members of our All-Volunteer Force
who have raised their right hand to say, ``America, in your time of
need, send me. I will serve.'' We instinctively understand that in
return for their service and sacrifice, especially in a time of war and
demanding operational tempo, we owe them a quality of care that is at
least equal to the quality of service they have provided to us.
I have visited Army medical facilities around the world, and I have
met with soldiers, staff, and patients in Iraq and Afghanistan; at
Landstuhl, Germany; at installations across the United States, to
include Walter Reed and Brooke Army Medical Centers. Without exception,
the people I encounter inevitably remind me that the United States is a
special Nation, blessed with incredible sons and daughters who are
willing to serve. From the wounded soldiers I meet, whose bodies have
been hurt, but whose spirits remain strong, to loved ones whose tender
attention and tireless dedication are easing our warriors' path to
recovery, to the medical staff who have devoted themselves to
fulfilling the promise of our Army's Warrior Ethos that we will never
leave a fallen soldier; I have witnessed unparalleled strength,
resilience, and generosity, and I am humbled by their bravery. Even if
all of our facilities were the best in the world, and every process,
policy, and system were streamlined perfectly, our solders and families
would still deserve better. Without a doubt, they deserve better than
we have been providing to date.
Today we have 248,000 soldiers deployed in more than 80 countries
around the world. When injured or wounded, every one of those soldiers
begins a journey through our medical treatment facilities with the top-
notch care delivered by Army medics, surgeons, nurses, and civilians in
the forward operating facilities. There, our soldiers receive
extraordinary acute care that has drastically lowered our died-of-
wounds rate, and is regularly cited as being without peer.
But it is after the incredible lifesaving work has been done, and
the recovery process begins, that our soldiers are subjected to medical
processes that can be difficult to negotiate and manage. Due to a
patchwork of regulations, policies, and rules--many of which need
updating--soldiers and staff alike are faced with the confusing and
frequently demoralizing task of sifting through too much information
and too many interdependent decisions. To compound this challenge, we
have not optimally managed Army human and capital resources to assist
wounded soldiers and their families. Some of our counselors and case
managers are overworked and have not received enough training yet. At
times, we do not adequately communicate necessary information. We must
make better progress in improving our administrative processes. Some of
our medical holding units are not manned to the proper level and some
of our leaders have failed to ensure accountability, discipline, and
the well-being of our wounded soldiers. We need to improve our
maintenance of some of our facilities. Most of these issues we can
repair ourselves, and we are working aggressively to do so. Some others
may require your support and assistance to resolve.
We have identified and fixed a number of problems, but there is
still much to do. The Army has launched a wide-ranging and aggressive
action plan to address current shortfalls, both at Walter Reed and
across our Army. We are committed to rapidly fixing these problems, and
are focusing our efforts in four key areas: soldier welfare,
infrastructure, medical administrative processing, and information
dissemination.
At Walter Reed, we have made significant progress in repairing and
improving conditions at Building 18. We have also accelerated
improvements to the medical hold organizations and medical processes
and are expediting the identification and implementation of ways to
improve the Physical Disability Evaluation System across the force.
We are reorganizing the Walter Reed medical hold unit by
establishing a wounded warrior transition brigade, creating an
additional medical hold company, and increasing its permanent party
personnel to ensure we have the right numbers of leaders with the right
skills to properly take care of our outpatient wounded soldiers and
their families. We have selected a command-experienced, promotable
lieutenant colonel and command sergeant major who will lead this
organization. We are assigning more platoon sergeants who possess
greater tactical leadership experience and are re-establishing the
Walter Reed Garrison Command Sergeant Major position to provide the
right level of skilled, caring leadership our wounded soldiers and
their families deserve.
To assist with outpatient care and reduce the delays in the medical
and physical evaluation process, we are adding more personnel,
improving their training, and adjusting our medical and administrative
processes. We are expediting the reassignment and hiring of an
additional 34 case managers and 10 physical evaluation board liaison
officers to handle the increased patient load at Walter Reed. We have
improved the physical, administrative, and medical transition of
patients between the hospital and the medical-hold task force, and have
implemented a revamped clinic appointment system for our outpatient
wounded warriors. Additionally, a complete review of the medical and
physical evaluation process is underway.
Addressing the emotional, physical, and administrative challenges
our wounded warriors and their families face is a major area of
emphasis. In addition to the improvements to our outpatient care and
administrative processes, we have assigned Army officers to meet and
escort the families of our wounded warriors from local airports to
Walter Reed. To assist with their needs at Walter Reed, we are creating
a streamlined ``one-stop shop'' Soldier and Family Assistance Center,
have hired additional bilingual staff, and have increased counselor
availability at the Mologne House. Finally, the Army has implemented
the U.S. Army Wounded Warrior Program, which provides long-term support
of our seriously wounded soldiers to help them be self-sufficient,
contributing members of their communities.
Let me conclude by reiterating that Army Medical care is the best
in the world. Each day selfless, dedicated Army doctors, nurses, and
support staff perform miracles to save lives and limbs, and provide the
best possible care for our wounded warriors and their families. We will
do what is right for our soldiers and their families. They can be
assured that the Army leadership is committed and dedicated to ensuring
that their quality of life and the quality of their medical care is
equal to the quality of their service and sacrifice.
On behalf of the nearly 1,000,000 soldiers that comprise our Army--
and our wounded warriors and their families in particular--I appreciate
the committee's concern for these critical issues, and for Congress'
continuing support of soldiers and their families. Army Strong!
Chairman Levin. Thank you very much, General Schoomaker.
Now, Secretary Chu, who did you plan on speaking next?
Dr. Chu. Dr. Winkenwerder, next General Kiley, then I will
come back on the disability evaluation system issue.
Chairman Levin. Dr. Winkenwerder, thank you.
Secretary Winkenwerder.
STATEMENT OF WILLIAM WINKENWERDER, JR., M.D., ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
Dr. Winkenwerder. Yes, sir, Mr. Chairman. Mr. Chairman,
distinguished members of this committee, thank you for the
opportunity to be here today to talk about the serious concerns
that have been raised with regard to housing conditions and
inappropriate bureaucratic delays and hurdles for our
servicemembers at Walter Reed and for others that might be
caught up in a similar circumstance elsewhere.
Our wounded servicemembers and their families expect and
they deserve quality housing and family member support, along
with well-coordinated services. In the case of the incidents at
Walter Reed, we failed them. Today I welcome the chance to talk
about these issues and what DOD is doing to move forward.
As you have just heard, corrective action plans in the Army
and DOD are already initiated, but they will take the following
approach. First, the top priority is on finding and fixing
problems. Where policy or process or administrative change is
required, DOD will do it.
Second, we welcome public scrutiny, even when it is
critical and it is painful to hear. Problems cannot be solved
and the people cannot be properly served if issues are not
brought to light, and this process is doing that. I think all
of us here endorse the statements of Secretary Gates. He has
made it clear that defensiveness and explanations are not the
route to getting things done. Standing up, making things happen
to meet the needs of our servicemembers and their families is
our only responsibility right now.
I would assess the problems before us as follows. There are
the physical facility issues we have heard about, there is a
process of disability determinations, and then there is the
process of care coordination. I will not speak about the
substandard housing because, as you have just heard, the Army
has already begun to correct that problem. Obviously, a wider
review is needed across all Services and I think that is
already underway.
With respect to disability determinations, let me just say
that the servicemembers deserve fair, consistent, and timely
determinations. Complex procedures must be streamlined or they
have to be removed. The system must not be adversarial. I think
you made an excellent point. It should not be adversarial, and
the system has just got to improve.
Likewise, coordination of services. There must be a higher
ratio of case managers to wounded servicemembers to ensure
personalized care, better support, communication with families,
and simpler processes. No servicemember should ever have to
work through a maze or a gauntlet, or be on his or her own to
figure things out. That is just unacceptable.
Let me address one thing, importantly, and make this clear.
The problems cited in the press reports are not the result of
unavailable or insufficient resources, nor are they in any way
related to the BRAC decisions to close the Walter Reed campus
as part of the planned consolidation with the National Naval
Medical Center in Bethesda. I know there is a concern about
that and we will be happy to answer questions during this
hearing about that.
Significant resources have always been available and we
continue to invest at Walter Reed for whatever is needed. For
example, there were some, I might note, who questioned the
decision in 2005 to fund $10 million to construct a new Walter
Reed amputee center. Yet we proceeded with this, and the new
center will open in a few months. That was absolutely the right
decision. We will not allow the plans for the new medical
center to interfere with ongoing issues of care or needed
improvements.
Secretary Gates's decision to establish an independent
review group to evaluate and make recommendations on this
matter will be very beneficial in my judgment. The group is
highly qualified, it is a bipartisan team of former
Congressmen, line, medical, and enlisted leaders. They have
already begun their work.
Let me just say this. The entire Department has been
informed of the review group's charter. Group members can go to
any installation, talk to any personnel, and review any policy
to get the information and answers they need. They will have
the Department's full support.
DOD will be driven for results in its actions in the weeks
ahead, engaged, action-oriented, and focused on making real and
permanent improvements. Findings and actions will be shared
with the public, the people we serve, the servicemembers, their
families, military leaders, Congress, the Secretary of Defense,
and the President. They all deserve to know that the job is
getting done.
We have attacked problems in the past, solved them, and
come out stronger as a result, and we can do that again. We
have established, as Dr. Chu has noted, new standards in
virtually every category of wartime medicine and also, I might
add, in other areas of everyday medicine in America. The
quality of our medical care for our servicemembers is
excellent. There is no question about that.
But with regard to these issues, which are quality-of-
life--and in my judgment they are equally important as quality
of care, equally important--we have not met our own standards.
In the current reports on Walter Reed, the trust that has been
earned through our great achievements has been damaged. We have
to re-earn that trust and that is our job.
Let me just say one final thing in closing and that is that
as we all work together on these issues, maintaining the morale
of those who care for our warriors and maintaining the
confidence of our entire military in this system is critically
important. It is important that people believe that they are
going to get the care that they need, no matter if it is on the
battlefield, in the hospital, after the hospital, or when they
are in the VA. I just urge that we are sensitive and careful
about that concern of keeping up our morale.
I look forward to working together with you, Mr. Chairman,
and with leaders within the Services and DOD in the remaining
weeks of my tenure in this important effort. I am grateful,
really grateful, to have had the opportunity to have worked
with the selfless and committed professionals and patriots who
care for and support our Nation's heroes. These heroes deserve
our very best.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Winkenwerder follows:]
Prepared Statement by Hon. William Winkenwerder, Jr., MD, MBA
Mr. Chairman, distinguished members of this committee, thank you
for the opportunity to discuss the Military Health System, and in
particular to address the concerns raised in recent news media reports
regarding treatment of servicemembers at Walter Reed Army Medical
Center.
Our wounded servicemembers and their families deserve coordinated
professional health care services--both clinical and administrative--
together with quality housing and family member support. In the case of
the incidents cited at Walter Reed, the Department did not meet our
patients' expectations, and we did not meet our own expectations.
I want to address the events associated with the media reports and
internal findings regarding substandard housing for some of the
servicemembers receiving outpatient, long-term rehabilitative care, and
the administrative delays and hassles associated with the military's
disability process.
I would first like to outline the principles that underlie the
Department's approach in addressing this problem.
We welcome public scrutiny, even when it is critical. Perhaps
especially when it is critical. In this case, the Department
accepts the fundamental premise of the reports by the
Washington Post that unacceptable conditions existed at Walter
Reed for some of our servicemembers.
Where change is required, the Department will make it. The
focus will be on understanding and fixing the problems using a
systems approach. As Secretary Gates has stated, persons who
allowed these conditions to persist will be held accountable.
Yet, several of the issues identified cut across organizational
boundaries, and our greatest attention will be to introduce
change to the processes by which we support our servicemembers
and families.
Our military health system is a unique, national asset. It
must be preserved. As we engage on this issue using the skills
and talents of our people to solve the problems, we must act
carefully to preserve the morale and trust of our dedicated
caregivers.
context within the larger military health system: medical support to
servicemembers
We serve over 2.2 million members in the Active, Reserve, and Guard
components, to include over 251,000 servicemembers deployed overseas,
and another 7 million families, and retirees. Over 9 million Americans
are entrusted to our care--and in both battlefield medicine and
traditional health care delivery here at home, we are excelling in our
mission. Based on data, measures, and independent assessments by health
care organizations around the country, the performance of our military
medical personnel on the battlefield and in our medical facilities in
the United States has been extraordinary. We have established new
standards in virtually every major category of wartime medicine, and
many areas of peacetime medicine:
Lowest Disease, Non Battle Injury Rate. A testament to our
medical readiness and preparedness, our preventive medicine
approaches and our occupational health capabilities, we are
successfully addressing the single largest contributor to loss
of forces--disease.
Lowest Death to Wounded Ratio. Our agility in reaching
wounded servicemembers, and capability in treating them, has
altered our perspective on what constitutes timeliness in
lifesaving care from the ``golden hour'' to the ``platinum 15
minutes.'' We are saving servicemembers with grievous wounds
that were likely not survivable even 10 years ago.
Reduced Time to Evacuation. We now expedite the evacuation of
servicemembers following forward-deployed surgery to stateside
definitive care using airborne intensive care units and the
latest technology, we have been able to move wounded
servicemembers from the battlefield to hospitals in the United
States in as little as 48 hours.
Our medical professionals have provided high quality medical
care, and indicators of quality compare very favorably with
national benchmarks. The Department of Defense (DOD) Patient
Safety Program is a national model, and efforts to reduce and
eliminate medical errors have achieved ground breaking results.
We are also ensuring our servicemembers are assessed before
deployments, upon return and then again 90-180 days after deployment.
These health assessments provide a comprehensive picture of the fitness
of our forces, and highlight areas where intervention is indicated. For
example, we've learned that servicemembers do not always recognize or
voice health concerns at the time they return from deployment. By
checking with them 3 to 6 months later, we've found that about half of
them report physical concerns, such as back or joint pain, and a third
of them have mental health concerns. As of January 31, 2007, 212,498
servicemembers have completed a post-deployment health reassessment
with 31 percent of these individuals receiving at least one referral
for additional evaluation.
We have introduced an Individual Medical Readiness measure that
provides commanders with a picture of the medical readiness of their
soldier, sailor, airman, and marine down to the individual level.
We have worked closely with our partners in the Department of
Veterans' Affairs (VA), in our shared commitment to provide our
servicemembers a seamless transition from the mility health system to
the VA. DOD implemented a policy entitled ``Expediting Veterans
Benefits to Members with Serious Injuries and Illness,'' which provides
guidance on the collection and transmission of critical data elements
for servicemembers involved in a medical or physical evaluation board.
DOD began electronically transmitting pertinent data to the VA in
October 2005 and continues to provide monthly updates, allowing the VA
to better project future workload and resource needs. Receiving this
data directly from DOD before these servicemembers separate eliminates
potential delays in developing a claim for benefits by ensuring that VA
has all the necessary information to award all appropriate benefits and
services at the earliest possible time.
Here in the United States, our beneficiaries continue to give the
TRICARE program high marks in satisfaction. Military health system
beneficiaries' overall satisfaction with medical care in the outpatient
and inpatient settings compares very favorably against national
civilian benchmarks. The quality of our medical care is further
attested to by such organizations as the Joint Commission on
Accreditation of Healthcare Organizations that has recognized the
excellence in our medical treatment facilities with ratings well above
civilian averages.
Internationally, our medical forces have deployed with great speed,
skill, and compassion. Their accomplishments in responding to
international disasters has furthered our national security objectives;
allowed us to constructively engage with a number of foreign nations;
and saved civilian lives throughout the world.
Operating on the global stage, our medics--from the youngest
technicians to the most experience neurosurgeons--have performed in an
exemplary manner in service to this country. We will make the necessary
changes to our policies and processes, while remaining mindful of the
skills, dedication, and courage of our medical forces.
identifying the way forward
The set of issues addressed recently in the Washington Post deserve
our immediate and focused attention. The Army and the Department have
taken swift action to improve existing conditions, and enhance services
provided at Walter Reed, and identify areas meriting further study and
improvement. Army leadership initiated immediate steps to control
security, improve access, and complete repairs at identified facilities
and sought to hold accountable those personnel responsible to provide
for the health and welfare of our Nation's heroes.
Most recently, Secretary Gates commissioned an independent review
group (IRG) on March 1, 2007, to evaluate and make recommendations on
this matter. The IRG shall conduct its work and report its findings to
the Secretary of the Army, the Secretary of the Navy, and the Assistant
Secretary of Defense for Health Affairs no later than April 16, 2007.
The report will include:
Findings of an assessment of current procedures involved in
the rehabilitative care, administrative processes, and quality
of life for injured and ill members, including analysis of what
these heroes and their families consider essential for a high
quality experience during recovery, rehabilitation, and
transition.
Alternatives and recommendations, as appropriate to correct
deficiencies and prevent them from occurring in the future.
The Department will be relentless in its actions--engaged, action-
oriented and focused on making measurable improvements. Goals will be
clear and milestones will be established.We will regularly inform the
people we serve--the soldiers, the families, military leaders,
Congress, the Secretary, and President--on our progress. Findings and
actions will be shared with the public.
We know that this approach works. It has been successfully employed
in attacking other issues over the past--the development and
implementation of pre- and post-deployment health assessments; clinical
guidelines for psychiatric care; the development of stringent health
information security measures and reporting processes; and the
electronic collection of deployment health data.
an assessment of the issues
There are a number of disturbing elements to the conditions at
Walter Reed, yet I am confident that each of these items is fixable
with sustained leadership and oversight.The Department, with the
assistance of the Secretary's IRG, will come forward with revised
approaches to addressing the more complex personnel and medical issues.
I would categorize and assess the problems before us as follows:
Physical Facility Issues
In the case of substandard housing, the Army has been able to
quickly implement a corrective action plan. Some of those actions have
already occurred with facility repair and improvements. Clearly, other
facility improvements may require more comprehensive repairs that may
take longer. I am confident the Army and the Navy are taking steps to
ensure that any needed improvements will be made.
Process of Disability Determinations
The critical first step in assessing this process will be to
identify the desired outcome. We know that there are expectations that
both the servicemember and the Department want:
Full rehabilitation of the servicemember to the greatest
degree medically possible;
A fair and consistent adjudication of disability; and
A timely adjudication of disability requests--neither hurried
nor slowed due to bureaucratic processes.
The fundamental problems did not result from a lack of available
resources. The main effort here must be focused on the processes being
analyzed and assessed for their value and alternatives. The processes
must be redrawn with the outcomes we have in mind, with as much
simplicity and timeliness as possible.
Process of Care Coordination
Again, the quality of medical care delivered to our servicemembers
is exceptional. This assertion is supported by independent review. Yet,
the process of coordinating delivery of care to servicemembers in long-
term outpatient, residential rehabilitation needs attention. The Army
will assess, and my office will review, the proper ratio of case
managers to wounded servicemembers. The administrative and information
systems in place to properly manage workload in support of the soldiers
will also be assessed.
The planned consolidation of health services and facilities in the
National Capital Region will enable the Department to best address the
changing nature of inpatient and outpatient health care requirements,
specifically the unique health needs of our wounded servicemembers and
the needs of our population in this community. The BRAC decision also
preserves a precious national asset by sustaining a high quality,
world-class military medical center with a robust graduate medical
education program in the Nation's Capital. The plan is to open this
facility by 2011. In the interim, we will not deprive Walter Reed of
resources to function as the premier medical center it is. In fact, in
2005 we funded $10 million in capital improvements at Walter Reed's
Amputee Center--recognizing the immediate needs of our warrior
population. We are proud of that investment in capacity and
technology.We simply will not allow the plans for a new medical center
to interfere with the ongoing facility improvements needed in the
current hospital.
The Legacy of Military Medicine
Sustaining a medically ready military force and providing world-
class health services for those injured and wounded in combat remains
our primary mission.
In the current spate of news reports on Walter Reed, the trust that
we have earned through our other many medical achievements has been
damaged. Everyone's efforts will be focused on repairing and re-earning
that trust.
Our civilian and military leaders have remained steadfast in both
their support of what we have accomplished, and their belief that these
matters can be fixed. U.S. military medicine and our medical personnel
are a national asset, representing a readiness capability that does not
exist anywhere else, and--if allowed to dwindle--could not be easily
reconstituted.We must preserve this asset.
As the problems that lie at the intersection of personnel issues
with health care delivery are addressed, it is our shared
responsibility to focus on the specific problems, and not the people
who have done so much to improve the health of our military
servicemembers. We are blessed with a rich cadre of dedicated, hard-
working, skilled professionals. I have complete confidence that they
will rise to the occasion again, as they have done in the past, learn
from what went wrong, and build an even stronger, more responsive
system for all.
After more than 5\1/2\ years of service as the Assistant Secretary
of Defense for Health Affairs, I look forward to working together with
you and with the leaders within the Services and DOD in the remaining
weeks of my tenure to begin this effort at rebuilding this important
part of our system that needs attention. I remain grateful for the
opportunity to have worked with such selfless servants that comprise
the military health system.
Chairman Levin. Thank you, Secretary Winkenwerder.
General Kiley, you are next, and then we will go back to
Dr. Chu.
STATEMENT OF LTG KEVIN C. KILEY, USA, SURGEON GENERAL, UNITED
STATES ARMY
General Kiley. Thank you, Mr. Chairman, distinguished
members of the committee. I am Lieutenant General Kevin Kiley,
the Army Surgeon General, Commander of U.S. Army Medical
Command (MEDCOM), and I am accountable for health care in the
U.S. Army MEDCOM. A commander's first responsibility is the
health and welfare of his soldiers. A physician's first
responsibility is the health and welfare of his patients. As we
have seen in the last couple weeks, we have failed to meet our
own standards at Walter Reed. For that I am both personally and
professionally sorry and I offer my apologies to the soldiers
and families, the civilian and military leadership of the Army
and DOD, and to the American people.
It is also clear that this complex, bureaucratic,
administrative medical evaluation board (MEB), physical
evaluation board (PEB) process is in need of urgent
simplification and I am dedicated to doing whatever in my power
and authority to make positive change to this process. Simply
put, I am in command. I am accountable, and I share in the
failures, and I also accept the responsibility and the
challenges for rapid corrective action.
As General Schoomaker has already outlined, the living
conditions and welfare of soldiers, the responsiveness of our
leaders and enhanced support services for our families are in
evolution and in place as we speak. We are also beginning to
put into effect long-term change to help with some of the
bureaucratic medical evaluation processes that are impacting on
our soldiers.
We have addressed the living conditions at Walter Reed.
General Bob Wilson and my team are out, as the chief has
alluded to, inspecting other installations to assure we do not
have these similar issues at other installations. But we do
have human problems, too, human systems problems, and that is
about soldiers and families. American soldiers go to war with
the confidence that if they are injured they can come back
through a system that will care for them every step of the way,
to include in particular Walter Reed Army Medical Center, and
in fact, to date, that record has been outstanding.
They say a soldier will not take an objective out of sight
of a medic, and by extension Walter Reed, both inpatient and
outpatient care, is an extension of our trust with our combat
soldiers, and nothing can be allowed to shake that confidence.
Secretary Gates has made it very clear that he expects decisive
action. He and our soldiers will get it.
As we have heard, the disability compensation and
transition system is complex, confusing, and frustrating. It is
further compounded by the exceedingly complex nature of the
injuries that our young men and women are suffering, and the
Army MEDCOM has been working with the Army to begin changing it
to make it more responsive to soldiers and to reduce the
confrontational and adversarial form that it presently has.
We are making the adjustments at Walter Reed. As we have
announced, we are increasing staff to improve ratios and
communications. But we really need to reinvent this entire
process and we are in the process of doing that now. We want to
take care of our soldiers fully, giving them time to heal and
then carefully documenting their conditions to give them best
outcomes through the disability process.
Our Army's medical professionals have earned a tremendous
reputation during this war and this is a result of three
factors: first, the dedicated, talented, caring professionals
at our facilities, to include and in particular Walter Reed,
and across the rest of the military system, many of whom have
already served in Iraq and Afghanistan.
Second is the application of cutting edge technology to
save lives on the battlefield and return them home safely.
Third and equally important has been the exceptionally
strong support of Congress and the American people in this
effort.
It is regrettable that you and the American people have had
to learn these issues at Walter Reed through the Washington
Post. That is something we should have known, I should have
known, and we should have been working on it immediately. But
the light has been shed on this and, to be clear, having made
those mistakes, we are taking immediate action and establishing
future actions to correct it and prevent it from happening
again.
I am committed to fixing it. I am personally committed to
regaining the trust and confidence that our soldiers
everywhere, and I, and the American people have had in Army
medicine.
I appreciate the opportunity to speak to the committee
today. Mr. Chairman, I look forward to answering your
questions.
[The prepared statement of General Kiley follows:]
Prepared Statement by LTG Kevin C. Kiley, USA
Mr. Chairman, Senator McCain, and distinguished members of the
subcommittee, thank you for the opportunity to discuss recent media
reports about the living conditions, accountability procedures, medical
care, and administrative processing of soldier-patients receiving
recuperative or rehabilitative care at Walter Reed Army Medical Center
(WRAMC) as outpatients. The leadership and staff of WRAMC are committed
to providing world-class care for our wounded warriors and we are all
upset by the problems detailed in the Washington Post series.
Let me begin by informing you that in the past 2 weeks I have
directed three separate investigations into various problems raised by
the Washington Post articles. First, prior to the articles being
published, I asked the U.S. Army Criminal Investigation Division to
open an investigation into allegations of improper conduct by Dr.
Michael Wagner, the former Director of WRAMC's Medical and Family
Assistance Center (MEDFAC). The Washington Post published these
allegations on Tuesday, 21 February 2007. In addition, I directed two
more investigations. The second investigation will look specifically at
the execution of command responsibility by the WRAMC Medical Center
Brigade and the WRAMC Garrison Command to ensure safe, healthy living
conditions for our recovering Warriors. The final investigation will
look into WRAMC's internal Medical Evaluation Board (MEB)/Physical
Evaluation Board (PEB) processing. The intent of these investigations
is to uncover systemic breakdowns in our processes and to improve our
system of care for wounded warriors. Once these investigations are
complete, we will report back to you on our findings and our actions.
Since 2002, WRAMC has provided highly personalized health care by
treating more than 6,000 soldiers from Operation Enduring Freedom (OEF)
and Operation Iraqi Freedom (OIF). Nearly 2,000 of these soldiers
suffered battle injuries, more than 1,650 of whom started their care at
WRAMC as inpatients--receiving lifesaving medical treatments, needed
surgeries and physical therapy then progressed to outpatient status
living near the hospital. A team of 4,200 medical professionals treat
these wounded warriors and dedicate their lives and hearts to helping
our soldiers. On average, more than 200 family members also join them
to help with recovery, provide emotional support, and offer a strong
hand or a warm hug to carry them through difficult days.
The requirement to assign soldiers to Medical Holding Units (MHU)
is dictated by internal Department of Defense (DOD) regulations. The
Army policy for assigning soldiers to MHUs is intended to support the
needs of the individual soldier and his/her family. Soldiers with long-
term debilitating conditions such as spinal cord and brain injuries or
terminal cancer fall into this category and require intensive medical
and administrative management only available at the MHU. In certain
circumstances a soldier may be assigned to a MHU while undergoing
outpatient treatment when the Military Treatment Facility Commander
determines that continuous treatment is required and that the soldier
cannot be managed by his or her unit, i.e., is unable to perform even
limited duty at the unit.
Army military treatment facilities have two types of MHU. Active
component soldiers whose medical condition prevents them from
performing even limited duty within their unit are assigned to a
medical hold company. Each Army hospital with inpatient capability is
authorized a medical hold company. Generally speaking, a majority of
soldiers assigned to medical hold companies have medical conditions
that will eventually lead to separation from Service or medical
retirement. Since 2003, Reserve component soldiers who cannot deploy,
are evacuated back to the U.S. during their units' deployment, or
return home with a medical condition are assigned to a medical holdover
company. At WRAMC, both companies are organized under the Medical
Center Brigade, which also has command responsibility for permanent
party and students assigned or attached to WRAMC.
The current conflict is the longest in U.S. history fought by
volunteers since the Revolution. Two dozen soldiers arrive each week
and remain on the campus an average of 297 days for active duty, and
317 days for Reserve and National Guard. Often the very first thing
they ask when they are able to speak is ``when can I get back to my
guys?''
The rehabilitation process at Walter Reed is also unique in its
focus to restore these wounded soldiers not just to a functioning level
in society, but to return them to the high level of athletic
performance they had before they were wounded for continued service in
the U.S. military if possible. This is the stated goal of the WRAMC
program, as well as the newer program at the Center for the Intrepid
which was modeled after the Walter Reed successes.
The amputee population deserves special note as an example of these
initiatives. There have been a total of 552 soldier members who have
suffered major limb amputation in the war. Of these, 432 of the
patients were cared for at WRAMC: 394 servicemembers from OIF (68 with
multiple amputations) and 38 servicemembers from OEF (6 with multiple
amputations). There have been 35 amputee patients with major limb loss
who were found fit for duty (17 that are Continuation on Active Duty/
Continuation on Active Reserve and 18 remaining to complete the Medical
Board process). Five of the 17 soldiers have returned to serve on the
front lines in Central Command. All of the soldiers were monitored and
supported by medical hold or medical holdover companies during their
rehabilitation at Walter Reed.
It is important to note that, with the exception of burn patients,
WRAMC cares for most of the critically injured soldiers. Our Brooke
Army Medical Center and its new state-of-the art rehabilitation center,
cares for many critically injured soldiers with units or home of record
in the southwest. The complexity of the injuries and illnesses suffered
by these soldiers often results in a recovery period that is longer and
more challenging than those cared for at most other DOD facilities.
This places significant stress on the soldier-patient, their families,
and the staff providing care. The media reports about inadequate living
conditions brought to light frustrations with billeting and the
administrative processes necessary to return these warriors to duty or
to expeditiously and compassionately transition them to civilian life.
I would like to address three problem areas reported in the Washington
Post series: Living conditions in Building 18; accountability
management of outpatient-soldiers; and, administrative processing of
MEBs and PEBs.
billeting issues and living conditions in building 18
As soldiers are discharged from inpatient status, many need to
remain at WRAMC for continued care. Historically, the combination of
permanent party soldier barracks, off-post lodging, and three Fisher
Houses have been sufficient to meet the normal demand for billeting
soldiers assigned to the MHU at WRAMC. Beginning in 2003, the
population of Active and Reserve component soldiers assigned to WRAMC's
MHU increased from 100-120 before the war to a high of 874 in the
summer of 2005. To accommodate this increase in outpatient-soldiers,
WRAMC made use of all 199 rooms in the Mologne House--a nonappropriated
fund hotel on the installation opened in 1996; 86 rooms in 2 buildings
operated by the Mologne House; 30 rooms in 3 Fisher Houses; and, 15
contract hotel rooms in the Silver Spring Hilton. With the exception of
Building 18, all of these facilities have had extensive renovations
performed over the last 10 years and have amenities similar to many
modern hotels.
In the summer of 2005, WRAMC began housing the healthiest of the
outpatient-soldiers in Building 18--a former civilian hotel across the
street from the main WRAMC campus. Building 18 was constructed in 1969
and leased periodically by WRAMC until the government acquired the
building in 1984. Between 2001 and 2005, more than $400,000 in
renovations were made to Building 18. In 2005, a $269,000 renovation
project made various improvements in all 54 rooms to include replacing
carpeting and vinyl flooring. Additional upgrades to the central day
room included a donation of a pool table and the command purchase of
couches and a large flat screen TV.
The healthiest of our outpatient-soldiers are assigned rooms in
Building 18 after careful screening by the chain of command, case
managers, and treating physicians. Patients who have trouble walking
distances, have post-traumatic stress disorder, or have traumatic brain
injuries are not allowed to live in Building 18.
Building 18 has 54 rooms. Whenever a new soldier was assigned a
room, the building manager directed the soldier and his/her supervisor
to identify any deficiencies or damage in the room and initiates work
orders to repair identified problems. Additionally, residents and their
chain of command may submit work orders through the building manager at
any time. This entire process is being reassessed to ensure proper
accountability. Since February 2006, more than 200 repairs were
completed on rooms in Building 18, repairs continue to be made, and a
rapid renovation is planned.
In spite of efforts to maintain Building 18, the building will
require extensive repairs if it is going to continue to remain in
service. Upon reading the Washington Post articles, I personally
inspected Building 18. As noted in the article, the elevator and
security gate to the parking garage are not operational. Twenty-six
rooms had one or more deficiencies which require repair. Two of these
rooms had mold growth on walls. Thirty outstanding workorders have been
prioritized and our Base Operations contractor has already completed a
number of repairs. We are also working closely with U.S. Army
Installation Management Command, the Army Corps of Engineers, and our
health facility planners to replace the roof and renovate each room.
There are currently no signs of rodents or cockroaches in any
rooms. In October 2006, the hospital started an aggressive campaign to
deal with a mice infestation after complaints from soldiers. Preventive
medicine specialists inspected the building and found rooms with
exposed food that attracted vermin. Removing the food sources and
increased oversight by the chain of command has since brought this
problem under control, although such problems require vigilant
monitoring, which is ongoing.
accountability and information flow to outpatient-soldiers
As of 16 February 2007 WRAMC had a total of 652 Active and Reserve
component soldiers assigned or attached to two MHUs. Currently there
are 450 Active component soldiers assigned or attached to WRAMC's
Medical Center Brigade. There are 202 Reserve component soldiers
assigned or attached. Platoon sergeants and care managers are key to
accounting for, tracking, and assisting soldiers as they rehabilitate,
recuperate, and process through the disability evaluation system. Prior
to January 2006, WRAMC only had a single medical-hold company to
provide command and control, and accountability for all of those
soldiers. Since January 2006, the hospital created new organizational
structures to decrease the soldier-to-platoon sergeant and soldier-to-
case manager ratio from 1 staff member for every 125 soldiers, to 1
platoon sergeant and 1 case manager for approximately 30 soldiers.
Platoon sergeants and case managers attend staff training every
Thursday. The training consists of various topics ranging from resource
availability to soldier services. Weekly Thursday training is
supplemented with a platoon sergeant/case manager orientation program.
Departing platoon sergeants work along side their replacement for
approximately 1 week. Reserve component case managers attend a 1-week
training program at Fort Sam Houston Texas for an overview of the
Medical Holdover Program, MEB/PEB process, customer service training
and the duties of a case manager. Upon arrival at WRAMC, these case
managers undergo a month-long preceptor program. Once hired by WRAMC,
these case managers undergo a 1-week training program to address
organizational structure, MEB/PEB process, case manager roles and
responsibilities, use of data systems, administrative documentation,
convalescent leave and available resources in the hospital and on the
installation, as well as expectations and standards. There is also a
weekly clinical meeting held with physician advisory board and case
managers for chart reviews and recommendation for the MEB process.
Where ever possible we are working to streamline and merge platoon
sergeant and case manager training to make it identical for all new
personnel such as incorporating the preceptor concept for both Medical
Hold and Medical Holdover units. We will also enhance the weekly
training to introduce topics that are not only important to the platoon
sergeant and case manager but address recurring issues/concerns raised
by soldiers and family members.
We are conducting a 100-percent review of the discharge planning
and handoff process to ensure the transition from inpatient to
outpatient is seamless and patients understand the next step in their
recovery. This discharge will now include a battle handoff to a platoon
sergeant. We are also in the process of hiring additional case managers
and will submit plans to increase other critical positions in the
Medical Center Brigade, which will reduce the current staff to
outpatient ratio to more manageable levels, allowing more personalized
service to the recovering soldier and family member in making
appointments, completing necessary paperwork, and navigating the
complex disability evaluation systems.
The MEDFAC will colocate functions performed by Human Resources
Command, Finance, and Casualty Assistance into the MEDFAC allowing
service in one location. In the near term, WRAMC will expand the staff
to support the family members and relocate the operations to a more
centralized 3,000 square feet space in the hospital providing an
improved environment for the families to obtain assistance.
The Medical Center Brigade recently established a Soldier and
Family Member Liaison Cell to receive feedback from soldiers and family
members. A recent survey of soldiers and family members in January 2007
indicated that less than 3 percent of the outpatient-soldier population
voiced complaints about administrative processes. The command will
continue to enhance the structure of the soldier and family member
liaison cell. We have requested three family life consultants from the
Family Support Branch of the Community and Family Support Center,
Installation Management Command to expand the resources available to
identify areas of interest as well as provide counseling support to
soldiers and family members. We also will expand the current survey
feedback process to include an intake survey for soldiers and family
members, a monthly town hall meeting and survey for ongoing issues, and
an outtake survey upon the departure of soldiers and family members.
This feedback will be reviewed by the WRAMC Commander and other key
leaders.
The Mologne House has approximately 30 personnel on staff that
speak Spanish. These personnel work in all departments and a number of
them are in management positions. These personnel have been assisting
the Spanish speaking soldiers and their families since the hotel
opened. The Mologne House is taking steps to ensure the desk has a
Spanish speaking staff member on call 24 hours a day to assist those in
need of translation services.
Patients arrive at WRAMC by aero-medical evacuation flights three
times a week--Tuesday, Friday, and Sunday. Additionally, some patients
arrive at WRAMC on commercial flights for medical care. Family members
may arrive with the soldier or through their own travel itinerary.
Soldiers and family members who arrive on medical evacuation flights
are met by an integrated team of clinical staff, MEDFAC, Red Cross,
Patient Administration, Unit Liaison Noncommissioned Officers, and
Medical Center Brigade representatives. Inpatients are triaged for
further evaluation and disposition. Outpatients remain on the ambulance
bus and are sent to the Mologne House with a representative from the
Medical Center Brigade for billeting. Family members are met by MEDFAC
and Red Cross and are escorted to the Mologne House for lodging.
Currently, there are 51 global war on terrorism inpatient
casualties. Our census ranges between 30 and 50 depending on the volume
of air evacuations (high of 359 in July 2003 to low since OIF began of
64 in November 2005). Roughly half of the patients come as inpatients,
and half as outpatients. Outpatients are processed through the Medical
Center Brigade for accountability and billeting when they arrive.
Inpatients are accounted for by the hospital's patient administration
office. We believe as many as one in five patients may be at risk to
miss some of the administrative in processing at the Medical Center
Brigade when they are discharged from the hospital, because of the
timing of their discharge, their underlying medical condition, or
miscommunication. I have directed a complete review of the discharge
planning and the development of a new handoff process between the
hospital and the Medical Center Brigade. This will include the
development of a ``Global War on Terrosim Discharge Validation
Inventory'' that will be completed by the attending physician,
discharging nurse, discharging pharmacist, social worker, brigade
staff, and hospital patient administration. The checklist will be
validated by the Nursing Supervisor, Attending Physician, Deputy
Commander for Clinical Services (DCCS) or Deputy Commander for Nursing.
Each soldier receives a handbook upon assignment or attachment to
Med Hold or Med Holdover. The Med Hold handbook is provided to soldiers
when they are assigned or attached by their respective platoon
sergeant. Newly arriving family members receive a Hero Handbook as well
as a newcomer's orientation binder. Family members attend a weekly new
arrival meeting, and a weekly townhall meeting where information is
exchanged to answer questions or discuss ideas. PEB Liaison Officers
(LOs) conduct monthly training sessions on the MEB/PEB process for
soldiers and family members. A Case Management booklet with frequently
asked questions is also provided to soldiers.
administrative processing of mebs and pebs
The MEB/PEB process is designed with two goals in mind: (1) to
ensure the Army has a medically fit and ready force; and (2) to protect
the rights of soldiers who may not be deemed medically fit for
continued service. This process was designed to support a volunteer
Army with routine health occurrences and it is essentially a paper
process. We can and will improve this process in order to ensure that
it can support a wartime Army experiencing large numbers of serious
casualties.
The average Reserve component soldier assigned to Medical Holdover
at WRAMC has been with us for approximately 289 days. We know from past
experience they will be with us, on average, for 317 days from the time
they are assigned to the Medical Holdover Company. The primary reason
for this lengthy stay is the requirement that each soldier be allowed
to achieve ``optimal medical benefit''--in other words, heal to the
point that further medical care will not improve the soldier's
condition. All humans heal at different rates and this accounts for the
longest part of the process.
Once the treating provider determines the soldier has reached the
point of optimal medical benefit the provider will initiate an MEB.
This is a thorough documentation of all medical conditions incurred or
aggravated by military service, and ultimately concludes with a
determination of whether the soldier meets medical fitness standards
for retention. If the treating provider and the hospital's DCCS agree
the soldier does not meet medical fitness standards, the case is
referred to the PEB.
The PEB is managed by U.S. Army Human Resources Command and is
comprised of a board of officers, including physicians, who review each
MEB. The role of the PEB is to evaluate each medical condition,
determine if the soldier can be retained in service, and, if not
retainable, assign a disability percentage to each condition. The total
disability percentage assigned determines the amount of military
compensation received upon separation. It is important to note that the
MEB/PEB process has no bearing on disability ratings assigned by the
Department of Veterans Affairs (VA), but thorough and complete
documentation of medical conditions is essential for expeditious review
by the PEB and will also aid the soldier in completing VA documentation
requirements.
The Washington Post articles provide anecdotal experiences of
soldiers and families who have had medical records and other paperwork
lost during the MEB/PEB process. All medical records at WRAMC are
generated electronically. However, paper copies must be printed since
the PEB cannot access the electronic medical record used by DOD
hospitals.
There are currently 376 active MEB/PEB cases being processed by the
WRAMC PEB LOs. The average time from initiation of a permanent profile
to the PEB is 156 days. The MEB is processed through the PEB and
Physical Disability Agency for an average of 52 days (including the 15
percent of cases returned to the hospital for further information).
Thus, the total time from permanent profile to final disability rating
is currently 208 days. At present, WRAMC has 12 trained PEB LO
counselors. We are hiring an additional 10 counselors and 4 MEB review
physicians to expedite the medical board process. It takes at least 3
months to train a PEB LO counselor and these employees are the main
interface between the soldier and the MEB/PEB system. As you might
imagine, PEB LO counselors need to have excellent interpersonal and
communication skills to perform well in a system that can be very
stressful for the soldier, family, and counselor.
In closing, let me again emphasize my appreciation for your
continued support of WRAMC and Army medicine. The failures highlighted
in the Washington Post articles are not due to a lack of funding or
support from Congress, the administration, or the DOD. Nor are they
indicative of the standards I have set for my command. Walter Reed
represents a legacy of excellence in patient care, medical research,
and medical education. I can assure you that the quality of medical
care and the compassion of our staff continue to uphold Walter Reed's
legacy. But it is also evident that we must improve our facilities,
accountability, and administrative processes to ensure these systems
meet the high standards of excellence that our men and women in uniform
so richly deserve. Thank you again for your concern regarding this
series of articles.
Chairman Levin. General Kiley, thank you very much.
Back to you, Dr. Chu.
Dr. Chu. Sir, thank you. Let me underscore at the outset a
point that General Schoomaker made, and that is we recognize
that to deal properly with these cases we need several echelons
of support in DOD. That is the reason a year ago we established
the Military Severely Injured Center as a backstop to the
Services' programs. It has a 1-800 number which any family or
any servicemember can call 24 hours a day, 7 days a week. It is
the place in which we try to bring together the Services and
the several government agencies that deal with these issues--
Department of Labor, Transportation Security Agency, and the
VA. It has been one of the elements we have used to ensure
there are VA representatives in our major clinical centers.
It has been our agent in helping establish the Heroes to
Hometowns program, in which we partner with local
organizations, with the American Legion, with the State VA
apparatus, to ensure that when the service person returns home
there is a sponsor, there is the kind of support the country
properly expects.
I want to thank Congress for its actions in support of
these multi-echelon efforts. As one example, in your National
Defense Authorization Act for Fiscal Year 2007 you granted the
authority we sought to allow us to award to the service person
the equipment that we provide them on Active Duty under our
computer electronics accommodations program.
But you raised, Mr. Chairman and Senator McCain as well, I
think the fundamental issue that I hope this debate will allow
us to address. That is the adequacy, the structure, the nature
of the Nation's disability programs for injured servicemembers.
As you appreciate, we have a variety of different programs that
support these members, the principal ones being those in the
DOD, but also, as you cited, the VA and the Social Security
Administration. These proceed from different statutory
authorities. They have somewhat different purposes and, as you
have noted, they reach somewhat different conclusions about
individual cases.
It is not surprising to us that individuals in the system
find it frustrating and difficult to navigate. I believe the
ultimate question here is whether the country has the right
paradigm or whether we should try to bring these programs
together. That is the question ahead of us; answering that
question I believe we will benefit from the several review
groups that have been appointed, both those constituted within
the last several days and those appointed earlier.
As you recall, sir, Congress mandated there be a commission
on veterans disability benefits. It is scheduled to report in
October of this year with its findings and we have been
supporting its deliberations.
Within the existing system, DOD has begun revitalizing how
we deal with these issues. We are in the process of revising
the instructions that apply to the program as it stands today,
the program that we administer, and the Services are addressing
their issues, because these programs are run by each military
department on a decentralized basis, I would point particularly
to the Army's transformation initiative in this regard.
I am confident, with the energy, the attention, the
interest that is being paid to these programs, with your
support for necessary statutory changes, that we can replicate
for disability and disability evaluation the same success for
the Nation that we have already achieved in our clinical
services.
I thank you, sir, and look forward to your questions.
Chairman Levin. Thank you, Secretary Chu.
There has been a statement submitted for the record by the
Veterans for America and that statement will be made part of
the record.
[The information referred to follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Levin. Senator Pryor, I believe, has to chair a
committee hearing and he wants to make a unanimous consent
request.
Senator Pryor.
Senator Pryor. I do have a statement for the record that I
would just ask be entered into the record. Also I have a letter
from a soldier from Arkansas who spent in and out about 2 years
in Walter Reed after being injured in Iraq. Mr. Chairman, I
just ask that be submitted for the record, and I want to thank
you and Senator McCain for your leadership on this issue.
Chairman Levin. Thank you, and they will be made part of
the record.
Senator Pryor. Thank you.
[The prepared statement of Senator Pryor follows:]
Prepared Statement by Senator Mark L. Pryor
I would like to start by apologizing to our service men and women
and their families--not just those who have suffered due to the
conditions at Walter Reed, but all of our veterans and servicemembers
across the country. This is unacceptable, period. It will be remedied,
and remedied soon. That is why I joined my colleague, Senator Obama, in
co-sponsoring the Dignity for Wounded Warriors Act. This legislation is
an important first step, and I encourage this committee to mark it up
and the full Senate to pass it soon.
When I read the Washington Post series, I couldn't help but think
that we've failed our brave service men and women. Like my colleagues
and most Americans, I was outraged and surprised to learn of the
unacceptable conditions in Building 18 of the Walter Reed Army Medical
Center. I've visited Walter Reed many times, even as recently as last
month, and was never informed of the poor condition of Building 18. I
didn't even know of the existence of Building 18. I guess I know why
Building 18 was left off of my tour.
What kind of message are we sending to these young soldiers and
their families when the hospital or medical facility has holes in the
ceiling and black mold growing on the walls? These men and women have
sacrificed so much to keep this nation safe and free. We owe it to them
and their families to provide the very best medical care and treatment
that this country has to offer. I refuse to believe that this is the
best we can do.
As the President proposes to send another 21,500 brave American
service men and women to serve overseas in Iraq and thousands of others
prepare to serve our country elsewhere around the world, the condition
of our medical facilities is even more crucial. We need to implement
change quickly--not just at Walter Reed but at any and all of our
Department of Veterans Affairs (VA) facilities that are in need of
upgrades or repairs, in addition to our battlefield facilities.
Although I've been to the VA facilities in Arkansas many times, after
hearing the revelations about Walter Reed, I plan to visit again at the
next available opportunity to ensure that I have the full picture of
the facilities' strengths and shortcomings.
I am somewhat heartened to see that the Army is taking some
responsibility for the failures at Walter Reed. Defense Secretary Gates
has expressed his commitment to resolving this issue, and several
officers with direct oversight of Walter Reed have either resigned or
been fired. I would like everyone to know that I intend on holding
Secretary Gates to his word, and I took forward to working with my
colleagues to provide active oversight to ensure that this never
happens again. I know my colleagues are as anxious as I am to move
forward and find solutions to ensure that our overburdened VA system is
able to care for all of our veterans--those just returning home and
those who served us in previous military conflicts.
I want to thank the chairman and ranking member for holding this
very important hearing. I want to thank our witnesses for being here. I
know that you'll be asked some tough questions, but hopefully we can
get to the bottom of this to make sure our service men and women get
the best medical care our government can provide.
Letter from a constituent who spent roughly 2 years at Walter Reed
Army Medical Facility.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Letter from a constituent detailing his experience at an active
duty facility.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Levin. We will have an 8-minute first round.
When we visited Building 18 last week we were told that
there were too few NCOs to take care of the assignment of the
medical needs of the outpatient soldiers under their
supervision and to do other things that needed to be done that
they were required to do, including the health and welfare
inspection of soldiers' rooms. We also learned when we visited
Walter Reed last week that there was a backlog in work orders
for the maintenance and repair in Building 18.
General Schoomaker, let me ask you, who in the chain of
command should have been aware that there were no inspections
going on of soldiers' rooms and that there was a backlog in the
work orders for maintenance and repair?
General Schoomaker. At Walter Reed, the commander of Walter
Reed is the ultimate authority there that should have known
that. He is supported by a chain of command that supervise the
soldiers on a day-to-day basis and he is supported by a
garrison command whose job it is to manage the maintenance, et
cetera, out there. So he had in my view adequate assistance on
the ground out there, and in the exercise of commandership and
leadership out there should have known this.
So should the Army have known it, though. I will tell you,
I went through Building 18. Never even heard of it before. I
went through it myself. There is nothing out there we could not
have corrected with the proper attention, and we should never
have had that problem.
Chairman Levin. General Kiley, were you aware of those two
specific shortfalls, that they were not being conducted, the
inspections of the soldiers' room, and that there was a backlog
of workorders for maintenance of Building 18? Were you aware of
those?
General Kiley. No, sir, I was not.
Chairman Levin. All right.
Dr. Winkenwerder, were you aware of those two shortfalls?
Dr. Winkenwerder. No, sir, I was not.
Chairman Levin. Should you have been?
Dr. Winkenwerder. Yes.
Chairman Levin. General, should you have been?
General Kiley. Certainly if the Walter Reed commander was
having any difficulty executing the repairs of those I should
have been aware of that. If General Weightman felt that I
needed to know that, I should have been aware of it. But I am
still accountable as his next higher commander.
Chairman Levin. General Kiley, General Weightman testified
yesterday before the House that, ``We had a system that
probably was accurate about 80 percent of the time'' as to the
handing off of inpatients to outpatient care. That was the
figure he used. About 20 percent of the time, he said, we did
not do a good handoff of those patients from inpatient to
outpatient. Would you agree with that percentage?
General Kiley. Sir, based on what he told me, yes, sir,
because I would believe him.
Chairman Levin. Were you aware of it at the time?
General Kiley. No, sir.
Chairman Levin. Should you have been aware of it?
General Kiley. Yes, sir, as the commander I should be aware
of that, particularly if it is an issue for General Weightman,
to bring more resources to bear.
Chairman Levin. General Kiley, veterans advocates, lawyers,
and servicemembers say that the Army is shortchanging our
troops on the disability retirement ratings and they point to
the fact that the same soldiers are more often being given
higher disability percentages by the VA than they are by DOD,
and this is particularly true, but not limited to, post-
traumatic stress disorder (PTSD) and traumatic brain injuries
(TBI).
Would you agree that we have been shortchanging troops in
that area, those two areas particularly?
General Kiley. Senator, I have said on multiple occasions
that the emergence of PTSD and the emergence of particularly
mild TBI is a very complex process that we are only now in the
last year or 2 beginning to realize how to diagnose and treat.
I would agree that it is very difficult for the disability
system of DOD to recognize the nuances, if I can use that term.
It is very clear to me in talking to soldiers even as recently
as last week that the present disability system recognizes
something as fundamental as a missing limb, but does not
appreciate or take into account the whole man theory, that the
PTSD this soldier may have, or TBI, may be as significant or
more significant for their future.
So I agree that we have an issue there and I think we need
to take that on.
Chairman Levin. In that respect, our failure to take those
problems into account, would you say we have been shortchanging
some soldiers?
General Kiley. Yes, sir, I think we have.
Chairman Levin. We are going to take every step we can
possibly change to correct that, working with you folks,
because it is a huge issue.
General, do you want to add a quick word there?
General Schoomaker. Sir, I do, if you do not mind. One of
the things I learned and I did not know before is, of course
there are two different laws, and I am not trying to--just for
clarity. The military system operates under a different law
than the VA system does, and I was very surprised to see that
where a soldier would be rated, say, at 40 percent in the
military system that the VA may rate that very same soldier at
70 percent.
This kind of problem is fundamental to people's
understanding and trust and confidence in the system, and it is
very difficult to explain.
Chairman Levin. It is not only difficult to explain, it is
unexplainable, it is inexplicable, and it is unacceptable, and
that is one of the reasons why these two committees are going
to be meeting together. We are going to try to end that
separation, that difference, the crack that exists between the
DOD and the VA.
There was a recent article that was written about PTSD by
Mark Bowell. He quotes Lieutenant Colonel Dr. Charles Engell,
who is the Director of Deployment Health Clinical Center at
Walter Reed, as saying that military doctors are reluctant to
diagnose soldiers with PTSD because it would, ``stigmatize the
person or bring harm to their careers.''
General Kiley, should military doctors be reluctant to
diagnose soldiers with PTSD to avoid stigmatizing them?
General Kiley. Mr. Chairman, I do not believe they should
be reluctant to, but I think that is absolutely the reality. As
part of the mental health task force that Congress has directed
and that I am co-chairing, we have visited Army, Navy, Air
Force, and Marine bases around the world. It is very clear that
our soldiers, sailors, airmen, and marines are very concerned
about being diagnosed with PTSD as it relates to security
clearances, as it relates to a perception among their peers and
their superiors that they are somehow inadequate or not capable
of being soldiers and leaders. I think it is one of the great
challenges in military medicine and in the Nation to move past
that.
Chairman Levin. But should doctors be reluctant?
General Kiley. What I believe happens is that the
individual soldiers are reluctant to talk to doctors about it
and the doctors know they are reluctant and so they attempt to
deal with it. There is a difference between helping soldiers--
but I do not think they should be reluctant. I think if a
soldier has a diagnosis of PTSD it should be documented.
Chairman Levin. There was a National Public Radio story
about Fort Carson, Colorado, where it was alleged that there
was a failure to provide adequate treatment for soldiers
suffering from PTSD and other service-connected mental health
problems. Are you, Dr. Winkenwerder, aware of that story? I
think you have looked into allegations; I believe you have now
undertaken an investigation at Fort Carson. What have you found
there?
Dr. Winkenwerder. Mr. Chairman, I did learn about that and
I learned about it during the interview. I had not been aware
that there were problems. I was disturbed to hear about the
individual cases because, as I heard about them, they had merit
in my judgment. It appeared to me that people had been
potentially improperly discharged or discharged without the
proper medical diagnosis, and it appeared that there might have
been some instances of retribution or just not the right
behavior.
I have worked very hard over the last 4 to 5 years to send
the signal and to work with all of our leaders, both medical
and non-medical, to destigmatize mental health issues and to
make caring for mental health part of the routine of what we
do.
Chairman Levin. We have a long way to go.
Dr. Winkenwerder. Yes, we do.
Chairman Levin. One final question has to do with the
funding. The fiscal year 2008 budget request actually has less
funding requested for the sustainment of defense facilities,
defense health facilities, than the fiscal year 2007 budget.
The fiscal year 2007 budget has $341 million. The fiscal year
2008 budget request has $335 million. Now, sustainment is the
funding that is used to maintain buildings at their current
level of quality. This is the fixing of roofs, air
conditioning, the kind of things that they are doing at
Building 18, and this includes preventative maintenance.
One hundred percent funding simply means you are doing
enough maintenance to keep your facilities at the same quality
as last year to prevent deterioration. This is 87 percent
request of this year's funding. How does the administration,
Dr. Chu, possibly justify requesting 13 percent less than is
needed to sustain our medical facilities at this year's level?
Dr. Chu. I think, Mr. Chairman, when you come to the budget
figures you have to take into account not only the base budget,
but also what is in any supplemental request.
Chairman Levin. You are saying there is a supplemental
request in this area, sustainment of medical buildings?
Dr. Chu. I think, if I may, sir, to get the full picture we
have to look at what was spent this year in 2007 and where that
is going to be, also what was spent in 2006, as well as what is
planned for 2008 to understand the condition of the actual
facilities. Obviously, it is our intent to request what is
necessary to keep those facilities in a good condition and
where they are inadequate to make sure they come up to the
right standard.
Chairman Levin. But your budget request does not keep the
dollars even at last year's level. I am just telling you that.
Dr. Winkenwerder. I will be glad to help answer this. The
figures I have are that in 2006.
Chairman Levin. There was a hurricane issue in 2006. That
is why I left it out. There was a big issue about hurricane
damage to one particular facility. So start in 2007: $341
million for sustainment; the request for 2008, $335 million.
That is a reduction. By your own figures, if you look at the
bottom line, it was 96 percent in 2007 of the level needed to
maintain it at the previous year's level; 87 percent; and in
2009 goes down to 77 percent. How do you justify budget
requests that are that reduced?
Dr. Winkenwerder. Sir, we will take a look at that. I just
would note for you that, not just in 2006 but 2005, the
sustainment and modernization budget for the entire military
health system was at 150 percent and 172 percent of the
requirement. There is no reluctance to provide whatever is
needed. There is just not an issue there, I can assure you
about that.
Chairman Levin. Well, the numbers do present an issue. You
will have to take a look at that.
Dr. Winkenwerder. We will look at them.
Chairman Levin. Thank you.
Dr. Winkenwerder. That should not be an issue.
Chairman Levin. It should not be.
Dr. Winkenwerder. Yes, sir.
[Additional information provided for the record follows:]
The fiscal year 2008 budget request of $335 million for the
sustainment of Defense Health Program (DHP) facilities is $7 million
less than the fiscal year 2007 budget of $342 million. This reduction
results from a detailed scrub of programs within each of the Budget
Activity Groups (BAGs). As a result, there was realignment of programs
and the associated funding among several of the BAGs; one such
realignment resulted in an overall decrease to sustainment funding
between fiscal year 2007 and fiscal year 2008. The primary decrease was
attributable to the realignment of funding to the In-house Care BAG for
patient appointing, a patient related cost.
The fiscal year 2006 budget request of $324 million for sustainment
of DHP facilities was $18 million less than the fiscal year 2007 budget
of $342 million. As a result of funding that became available during
the year, total fiscal year 2006 expenditures for sustainment of
facilities equaled $512 million. Funding may become available during
fiscal year 2007 to perform additional facility sustainment
requirements (see table below).
Facilities Sustainment Model (FSM)
----------------------------------------------------------------------------------------------------------------
Fiscal Year
--------------------------------------------------
2006 2007 2008
----------------------------------------------------------------------------------------------------------------
Actual Estimate EstimateFSM Requirement.............................................. $ 351,385 $ 356,302 $ 387,890
Budgeted..................................................... 323,859 341,937 334,858
Funded....................................................... 512,072 341,937 334,858
Funded to FSM Rate........................................... 145.7% 96.0% 87.0%
----------------------------------------------------------------------------------------------------------------
Chairman Levin. Senator McCain.
Senator McCain. Thank you very much, Mr. Chairman.
I would like to note the presence today of members of our
veterans service organizations, the Veterans of Foreign Wars,
American Legion, and others, who are with us, who I have had
the honor of working with for the last 25 years. I think there
is no one more capable of providing us the advice and counsel
on these issues than our veterans organizations, who themselves
have served. So I am glad to have them here with us.
Chairman Levin. Thank you, Senator McCain, for pointing
that out, and I know you do that on behalf of the whole
committee. We join you in that.
Senator McCain. General Schoomaker, do you think that the
Washington Post articles fairly characterize the problems at
Walter Reed?
General Schoomaker. I believe they did, especially in
regards to the frustration of the soldiers. I think Building 18
became a metaphor for a bigger problem, and that is the
frustration that we have been discussing and the bureaucracy,
and the inexplicable rules and the bureaucracy that surrounds
it. So in that regard I would say yes.
Senator McCain. So how do you evaluate Lieutenant General
Kiley's responsibility for the problems at Building 18 and the
lack of resources assigned to medical hold personnel?
General Schoomaker. General Kiley is the Surgeon General of
the Army and he is the principal, he is dual-hatted. He is both
the medical command commander--he commands the entire medical
command across the whole United States Army, as well as being
the principal medical adviser to the chief of staff of the Army
and the Secretary of the Army. So from the standpoint of
knowing something specifically that had not been brought to his
attention in a single barracks someplace, I would say that is a
stretch.
However, the system should elevate the kinds of things that
require resources and they get fixed. I will say that what is
inexplicable is that we, for 3 years, have been putting
hundreds of millions of dollars into substandard barracks. I
have been in the Army for almost 4 decades. We have never
funded barracks, housing, and things the way they should be
funded, either in terms of numbers or in terms of maintenance.
It has always been a stretch.
We tried to correct that in the last 3 years by making some
major shifts. You can find years where we are funding
maintenance at less than 50 percent of what was required. That
is not unknown to people. So to have--with all of the energy
that we put into trying to fix this problem Army-wide, it is a
surprise to me that we would have any reluctance to get
Building 18 fixed. So what I am telling you is that the
commander on the ground there clearly should have had it fixed
and been accountable for it. We should have known about it if
it was a problem.
Senator McCain. I appreciate that, General. But already
there are stories, there are complaints about conditions at
Fort Lewis, Fort Dix, Fort Knox, Fort Bragg, and Fort Irwin
according to published stories today. What credence do you give
those complaints?
General Schoomaker. We are going to check, and we are going
to find out, and we will correct those that we have.
Senator McCain. So it is not just a Building 18, maybe?
General Schoomaker. Maybe not, that is correct. Again, I
want to reemphasize something, that this has been a challenge
for decades. We have short-shifted maintenance because we had
to carry readiness accounts, we had to train, we have had to
repair equipment. That has always been a challenge.
Senator McCain. General, with all due respect, I know of no
time in the 24 years that I have been a Member of Congress that
the DOD has come over and asked for funding for this kind of
needs for the military it has ever been turned down. So I
understand your statement and I think there may be something to
it, but every time there has ever been a request that has to do
with personnel matters in 24 years that I have been in Congress
we have always not only granted those funds, but we have tried
to exceed them.
So maybe there is something wrong in the system that has
caused, maybe at Secretary Chu's level and Secretary
Winkenwerder's level, that we have not funded these facilities,
because it certainly is not a reluctance on the part of
Congress and the American people.
General Schoomaker. Sir, I certainly was not saying that
that was the problem. I was stating the facts, that in my
entire experience this has always been a challenge and I think
we all know that. So it is not an excuse, either. It is just a
fact. So I only bring it up because with the emphasis that we
have put on trying to rectify this and improve the quality-of-
life of our soldiers and their families that there is really no
excuse for this kind of thing not to have surfaced and been
rectified.
Senator McCain. Again I would assert that these kinds of
problems are viewed as unacceptable by everyone, and they
exist, apparently they exist in other bases around the Nation
as well.
General Kiley, I want to read you a quote from the
Washington Post on February 23, 2007, where you conducted a
tour by the press in Building 18. `` `In the next room there is
a little water drop in the ceiling. You can get a nice shot of
it,' Kiley joked.'' According to the report, there was water
dripping into a wastebasket in the game room used by recovering
soldiers in Building 18.
If that quote is accurate, what does that say about your
attitude to this problem, General?
General Kiley. Sir, I do not believe that quote is
accurate. It was in room 416. It was in a double, a two-room
suite on the fourth floor of that building. I had been in that
room earlier in the day and had talked to the sergeant who
lived in there about the leak. They had offered to move him out
and he was okay with it. He was getting ready to leave the
area.
I was attempting to provide full disclosure to the press
about what we had found in terms of our walkthrough. I was not
joking about anything. This is very serious. It had rained a
little bit earlier in the afternoon before the press corps get
in there. We went up, I walked into the room and one of the
reporters asked me to point out the drop. So I put my finger up
at the drop and it disappeared and we waited for another drop.
But there was nothing humorous. We were not in the process of
making jokes about this process.
Senator McCain. Dr. Winkenwerder, beginning last year your
office initiated a so-called ``efficiency wedge,'' which is a
deduction from the service medical budgets. Both the Army and
Navy Surgeons General have indicated that these reductions are
unexecutable. What is the value of the efficiency wedge
reductions across the Army, Navy, and the Air Force between
2007 and 2009?
Dr. Winkenwerder. I do not have that figure right in front
of me, but it is several hundreds of millions of dollars over
that span of time.
[Additional information provided for the record follows:]
The table below provides details of the reduction to the Services'
budgets for the period fiscal years 2007-2009 as a result of the
efficiency wedge:
[In millions of dollars]
----------------------------------------------------------------------------------------------------------------
Fiscal Year
-----------------------------------------------
2006 2007 2008 2009
----------------------------------------------------------------------------------------------------------------
Army:
DHP O&M....................................................... 4,970.6 4,635.8 4,867.5 4,963.9
DHP Procurement............................................... 66.0 73.8 78.8 73.0
DHP RDT&E..................................................... 354.0 222.5 5.0 5.0
Medical Milpers............................................... 2,114.2 2,232.2 2,141.4 2,190.0
-----------------------------------------------
Total....................................................... 7,504.8 7,164.4 7,092.7 7,231.9
-----------------------------------------------
MTF Efficiencies.............................................. 29.8 82.1 142.3 227.3
Percent of Total.............................................. 0.4 1.1 2.0 3.0
----------------------------------------------------------------------------------------------------------------
Navy:
DHP O&M....................................................... 2,877.9 2,862.4 2,657.3 2,737.0
DHP Procurement............................................... 61.5 53.2 50.8 52.7
DHP RDT&E..................................................... 46.9 29.8 23.8 24.3
Medical Milpers............................................... 2,435.8 2,431.6 2,420.5 2,400.6
-----------------------------------------------
Total....................................................... 5,422.1 5,377.0 5,152.3 5,214.6
-----------------------------------------------
MTF Efficiencies.............................................. 30.6 84.4 146.5 234.2
Percent of Total.............................................. 0.6 1.5 2.8 4.3
----------------------------------------------------------------------------------------------------------------
Air Force:
DHP O&M....................................................... 2,506.0 2,477.6 2,377.8 2,528.6
DHP Procurement............................................... 104.5 66.2 63.0 52.2
DHP RDT&E..................................................... 54.2 19.0 22.0 22.5
Medical Milpers............................................... 2,810.9 2,717.9 2,812.9 2,828.4
-----------------------------------------------
Total....................................................... 5,475.6 5,280.6 5,275.7 5,431.7
-----------------------------------------------
MTF Efficiencies.............................................. 33.6 92.5 197.5 323.7
Percent of Total.............................................. 0.6 1.7 3.6 5.6
----------------------------------------------------------------------------------------------------------------
[In millions of dollars]
------------------------------------------------------------------------
Fiscal Year
-----------------------------------
2007 2008 2009
------------------------------------------------------------------------
Army................................ -$82.1 -$142.3 -$227.3
Navy................................ -$84.4 -$146.5 -$234.2
Air Force........................... -$92.5 -$197.5 -$323.7
-----------------------------------
Defense Health Program Total...... -$259.0 -$486.3 -$785.2
------------------------------------------------------------------------
Senator McCain. What was your rationale in imposing a tax
on medical operating budgets of hundreds of millions of dollars
in time of war?
Dr. Winkenwerder. This was part of a long-term budget plan
that had been developed about 3 years ago in conjunction with
the then surgeons general, and the vice chiefs, and the leaders
from all of the Services about what was believed to be more
efficient, effective delivery of health care that could take
place as part of that. Some of that led into some of the BRAC
decisions, for example, with closing small community hospitals
so that we could, in turn, use care that would be out in our
network that would be equally, if in some cases better,
received by our beneficiaries, but would be a dollar savings to
the DOD.
We are charged with trying to do the right thing in terms
of managing the budget. I think you raise a very good question
that I think that needs to be reevaluated in the context of
everything that we are dealing with right now.
Senator McCain. If a plan was developed 3 years ago, I
would have hoped you would not wait until this hearing to
evaluate it, given the level of conflict that we are in
throughout the world today in Afghanistan and Iraq.
Dr. Winkenwerder. We do evaluate things each year. So it is
not like we make a decision and forget about it. But I take
your point and we will be doing that.
Senator McCain. I hope you will inform this committee as to
what the needs are, because clearly any proposal to reduce
spending, as the chairman just pointed out, given the level of
casualties that we are receiving, is also hard to fathom.
Dr. Winkenwerder. I will. I would, Senator, if I might,
note that our aggregate budget--Congress has been very
supportive. One of my goals coming on board 5\1/2\ years ago
was to ensure that we never ended up in a position where,
frankly, DOD and the military health system had been before,
where we were coming to Congress year after year, falling
short, needing supplemental funds and we had to fight, frankly,
to ensure that the out growth projections were accurate based
on what the increased cost of health care is.
So our budget has more than doubled. It was about $18
billion in 2001. It is approximately $40 billion today. So we
are spending a lot more money, but we need to spend money to
make sure that we get the job done right.
Senator McCain. Mr. Chairman, I want to thank you for the
additional hearings we are going to hold with the Veterans
Affairs Committee, because one of the major policy issues that
needs to be addressed by Congress is this disconnect, which you
have already talked about and is being discussed, between our
VA care, treatment, hospitalization, et cetera, and those who
are on Active Duty.
It seems that the experts I have talked to believe that
there needs to be a seamless transition here and clearly that
is not taking place and is a cause of a lot of the very
significant difficulties, the manifestations of which we are
exploring today.
I thank you, Mr. Chairman, for holding these hearings and
the future ones we will hold with the Veterans Affairs
Committee.
Chairman Levin. Thank you, Senator McCain.
Senator Lieberman.
Senator Lieberman. Thanks. Mr. Chairman, I thank you and
Senator McCain as well for what you are doing here.
General Schoomaker, you made a comment that I think ought
to resonate and ring through our brains and hearts and souls as
we go on with our response to the Washington Post series on
Walter Reed, which is that what was happening in Building 18
really is a metaphor for a lot else that is wrong with the
system. I think you are right. It is a metaphor, it is a wakeup
call.
I think what is important is to focus on the fact that the
element of the story that infuriated most of us, embarrassed us
most--the rodents on the floor, the mold on the walls, which
none of us want our veterans, particularly those injured, to
have to cope with, those problems can be resolved rapidly. They
have been resolved. The mold has been taken away, the rodents
have been eliminated. But what remains both in the DOD and I
think increasingly we will find in the VA is a system that
simply shortchanges those who have served us, both because of
the bureaucratic red tape that is part of it--I thought,
General, as you approach the conclusion of your great career of
service to our country, your statement earlier about the red
tape that surrounds so much of what you try to do to protect
our national security--I think you used the metaphor there of
feeling like you were going constantly through a swamp--is
something that also ought to ring bells in a lot more that we
do and that is done within the Pentagon.
But let me come back to it. The mold on the walls, the
rodents on the floor, they are taken care of. But what remains
is a system in the DOD and the VA particularly, I think, that
is too bureaucratic, and that in that bureaucratic red tape
frustrates and in some sense insults the veterans because of
what it puts them and their families through.
But also I believe as I have gotten into this deeper and
deeper that what we all have to come to conclude--let me just
speak for myself; I conclude--we have not made a national
commitment to our veterans in this war on treatment, including
particularly Iraq and Afghanistan, commensurate, as great as
the service and sacrifice that we are asking them every day to
give.
We have simply got to close that gap between what we are
asking them to do for us on the battlefield and what we as a
Nation are doing for them when they come home. The fact is, and
the other thing that we ought not to let the mold and the
rodents conceal, is that the battlefield medical care, the
acute care they are getting, and the care that they are getting
as inpatients, so much of which is going on at Walter Reed and
Bethesda, is the best in the world. But in a lot of other ways,
in the outpatient services and in the red tape about
disability, we are really failing them.
That is where I echo what has been said. I think Senator
Levin and Senator McCain are doing something very important in
bringing us together with our colleagues on the Veterans
Affairs Committee. There are hundreds of thousands of claims
for disability that are pending today in the VA. They are
waiting 6 months to as long as 2 years. It is just shocking and
unacceptable.
Whatever it takes--and I think it is going to take some
money in addition to reorganization--we have to resolve to end
that gap and take care of our veterans in some way approaching
the way they have taken care of us.
General Kiley, you indicated in response to earlier
questions that there were some things going on that you did not
know in your role as Army Surgeon General. I want to ask you
what your conclusion is about why you did not know them and
what you are going to do now to correct that situation so you
will know anything that is wrong with the system henceforth?
General Kiley. Senator, if you are referring to this
complex bureaucratic process of the MEB and PEB process, I
think I probably should have known more, and what is going on
at Walter Reed in terms of the frustration of the staffs and
the patients is probably mirrored to some extent in most of our
other facilities, as I hear commanders talk to us about these
issues. I think it is amplified a little at Walter Reed because
of the sheer numbers. There are a lot of soldiers at Walter
Reed that are going through that process.
We clearly need to take a look at everything from what we
call quick fixes that we could suggest to the Department of the
Army that we eliminate as part of the 22 different forms. We
need to reenergize, I need to reenergize, commanders to
understand that they have all the resources they need. They can
hire all the case managers and doctors, not just at Walter
Reed, but across MEDCOM, to get these conditions corrected if
they are there.
I think we still need to recognize that soldiers still need
time to heal and that in that healing process there is
consultation and time. So I am always faced with the challenges
as the commander of MEDCOM through my commanders. We want to
give soldiers enough time without delaying it, and some feel
that their processing is being delayed. As we try to expedite
that care, soldiers feel we are rushing them out of the system,
that we are not giving them time to heal. It is a very tight
rope that the commanders, the attending physicians, the case
managers across MEDCOM have to walk.
We talk to them at commanders conferences. I talk to the
senior leaders on video-teleconferences (VTCs), if not weekly,
monthly about these kinds of issues. When there are special
issues or problems associated, for example, with deployment or
redeployment of major combat units into installations, we keep
an eye on the med holdover and med hold soldiers. So there is a
lot going on.
Senator Lieberman. General, let me ask you this personal
question. From 2002 to 2004 you were the commander of the
Walter Reed Army Medical Center.
General Kiley. Yes, sir.
Senator Lieberman. I do not know, I presume you do not
know, whether the conditions at Building 18 during that period
of time were what they were when the Washington Post did the
investigation. But presumably the red tape problems that a lot
of the soldiers are finding did exist. As you look back, do you
hold yourself accountable for the development of some of the
shortcomings or do you hold others under you accountable?
General Kiley. I hold myself accountable. As I relinquished
command in 2004, the number of soldiers on the post was
increasing. We were filling up all the rooms in the Mologne
House. We had just begun the case manager process. I think we
still had, if I remember correctly, patients serving as platoon
sergeants, and we were starting to hear that was not fair to
the sergeants and it was not fair to the rest of the soldiers.
I probably could have, and should have, taken action
earlier, trying to learn lessons from that installation and the
other installations in my North Atlantic Region, to include
Forts Dix, Drum, Knox, Attaberry, and McCoy. We were out
looking at this all the time, attempting to improve it, never
wanting for resources, but sometimes difficult in execution.
General Schoomaker. Senator Lieberman, if I could add
something here.
Senator Lieberman. Yes, sir.
General Schoomaker. Building 18 I have now learned has gone
through--it went through a renovation in 2001. It went through
another renovation in 2005. But there is a metaphor within the
metaphor here. We fixed the mold, we fixed the things that you
talked about, but the roof is not fixed. If you do not fix the
roof, these things are going to be back if that is the problem.
Senator Lieberman. Right.
General Schoomaker. It really is a metaphor for a much
bigger challenge that we have. I will tell you: How much energy
have all of us here spent on the VA, MILCON, BRAC bill this
year? We are 6 months into the fiscal year and we do not have a
bill.
Senator Lieberman. Right.
General Schoomaker. We spent a lot of energy, and we are
about $2 billion short on the BRAC, on the deal which is going
to be--this is not pointing fingers. Last year we worked--we
did not get our first funding until December 30, a quarter into
the fiscal year. We did not get our other increment until the
end of June, only 90 days left. So we are running through this
swamp, spending our energy in a huge way at the senior level,
and that energy could be so much better spent trying to be more
effective leaders and managers down there. But that is just the
reality. That is the bureaucracy.
Senator Lieberman. It is a point well-taken.
My time is up. I do not want to ask a question, but I just
want to ask you to please think about something, whether we
ought to go back and take a second look at the BRAC
recommendation to close the Walter Reed Army Medical Center. It
just seems to me that when we know there is going to be an
increasing demand from veterans for services, medical services,
to close this facility that has some state-of-the-art services,
I am not sure it makes sense.
It may be that you want to concentrate certain medical
services there to veterans, not just in the Army, or soldiers
not just in the Army, but across the four Services and to
concentrate some more in Bethesda. I am having second thoughts
about the wisdom of that.
General Schoomaker. First of all, the BRAC thing is way
above my pay grade, but I will say is that we need that
hospital at Fort Belvoir, because that is where the center has
moved. The transportation system supports it. We need to get
better medical care for the broader community.
Second, we need to improve Bethesda and get the Uniformed
Health Services University, get the research center and
everything set up.
Third, I have concerns as we go through this long war about
taking down capacity that may be needed. So I am not suggesting
opening BRAC or anything else, but I think we ought to be very,
very careful about disconnecting certain things with the
realities that we face today.
Senator Lieberman. I totally agree with you and that is why
I think we ought to take a second look at that decision about
Walter Reed.
Mr. Chairman, I have gone over my time.
Chairman Levin. Secretary Winkenwerder did want to comment,
apparently, on that.
Dr. Winkenwerder. Yes, I would like to comment on that as
well. I do think it is the right decision to bring these two
great facilities together. We will be stronger. Military health
care will be stronger. We will be more joint.
Chairman Levin. If we do what?
Dr. Winkenwerder. Bring these two institutions, Walter Reed
and Bethesda, to the new Walter Reed National Military Medical
Center.
Chairman Levin. To the Walter Reed?
Dr. Winkenwerder. The new, the new Walter Reed; move
forward with the BRAC recommendations.
For all the reasons that are talked about, there is the
opportunity to get all of our great expertise in one place with
our medical school, the research, and the National Institutes
of Health is right across the street with the great research
programs there. There is an opportunity to invest a large sum
of money. We are talking approximately $2 billion that is to be
spent on state-of-the-art facilities.
The people are the key and the people obviously are not
going away. The programs are not going away. It is the facility
at that location that I think is the right thing.
Now, having said that, I totally agree with you that we all
need to be absolutely careful, scrutiny to the highest degree,
to make sure that nothing falls through the crack, nothing is
left undone, until the day that that move occurs. We absolutely
have to continue everything just as if Walter Reed were going
to continue for another 15 years until that move occurs.
So that is my view. I know that there will be other
discussions on it.
Chairman Levin. Thank you.
Senator Warner.
Senator Warner. Thank you, Mr. Chairman.
Mr. Chairman, I have to reflect that in the 29 years that
you and I have been together on this committee, as I approached
this hearing this morning it was with a feeling of great
distress. This is one of the most distressing situations that
we have ever seen in the time that we have been here together.
I commend you and Senator McCain and others at the
forthrightness with which this committee is going to address
it.
I think as we listen to the accountability unhesitatingly
coming forward from this group of witnesses we should also
examine our own oversight process and to see how a situation of
this magnitude in many ways was not brought to our attention.
Of course, our oversight is performed not only through the
hearings and the witnesses, but from constituent inquiries, and
when I visited Walter Reed, which was just the Friday following
the disclosure of the very valuable investigative report in the
Washington Post. I was present when Secretary Gates came out
and spoke at Walter Reed about this situation and his first
steps that he took, and I commend him for the expeditious
manner in which he stepped up to accept his share of
responsibility as we deal with this question.
But I want to bring to the attention of our witnesses again
the value of constituents contacting us. When I was out there I
visited with a staff sergeant--I will withhold his name,
although if necessary I will make it disclosed--and his
commander out there, a colonel, full colonel, who dealt with
this issue.
My first question goes to General Schoomaker. I have had
the privilege of being associated with the military for many
years and the limited contribution I may have made came up
through the Reserve side of our military. I have always been
concerned about the differential treatment between the Reserves
and the regulars. In the context of the problem we have here
today, constituent inquiries on this issue bring this question
to mind.
I go back to the famous slogan that the Army had for many
years, ``An Army of One.'' What did that mean, General? I
interpret it as meaning that Reserves and regulars are to be
treated as one. Is that correct?
General Schoomaker. That would--sir, really we talk about a
total Army.
Senator Warner. Total Army.
General Schoomaker. I think you know that throughout my
entire tenure I have made that one of my highest priorities.
Senator Warner. No question about it.
General Schoomaker. Made this one Army. I will tell you
that I believe that we are on the path to do that.
Senator Warner. I want to say as you begin to draw to a
close your distinguished career, as you say, of 40 years, it
has been a privilege to work with you. You are a man not only
of proven combat courage, but a man of enormous compassion for
your soldiers of all ranks and their families, and I know this
situation you find very distressing. As a matter of fact, when
you greeted me here at the dais this morning I think those were
the words that you used.
But let us go back to that ``Army of One,'' because part of
the oversight performed by this committee was in the context of
our National Defense Authorization Act of Fiscal Year 2006, and
in it we directed the Government Accountability Office (GAO) to
review the results of the military disability and evaluation
system, the very thing that is before us today. That report
when it was released said as follows: ``GAO's analysis of the
military disability benefit decisions for soldiers who were
determined to be unfit for duty were less definitive, but
suggests that the Army reservists were less likely to receive
permanent disability retirement or lump sum disability
severance pay than their Active Duty counterparts.''
It is interesting. Just yesterday I was visited by a member
of the Veterans of Foreign Wars (VFW) here in Washington for
the conference, as Senator McCain mentioned, and there is
another means by which members of this committee receive
valuable information to work on our legislative and oversight
responsibilities.
But let us go and address that, because this sergeant whom
I visited on Friday, February 23--it was the afternoon of the
press conference by the Secretary of Defense. As I mentioned,
he stepped up and accepted his accountability; very prompt and
decisive direction in that conference. But this sergeant
brought that up, and he had with him a full colonel who was in
charge of the cadre of soldiers in the Reserve and the Guard,
and he confirmed what this sergeant had said.
If you look back on this extraordinary chapter of military
history here in regard to Afghanistan and Iraq, we have relied
upon the Guard and Reserve to a greater extent than ever in I
suppose the contemporary history of our military.
So can you, General, talk to the question of the
credibility of these comments with regard to different
treatment between the Reserve and the Guard? A wound is a wound
whether it is borne by a guardsman, reservist, or a regular
Army soldier.
General Schoomaker. Sir, first of all, I agree with you. In
fact, I do not think our system at the medical--the doctors do
not differentiate. I certainly do not when I go around and
visit these patients. Now, the realities are as they go back
out through the system there are other challenges. Whereas an
Active component member comes from an installation that has a
support base that is coherent and cohesive in a certain sense
many of our Reserve component members go back out into smaller
communities and the Guard Bureau and the Army Reserve Command
have other systems to help make up for that.
But one of the points is, is there a difference in the
disability ratings, et cetera, and I would be glad to provide
for the record some figures here that I got out of our
personnel and medical command that shows that in fact the
Reserve component soldiers have gotten a higher percent--in
2005-2006, actually received a higher percentage of permanently
retired and temporary disability retirement list ratings than
the Active component did.
I think it indicates that Reserve component soldiers are
not being disadvantaged in terms of how they are being
evaluated.
Senator Warner. Yet the GAO seemed to have found that there
was a disparity.
General Schoomaker. We will provide the figures.
[The information referred to follows:]
U.S. Army Medical command does not discriminate among patients
based on component. The only factor considered in scheduling
appointments or the administrative processing of soldiers is the
clinical requirements of the patient as determined by the treating
health care providers. A review of scheduling information for clinics
at Walter Reed Army Medical Center and across U.S. Army Medical Command
indicates no differences between Active and Reserve component soldiers
in access or timeliness of appointments.
Senator Warner. All right. Let us ask the Surgeon General.
Incidentally, on my visit on February 23 following Secretary
Gates' press conference you and I met. You took me through
Building 18 and I think we discussed that issue, and what was
your observation as to any disparity of treatment between the
Reserve and the regular?
General Kiley. Senator, in the 4 years from Walter Reed to
my command of MEDCOM there clearly has been a concern among
Reserve and National Guard soldiers that they perceive that
they are not getting timely enough care quickly enough, and
consistently our message to commanders, to clinicians, is not
only are they to get the same access, but because of some of
the uniqueness, unique administrative requirements for Reserve
and National Guard soldiers as they work their way through the
process of the MEB-PEB, I have asked commanders to move Reserve
and National Guard to the front.
Senator Warner. My time is coming to a conclusion.
General Kiley. Yes, sir.
Senator Warner. I would like to have you join with the
Chief of Staff of the Army in reporting to this committee.
General Kiley. Yes, sir.
Senator Warner. I would like to return to the issue of this
BRAC issue. I have been looking into it. Indeed, following a
hearing in the House there were similar representations by the
Subcommittee of the Appropriations on Defense. Indeed, General
Cody said the following: ``I think we need to take a look at
and address whether we should sanctuary Walter Reed during this
long war.'' I think he meant by ``sanctuary'' put it in some
holding status, which would require going in and amending--only
by law could we do it--the BRAC process.
I urge that we, if we wish to look at that, certainly we
should, but on the other hand it seems to me, Mr. Chairman and
Senator McCain, it would be incumbent on this committee perhaps
to reach a recommendation that we should begin to expedite the
funding profile to do the augmentation at Bethesda and to begin
to break ground and proceed with the new hospital. Is it to be
called Walter Reed, the follow-on? Fine.
Dr. Winkenwerder. Yes, sir.
Senator Warner. Which is at Fort Belvoir. Now, I am going
to address those questions, but I think those who want to try
and reinvigorate Walter Reed should look at the volume of
expenditures required. Did you not mention that to me on
Friday, General Kiley, your estimate of the amount of MILCON
that would be required to put Walter Reed back into a situation
where it is a front-line military facility?
General Kiley. Sir, I think it is a front-line military
facility. But there is a master plan that at its maximum called
for multiple hundreds of millions of dollars for renovation
projects, yes, sir.
Senator Warner. So we have to balance that. Thank you. When
I used the word ``front-line'' I meant to put it in condition
so that it can continue to do the work.
By the way, the medical attention received by individuals
in the course of this very tragic dispute has not been
questioned. I think that should be made clear for the record.
All right. I do hope that we look at the BRAC in the
context of moving ahead, keeping the BRAC decision with the new
facility.
Chairman Levin. Thank you, Senator Warner.
By the way, General, you have used the term twice now,
``PEB'' and ``MEB''. I think we know what they are, but for the
record you should state.
General Kiley. ``MEB'' is the Medical Evaluation Board and
``PEB'' is the ``Physical Evaluation Board.''
Chairman Levin. The MEB comes first and then the PEB?
General Kiley. Correct, Senator.
Chairman Levin. Thank you.
I am glad I asked that question. I do not know if Senator
Bill Nelson is happy, but Senator Reed is next.
Senator Reed. Thank you, Mr. Chairman.
Thank you, gentlemen. Dr. Chu, there are two icebergs that
are looming as the administration steams ahead. One is the
adequacy of the DOD medical system itself, the hospitals, the
capacity, the human capacity, doctors, et cetera; and the other
one is the capacity of the VA to handle all these young
Americans, probably for 50 years. Specifically, you mentioned
the coordination, but do you have a sense right now which you
communicate to the VA where these people are going, their costs
over time? Because this is not a transitory issue.
Are you providing the kind of coordination or do you have
the authority to coordinate so that you can assure these young
people right now that, not just through their military service
and their first few years in the VA, but for 50 years that they
are going to be cared for with the same level of concern we
have all expressed here tonight, or today rather?
Dr. Chu. Senator, thank you. That is I think a significant
issue. We believe that the procedures and processes in place
will sustain these veterans over the long-term. We meet
regularly with our VA counterparts. We have constituted, in
addition to a health executive council that Bill Winkenwerder
co-chairs with Dr. Kussman, his VA counterpart, a benefits
executive council, and the VA deputy secretary and I co-chair a
joint executive council that meets quarterly to confront
exactly these issues.
Do we have all the authority we need? I am not confident
that that is the case, although I would like to wait for
several reviews that are ongoing, including one that I have
asked our own inspector general (IG) to do. Let me just point
to one of the same issues, which is as long as they are on
Active Duty there are certain things they cannot get from title
38, the VA statute. We may want to come back to Congress and
ask to allow an overlap here.
A similar issue, for example, with support for the families
of injured veterans. This is not so much the long-term. This is
more the short-term. We can, under statutes this committee has
granted, provide support to families to visit the bedside and
so on and so forth. VA does not have, as I understand it,
similar authorities. So one transition issue is, back to
Senator Levin's question, when they move from us to the VA
there is under American law a different set of rules of the
game.
We can ameliorate that with voluntary organizations,
support from America at large, and we do mobilize that. Again,
it is premature for me to make a recommendation at this stage,
but I do hope within a few months we will come to the
conclusion, what do we need to do, perhaps less on the long-
term, more on the, as Senator Levin pointed, short-term
transition issue from DOD to VA.
Senator Reed. How many billions of dollars do you estimate
it will cost just at this point to care for these young people
over the course of their lives?
Dr. Chu. I do not have an estimate at the top of my head,
sir.
Senator Reed. Will you get that estimate?
Dr. Chu. I would be delighted to work on one, yes, sir.
[The information referred to follows:]
This question addresses lifetime costs of caring for Iraq/
Afghanistan veterans, the biggest piece of which will be Department of
Veterans Affairs (VA) costs. Since we do not possess VA cost data, we
respectfully defer to the VA on this question.
Senator Reed. Let me ask another question. For years now
many members of this committee and other colleagues have called
for the increase of the Army's end strength, and until a few
months ago the administration rejected in a serious way those
proposals. My understanding is that during that period of time
the Army was trying to constitute maneuver brigades by taking
people out of overhead. Did that overhead include either the
medical system by not adding additional positions or by taking
people away from the medical detachments and the medical
service corps elements?
Dr. Chu. I do not believe so, sir. I will let Dr.
Winkenwerder and General Schoomaker speak to the specifics of
Army medical manning. It is the case that the Army has
converted some military billets to civilian status within its
system, although its conversions are generally more modest than
those of the other military departments because it started with
a higher civilian content than the others. But I believe the
staffing is stable or possibly growing, sir.
Senator Reed. I will ask General Schoomaker. But what
prompts the question is that before the conflict in Iraq and
Afghanistan the inpatient population of Walter Reed I am told
was roughly about 100 people. It swelled in 2005 to 874. They
now have 674. Average patient stay is 45 days. Outpatient stay
is 300 days. Yet I do not think there is any concomitant
increase in the number of people in the medical hold detachment
and in those nonclinical areas.
General, as we talked about this issue before, the Army was
desperately trying to pull people out of TRADOC and other
places. If not directly contributing to this problem, was there
the implicit notion that you could not ask for more people to
go up and staff a medical detachment at Walter Reed?
General Schoomaker. The answer, sir, is no, I do not think
that there is any connection between the two. I think that we
were successful in growing the operational portion of the Army
through some moves. We are constantly looking at it because we
are concerned about what institutional risks we take. We have
been aggressive on the military to civilian change. But we have
also mobilized a great many medical professionals, reservists,
and we have looked at joint solutions.
I will give you a good example. Landstuhl largely has been
staffed by Reserve component soldiers over there. Today--in
fact, I think it took place when I was there at Christmas time.
They had just turned over. We have about 300 to 350 naval
medical personnel now that are staffing Landstuhl. So there
have been joint solutions to this. There have been Reserve
component solutions. Quite frankly, in our structure we have
actually grown medical capacity for the battlefield on that in
terms of our structure.
Senator Reed. General Kiley?
General Kiley. Sir, I agree with the Chief. We have watched
that military-to-civilian conversion very carefully in MEDCOM.
It is spread across all our facilities, not just at Walter
Reed. The risk that we take at a place like Walter Reed is
where for other medical services and capabilities we can
contract or hire civilians, you cannot put civilians in as
platoon sergeants and company commanders.
Where we failed is in not asking the Army for help, which
is now what we are doing, bringing in soldiers from the line
Army to stand up this task force. So that in that respect I
failed in terms of realizing the potential impact on that.
Senator Reed. I think that is an accurate after-the-fact
evaluation, because I think obviously, we recognize there has
been a failure there. Interestingly enough, and I will not
dispute your analysis, General Schoomaker, but so many times
when we find a problem the solution seems to be, well, put more
people there, where before the problem was discovered obviously
we did not have enough people.
Just one final area of concern and that is the culture of
the organization. Most major medical organizations I know are
not run by doctors any longer. They are run by Masters of
Business Administration (MBAs). Yet in the military system it
seems all these major facilities are run by physicians, who
have great clinical training, great care, great compassion. Are
we going to look seriously at a new model of running
institutions like this, doctor, secretary?
Dr. Winkenwerder. That is a great question and I welcome
that. Just for the benefit of your background--I spent most of
my--I am a physician, trained, an internist. I also trained in
business and have a business degree, and fortunate enough to
have worked with some great health care organizations in the
private sector.
One thing I will say just is this is the toughest
organization. I totally echo General Schoomaker's remarks. We
are a very complex, very large organization, tremendous
management challenge. One of the things I see a need for--and
we have talked about this, but again this may take legislative
change or regulation change--is a need for strong civilian
administrative capability in these locations. All of the
military treatment facilities are managed through the Services.
One of the issues we face is turnover of people, changes of
command and leadership. Our people work hard. They are
wonderful people, committed and talented managers. I think if I
am to compare from my private sector experience, we have some
great managers. But I think we would be well-served to have, if
you will, some leadership that is administrative that provides
some continuity, so that things do not fall through the gaps
and that we can make sure we get it right.
Senator Reed. Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator Reed.
Senator Inhofe.
Senator Inhofe. Thank you, Mr. Chairman.
First of all, I thank both Secretary Chu and General
Schoomaker for beginning your remarks complimenting the people
who are offering care at our various institutions. I have been
to all of them and you have, too. But I think when you look at
some of the statistics, World War II, 30 percent of those who
were injured died. In Vietnam it was 24 percent. Now it is 9
percent. A lot of that is due to better equipment, I understand
that, but also better treatment.
What I get, whether it is Landstuhl or Walter Reed, in
making my visits I hear from the troops who are injured and
their first concern is--they are very complimentary on the
treatment they are getting and the first thing they want to do
is get back to their unit. So I am glad that we are all
recognizing that. There is a lot of people watching us now that
are thinking it is the quality of treatment in areas where it
is not.
I do want to get to the PEB and the MEB thing. I think that
is very important. Each one of us up here has cases where we
have been called by veterans. I have one where a soldier had
lost his leg actually to cancer, but it was diagnosed as an
aggressive cancer and he did qualify. Then when that paperwork
reached Washington they rediagnosed it and decided it was a
slower growing cancer and he was not qualified. We corrected
that problem. But I thought that was an isolated case until I
have been hearing some of the testimonials in conjunction with
this hearing.
Now, General Schoomaker, I cannot figure this out, but when
you look at the GAO report, unless I misread it, it talks about
the Marines, the Air Force, and the Army. Thirty percent of the
cases before the Marine PEB have been granted permanent
disability, 24 percent of the Air Force, and only 4 percent of
the Army. I have to ask what could be the reason for that?
General Schoomaker. Sir, I have asked the same question. I
cannot figure it out either. Some people have said, we are
talking about in many cases a younger population that does not
have the years of service and therefore there is a different
deal. But I am not satisfied that we know the answer. In fact,
General Kiley and I were having this conversation. So I think
we owe you an answer and we will probably have to do it for the
record, but it does not make sense.
[The information referred to follows:]
The 4 percent figure and disparity with other Services comes from a
quote on February 25, 2007, in The Washington Post Magazine: ``The
Defense Department reports that the Army, which handles more than half
of the military's disability cases, put less than 4 percent of the
10,460 active duty soldiers and reservists it evaluated last year on
permanent disability retirement and less than 15 percent on the
temporary list. (Temporary retirees undergo periodic reassessments of
their condition for as much as 5 years before a final decision.) By
comparison, the Navy (including the Marine Corps) retired about 35
percent of its injured, temporarily or permanently, and the Air Force
about 24 percent the Defense Department says.'' Although not stated in
the article, these Department of Defense figures are only from fiscal
year 2006.
Approximately 19 percent (4 percent + 15 percent mentioned above)
is the appropriate Army disability retirement figure to compare to Navy
and Air Force. Further refinement of the Army disability retirements:
fiscal year 2006--18.70 percent; fiscal year 2007 through February 28,
2007--21.36 percent.
Senator Inhofe. That is fine for the record, but I was
wondering. I was an Army guy myself and I always look out and
see the differences in treatment, and I want to make sure that
is not the case. I would not want the Army to be out of step
with the other Services.
Now, Senator Lieberman said that Walter Reed is kind of a
metaphor or a wakeup call for other institutions and, General
Kiley, you talked about directing three investigations. One of
those investigations was the MEB and PEB insofar as Walter Reed
is concerned. Now, are you also taking into consideration
looking into all the other institutions as well?
General Kiley. Senator, we are doing an in-depth analysis
of how the medical board process works inside Walter Reed, so
that we can streamline it, iterative-reiterative process of
looking at how the doctors and the soldiers--that is one.
The second process is this team that I have sent out with
Bob Wilson and the professionals who are looking across all the
installations for communications, infrastructure, bureaucracy
issues, to make sure we do not have duplication. Then I have a
series of investigations going on, one by CID and two what we
call AR-15-60s.
Senator Inhofe. I see, okay. The GAO, in the same report,
reported that the PEB caseload grew from 7,200 cases in 2001 to
13,700 in 2005. The number of soldiers waiting to go through
the process across the country averages 5,000 cases.
I am not saying this critically, but I know that the Army
particularly, and other Services too to a lesser degree, during
the drawdown of the 1990s--I can remember going to the floor
many times and talking about we are going to come back and pay
for a lot of this, because it was a reality at that time. Now,
if funding is the problem we really need to know it. Mr.
Secretary, you mentioned I think--maybe I misunderstood you,
but you did not think it was. You think you have had all the
resources you need. When you said that, I did not quite agree
with it, because it appears to me that funding is a problem.
We all know what we went through recently. General Cody,
who I thought was originally going to be on this panel, his
concern at one time, it looked like we were not going to be
able to pay reenlistment bonuses, we were not going to pay
widows benefits, and things that would really be a disaster
unless we have the proper funding. Then of course they pulled
$3.1 billion out of the BRAC account, which is I think really a
disaster and it needs to come back in, not at the expense of
something else, because there is no fat left out there. It
cannot come out of modernization, it cannot come out of Future
Combat System, it cannot come out of the RPM accounts, or
whatever they call those accounts now.
But I seem to think this is a problem. I would like to have
you, each one of you, address this, because I think we are
looking at a funding problem. Here is a quote that I have from
General Cody. He said: ``Our counselors and case managers are
overworked. They do not receive enough training. Our medical
holding units are not manned at the proper level.''
Do you have any comments?
General Schoomaker. Sir, that is precisely what we are
fixing.
Senator Inhofe. You cannot fix it without adequate
resources and money.
General Schoomaker. That is correct, and so I want to
address that. One of the things that I think I have to say
here, because I think maybe we are overlooking it, and that is
even before the war we had thousands of people that were going
through the MEB-PEB process. Every soldier, regardless of
whether they are injured in battle, whether they are injured in
training, whether they are injured through whatever, deserves
exactly the same treatment.
I looked at some figures the other day. Seven of the
soldiers at Building 18 that were living in there, were battle-
injured soldiers. The others were not battle-injured soldiers
that were living there. So there is a baseline of soldiers that
have always been in this system. Part of our problem is that as
we go through the budget deliberations and get in these
arguments everybody talks about how much more money we have
today than we had before. The issue--we have always had too
little money. I have testified here too much about the
underfunding of the United States Army historically.
This is about how much we should have and how much the
Nation can afford to do. So we need to take a look at it in a
direction that says this is the standard for these soldiers,
regardless of whether battle-injured, non-battle-injured,
whether they are sick, cancer like your constituent, et cetera,
and we need to fund this correctly. We need to make sure the
pay systems interact, that the VA-DOD health system interacts.
This country can do this. But you cannot do it when our
energy is not being spent on doing it and we are arguing over
stuff that we should not have to argue over. I say this because
I do believe we have to put it in perspective.
The last thing I would like to say is we all have
constituents. My constituents are soldiers and their families,
and when I have gone around, everywhere I have gone they have
complimented the health care providers in our system. If we are
guilty of one thing, it is we have been drinking our own bath
water about how well we have been treating everybody. Everybody
is giving us thumbs up on it, and we have overlooked something
that we should not have overlooked. Digging down inside the
bureaucracy, and there is this category of soldiers that we owe
exactly the same kind of care to, and we have just let them
down.
I just needed to get that out and make sure that we do not
run down a rabbit hole here, because we still have this big
context and this future, not only the long war, but the future
volunteer force, must be resourced properly.
Senator Inhofe. That is why I asked the question. This is a
good forum to bring it out, and I knew you would and I
appreciate it very much.
By the way, when Senator Warner talked about you will be
before long going into retirement, you have already been there,
and you have come back and answered the call for service. I
want to tell you how much I appreciate the service.
My time has expired. Just I only want to ask, Mr. Chairman,
the Building 14 that you mentioned that you are moving some of
this to, what is in that building now? Is somebody else going
to have to be kicked out in order to utilize that?
General Kiley. Sir, there were permanent party soldiers
that were in there. They had empty rooms. We moved some of the
soldiers from Building 14 into some very nice apartments.
Senator Inhofe. So it was more of a barracks operation?
General Kiley. Yes, sir. Building 14 is a barracks. It is
an exceptionally outstanding, just renovated, $25 million
barracks at Walter Reed. There are individual rooms for
soldiers. That is where those soldiers from Building 18 are now
sitting, are now housed. They are living there now.
Senator Inhofe. Thank you very much.
Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator Inhofe.
Senator Bill Nelson.
Senator Bill Nelson. General, you said unfortunately we
have let them down. I am going to point out another area where
it appears that we have let them down and I would like to know
what you can do about it. One of the most serious injuries that
we are seeing in Iraq is TBI and it is often caused by the
explosions coming out of those IEDs. There are four TBI centers
in this country. They are set up under the VA hospitals.
Medical experts tell us if there are any delays in the
initiation of the comprehensive rehabilitation for those
soldiers who suffer the brain injuries then they are going to
have a long-term problem of long-term recovery. In other words,
the delays in treatment lessen the chances of recovery for our
soldiers.
Now, this was of concern last summer to the VA's IG and he
wrote a comprehensive report on this. He pointed out--and I am
just going to read from the report--that he found that ``Groups
differed substantially with respect to the median length of
time from injury to initiation of comprehensive TBI
rehabilitation.'' He pointed out that in model systems the
delay was only 2.1 weeks and in the VA it was 6.1 weeks.
Now, the IG also found out that remaining on Active Duty--
this is where you come in--was a barrier to soldiers receiving
more timely rehabilitative care from a veterans facility. He
further pointed out--I am quoting here from the IG report: ``We
identified one soldier on duty at a military post who had had
little constructive activity for several months while she
waited to be discharged. Another patient''--I am still quoting
``still on Active Duty spent 4 months without rehabilitation
after the lead center staff had told them to go on and get that
soldier taken care of.'' At that veteran's medical facility he
was told he would not be eligible for care until he was retired
or discharged.
Further, in talking with some of these soldiers the IG
found that 40 percent of them said that they felt uncertain
about whether they were receiving quality care. This is the
TBI. Seventeen percent said they lacked the money to pay for
the medical services and rehab and 8 percent said they were
receiving no medical care.
Beyond that report, I have received complaints and one of
the complaints just received a day or so ago, now that this
Building 18 issue has raised the visibility. Familiar with a
particular brain injury facility, decried the conditions, and I
quote, as ``horrible.''
So we have two issues here with regard to you. Where there
are Active Duty soldiers on a VA facility receiving care, that
is good if the facility is not ``horrible.'' So there has to be
some interagency cooperation between you to see that our
soldiers are being taken care of. Or, number two, of processing
those soldiers faster so that they are not a ping-pong ball,
being referred to the VA facility, which has happened in the
case of some of these four brain injury centers in this
country, then to be bounced back by saying, we cannot take care
of you in this VA facility because you have not been processed
out of the military.
Now, that is just, as we have heard the word used over and
over here, inexcusable. So what can you do and what have you
already done to ensure that the rehabilitation and the lifelong
care for these brain injured soldiers are initiated quickly and
without regard to Active Duty status, where they get delayed as
that one soldier was in this IG report for 4 months or they get
to be a ping-pong ball because they have not been outprocessed
by the military?
General Schoomaker. Sir, Kevin will handle this, but let me
just say something. Everything you describe there is totally--
number one, it is unacceptable. But number two, it is all
feasible; there is no argument that that occurs. There are
people that have experienced TBI, kinds of concussive events
that do not end up with any shrapnel holes in them or bullet
holes and they continue with duty, and many of them--and I
think you would have to agree--do not even know they had this
injury until later. It is like a boxer, a football player, a
bull rider and everybody else who gets knocked in the head.
Sometimes this stuff is--so that is one thing.
You have the situation where we are rapidly evacuating
people through the system and they get the very best of care
and the medical process works perfectly. I have been to one of
those four hospitals, the one in Tampa, the Polytrauma
Rehabilitation Center down there, VA center, which is an
extraordinary facility, and everybody wants people to get that
kind of care.
So what I guess is part of the problem we have here is the
fact that every one of these is an individual story, that is
what I am trying to say.
Senator Bill Nelson. Of course the IG was not addressing
that. The IG was addressing the deficiencies.
General Schoomaker. Yes.
Senator Bill Nelson. That is the question, what are you
going to do about the deficiencies?
General Schoomaker. The problem is that the solutions have
to--as we try to solve these challenges, we have to solve them
understanding that there are so many individual kinds of
solutions that will be required.
Senator Bill Nelson. I do not doubt that. But a soldier
should not be a ping-pong ball----
General Schoomaker. He should not.
Senator Bill Nelson.--needing that rehabilitative care for
a brain injury, and saying we cannot treat you because you are
still on Active Duty status.
General Schoomaker. That is right. All I am trying to say--
I am not trying to defend the system. I am saying as we move to
solve it how we start to solve it is going to have a lot to do
with where we end up. If we do not understand that this is a
very complex thing and approach it with its complexity, we will
miss the boat and come up with some generic cookie cutter
solution that is going to disadvantage people.
Senator Bill Nelson. What is the solution? That is what I
am asking.
Dr. Chu. Senator, if I may, it is exactly----
Senator Bill Nelson. I want to hear General Kiley and then
I will come to you, Secretary Chu.
General Kiley. Senator, I agree with you completely in all
these comments, and I recognized this last summer as a major
issue that had not been addressed. I thought we were doing
fairly well with amputee work. The mental health task force was
coming to closure. I asked one of my senior medical leaders to
establish a task force to look at every piece of TBI, from
research to ongoing diagnosis to therapy to follow to long-term
follow-up.
Over 2 years ago or at least a year and a half ago, I put
Active Duty ombudsmen into the four VA Polytrauma centers in an
effort to coordinate the same kind of care soldiers coming to
Walter Reed and Brook get at Tampa, Minnesota, Palo Alto, and
Richmond. I was in Iraq in January and the senior medical
leadership in Iraq informed me that they have established a TBI
protocol over there for the practitioners.
I think we are just recognizing the depth and extent of the
challenges associated with these very mild but extremely
important conditions. As the Chief has said--in fact, Senator,
we got into a discussion about, frankly, should a TBI qualify
for a Purple Heart. I mean, there are some criteria for that.
This is the level of intense interest the medical community has
in this.
The capability to take care of an Active Duty soldier in
the VA should be transparent to the soldier. Refer back to my
comments about the complexity and the frustrations associated
with taking care of soldiers. That is something that we will
have to work out between the two Departments, I agree with you.
Some soldiers do not want to be retired, feel like they are
forced into retirement simply so they can get this health care.
We have to fix that.
Senator Bill Nelson. It ought to be transparent. But there
is an IG report from June of last year that says it is not.
General Kiley. Yes, sir.
Senator Bill Nelson. So what are we going to do, Secretary
Chu?
Dr. Chu. We already did something and therefore I am
puzzled by the IG's finding. I am not familiar with this
report. I will look into it, obviously.
[The information referred to follows:]
In general, the Department of Veterans Affairs (VA) requires proof
of separation to care for servicemembers, unless they are acting in the
role of supplemental care provider. Supplemental care is a system to
pay for care for Active Duty servicemembers when local military health
care is not available. VA medical centers are often providers under the
supplemental care system. In the case described in the VA Inspector
General report, it appears that the patient should have received
services through supplemental care either at the local VA or through
another local provider, if these services were required and the
servicemember was at home for convalescence after discharge from a VA
Lead Center.
There appeared to be some confusion on the part of the Lead Center
staff, who apparently told the servicemember to go directly to the
local VA medical center for care. In fact, the military medical
treatment facility responsible for case managing (from the military
viewpoint) the care at the Lead Center should have made arrangements
for his local VA medical center to supply that care under the
supplemental care program, and should have made arrangements for a
coordinated transition of that care (from supplemental care to VA
authorized care) upon return home and upon separation from service.
The confusion in this case needs to be addressed, and we will do so
as part of our larger effort to simplify and streamline current
processes.
Dr. Chu. Exactly for this reason, several years ago, after
great effort by Dr. Winkenwerder and company, we signed an
agreement with the VA that we would treat each other's patients
on a standard reimbursement schedule. So I do not understand
how a patient was ``refused'' because they were still Active
Duty. We will look into it, try to understand why that
occurred. It should not have happened, bottom line.
Chairman Levin. Thank you.
Thank you very much, Senator Nelson.
Senator Collins.
Senator Collins. Thank you.
General Schoomaker, I received a letter from a mother in
Portland, Maine, whose son was injured in Iraq. I want to read
to you part of this letter because it is so disturbing to me
because it suggests that the problems we are facing with
military health care go far beyond one facility at Walter Reed.
This mother writes about the horrors that her son David faced
while trying to recover over the past few months. She says:
``The recently published Washington Post articles on
Walter Reed detail conditions and treatment that are
appalling. I can assure you that the issues were
virtually the same at Fort Hood, Texas, where my son
was stationed. I can also assure you that the public is
just starting to become aware of the problems and anger
is building.
``David had nothing but great things to say about the
doctors and nurses and med-evac flight crew that
transported him to Germany. His complaints stem largely
from an Army bureaucracy culturally unprepared to
handle the wounded and sick, an Army so desperate for
manpower that many NCOs are poorly suited for authority
and commissioned officers are fearful of being removed
from career tracks if they try and change the system.
It is also a system that wastes money daily while
charging wounded soldiers for the most basic of
needs.''
This is a disturbing indictment because it suggests that we
are facing far greater problems than just the physical
conditions at Walter Reed or even the battles that soldiers are
having trying to get disability payments. What is your reaction
to what I just read you?
General Schoomaker. I am disappointed that that was the
experience, and I think that as we go down looking
comprehensively through the thing we ought to be seeking out
these kinds of anecdotes and find out what is the root cause of
it.
I will tell you that the Army has undergone more change in
the last 4 or 5 years than it has in over a quarter of a
century. The fact of the matter is while we are fighting a war
we are radically changing not only the culture, but the
organization and the doctrine and everything else that we are
doing. So I would tell you that change is very much part of our
culture right now.
But nevertheless, these kinds of anecdotes are
extraordinarily disappointing. They should be pursued. We
should find out what the problem is and make sure that they are
not perpetuated for more people.
Senator Collins. I guess what troubles me is this mother's
conclusion that there is an Army bureaucracy culturally
unprepared to handle wounded and sick soldiers. That suggests
that we need to do way more than remove molds or repair a roof.
I wonder if we should take a look at the entire way that we are
delivering health care in the VA system and in our military
system. I am not sure that that is the answer, but I was
thinking this morning about the fact that the GI bill is
unanimously acclaimed. It has been very successful. It
essentially gives a voucher to a retired soldier to pursue his
education. That contrasts with the VA system and the military
system we have. We are trying to do better with community-based
clinics, but I still have World War II elderly veterans
traveling 5 hours to get to the one VA hospital in Maine.
Should we take a look at our VA and military health care
system and consider a whole different approach of delivering
services?
General Schoomaker. Ma'am, I think that--and I will just
give you my opinion, but I want to throw a caution out here.
The military health care system in this country is the best in
the world. There is no other country in the world that has it.
Every one of our allies are looking at us and are--``jealous''
is not the right word; or ``desirous''--but they really like
what they see.
For instance, my British counterpart. The British have no
corresponding system. They have military wings in civilian
hospitals. They are very critical of what they are going
through by going to commercial initiatives on these kinds of
things, and they have virtually no follow-up in the manner that
we are talking about right here.
So with all our warts, we better be careful that we do not
really damage what is an extraordinary system that has
problems. We need to correct the problems.
Dr. Winkenwerder. If I might add as well, Senator.
Senator Collins. Yes, doctor.
Dr. Winkenwerder. I would echo General Schoomaker's
remarks. There are so many areas in which the system broadly is
working very, very well. The TRICARE health plan is one of the
top-rated plans. We know that, consistent increased
satisfaction. Things work. Battlefield medicine works. Acute
care works. Outpatient care across the board tends to work
well.
But the issue, if I can hone it in to where I think, to
answer your question where is the problem or problems, it is
those who have been injured and wounded after their acute care
in this phase, the seam, the transition, and the disability
determination process and the coordination, at that point,
which is critical because those individuals deserve our very
best. That is where our focus should be, I believe, because so
many other things are working well.
The other thing I would say is that we have great capacity
in this TRICARE network. We have the ability for any of our
Active Duty and our retirees to see over 240,000 physicians
across the United States, that network, in nearly every
civilian hospital.
So there is a lot of capacity in this system. I am not sure
we have used it properly between that and the jointness. We
have not talked today about using Air Force, using Navy when
Army is overstressed, and that has happened in the theater. The
Blalad facility is staffed by the Air Force, so we have to
think better about how to manage those resources.
Senator Collins. We do. But there is clearly a problem.
These are not isolated stories or anecdotes. There is a pattern
here of very good care on the battlefield and inpatient and
then it seems to fall apart after that. I think we have to
remember that these in many cases are soldiers who are going to
have life-long problems as a result of the injuries. So the
aftercare is as important.
General Kiley, I want to bring up a comment that you are
reported to have said at the House hearing yesterday because I
really found it disturbing, assuming you were quoted correctly.
You were asked why you were unaware of the living conditions
across the street from your own home and according to the paper
you replied: ``I don't do barrack inspections at Walter Reed.''
I must say that I found that to be a stunning and troubling
response. The maxim of the military has always been that you
get what you inspect, not what you expect. I realize that you
personally do not go and do barracks inspections, but you are
responsible for ensuring that they--or you were responsible for
ensuring that they do get done. I just would like to hear
further from you because it struck me as such a disclaiming of
responsibility that it was enormously troubling.
General Kiley. I am sorry if I misled anyone in that
hearing. It was not my intent to somehow shed responsibility
for that. What I was attempting to explain, and I did not do a
very good job of it, was that, consistent with the chain of
command, there are company commanders and first sergeants,
colonels and a general on the post whose primary responsibility
is to inspect barracks. I would inspect barracks. I have
inspected barracks. I understand that is part of command
responsibility and accountability. Just as we have talked
earlier, barracks inspection, the health and wellness of
soldiers is critically important.
I only meant by the comment, because it was pointed out
that I live right across the street and somehow that I should
have been inspecting, it was not that I would not inspect it if
someone came to me, particularly General Weightman, and said,
you need to go see these, or if somehow talking to a soldier it
came to my attention that there were mold or rats or problems
in the barracks. I would have been right over there looking at
it. I certainly would have alerted the chain of command that I
was going to look at it.
I do apologize if I misled you or misled anybody on that. I
simply was attempting to articulate the concept of the chain of
command and authority in the sense that commanders have
responsibilities. In this case I obviously did not check enough
on what was going on at Walter Reed. But I do inspect barracks.
I have inspected barracks. I inspect hospitals. I visit
hospitals and walk through hospitals. I visit new medical
facilities that we are building as part of our Army
transformation.
Senator Collins. Thank you.
Chairman Levin. Thank you very much, Senator Collins.
Senator Ben Nelson has very generously agreed to switch
places with Senator McCaskill, so that the order now on this
side will be Senators McCaskill, Clinton, and then Ben Nelson.
Senator McCaskill.
Senator McCaskill. Thank you, Mr. Chairman, and thank you,
Senator Nelson, very much.
General Kiley, you just referenced, in response to Senator
Collins's questions, about the chain of command. But you are in
fact responsible for the culture of command within the MEDCOM
of the United States Army, is that not correct?
General Kiley. Yes, ma'am.
Senator McCaskill. I am here today to try to--and what I am
going to say is going to make probably some uncomfortable and
it is going to be awkward, but I think it has to be said about
your command of the MEDCOM unit. I would like to speak on
behalf of a sergeant from Missouri who is at Walter Reed. He
has been there since he lost both of his legs on the
battlefield 10 months ago. I had the opportunity to meet him
when I went to Walter Reed and spent 3 hours last week.
I have tried to communicate with him since then. At 8
o'clock last night he sent me an e-mail and I would like to
read what this sergeant said:
``General Kiley had the opportunity during his time
as Walter Reed commander to identify and begin
correcting the issues that were evident. Rather than
addressing those issues, General Kiley simply swept
them under the rug. General Kiley received more avenues
to dispose of the issues once he was appointed as the
Army Surgeon General. However, rather than addressing
the problems he was more aware of than anyone, he
continued to downplay and minimize the issues.
``We as injured veterans and those family members who
depend on military medical facilities deserve nothing
less than the resignation of General Kiley.''
The question becomes, General, what did you know and when
did you know it? In late spring 2003, the Veterans for America
had a meeting with you and outlined their concerns about what
was going on at Walter Reed. Specifically, they talked about
people in barracks are drinking themselves to death and people
who are sharing drugs and people not getting the care they
need.
February 17, 2005, you sat in on a congressional hearing
where the following testimony was given: ``Soldiers go months
without pay, nowhere to live, their medical appointments
cancelled. The result is massive stress and mental pain,
causing further harm. It would be very easy to correct the
situation if the command element supported it. The command
staff at Walter Reed needs to show their care.''
This was testimony by Sergeant First Class John Allen, who
was wounded in Afghanistan, who said ``Walter Reed has a
dysfuntional system.''
On December 20, 2006, a board that you co-chair, the DOD
Mental Health Task Force, once again you heard testimony
concerning the systemic problems of outpatient care at Walter
Reed.
The problems of the bureaucracy have been referenced in
your testimony today. In fact, the entire panel has referenced
the problems of bureaucracy. General Kiley, you are a
professional, not a bureaucrat. My question to you is, do you
have the authority as the commander of the MEDCOM in the United
States Army? Do you not have the authority to fix the
bureaucracy?
General Kiley. In terms of your question about fixing the
bureaucracy of med holdover, yes, I do have the authority to
fix communications and infrastructure. As it relates to the
member of the MEB process inside Army regulations and
particularly the PEB process, its adversarial role and the
resulting sense of despair among soldiers, I individually do
not have authority to change that, but I am bound to work with
the rest of the Department of the Army, particularly the
personnel community, to fix that.
We recognized some of that in the summer of 2003 and held a
task force, a summit, with the Army personnel community and the
Adjutant General to begin to address some of the issues that we
were seeing in spring 2003 after our ground operations in Iraq
began.
I have listened to Mr. Robinson's brief as part of the
Mental Health Task Force brief in terms of his presentation
along with members of his organization. I do not remember
meeting him in 2003, but we were aware of and became aware
through my own counselors and my own chain of command whom I
met with, if not weekly, twice a month, to address issues of
med holdover when I was the hospital commander at Walter Reed.
Clearly, some of these challenges are complex. They are
buried in Army regulations. They are buried in DOD
Instructions. Again, I reference the complexity, the injuries
we were seeing, and the growing number of them. It was a source
of frustration for me as the Walter Reed commander that it
seemed every day we had new issues that we had to address. We
were anticipating as best we could. But the staff worked hard.
We paid very close attention to the soldiers' needs. We
instituted soldier lounges where the soldiers could sit and
watch games, et cetera.
I do not think I was passive in command at Walter Reed. But
obviously, as the commander of MEDCOM we sit here today because
of my failure to anticipate and correct these things before
they happen.
Senator McCaskill. I am just concerned that General
Weightman was relieved and the Secretary of the Army was
relieved, and it appears to me that you are in fact the
commander that was in the position to know the most and be in
the position to do the most about it. In fact, in your
testimony I am concerned, General, because on page 8 it is
almost like you still continue to try to diminish the severity
of this problem and the fact that it is systemic and that there
is so much work that needs to be done.
You say: ``Soldiers and family members in January''--this
is your testimony today. ``Soldiers and family members in
January 2007 indicated that less than 3 percent of the
outpatient soldier population voiced complaints about the
administrative process.'' It would be hard to walk through
outpatient at Walter Reed and talk to soldiers and not confront
a complaint in terms of the bureaucracy and the problems. The
fact that you want to point out that there were only 3 percent,
is that not more a reflection--you do not really believe that
only 3 percent of the outpatients had complaints, do you?
General Kiley. I think that was General Weightman's
testimony, Senator, not mine. But what that came from----
Senator McCaskill. This is your statement that I just read
you provided to the committee today.
General Kiley. Yes, ma'am. In the discussions, I was
referencing the discussions yesterday. What we did in response
to our concerns about families and the issues with families was
to begin surveys of soldiers as to what their issues and
concerns were. We have not gotten back all the surveys. We
continue to do surveys.
There is another way to pulse the system to see if we can
find issues and problems. My understanding as I sit here today
was that the ratings on the case managers were very good, the
ratings for the doctors were very good, but we had a whole list
of issues that soldiers had about the bureaucracy, sometimes
inpatient, often outpatient.
Senator McCaskill. On the sergeant that I have been
visiting with who, as I said, is a double amputee, he indicated
also problems with the electronics system, and I want to
briefly bring that up. As he says, on any computer in the world
he can bring up his enlistment contract, all of his award
recommendations and commendations, even his counseling
statements and evaluation that he received during his time in
the military. This can be sent ahead of a soldier that is
permanent change of station (PCS)'ing, somebody who is changing
their station--for people who do not understand--their
permanent station, so the receiving unit knows the caliber of
the soldier they are receiving.
Why cannot that same technology be used to expedite the
MEB-PEB process? Why is that not a problem that has been
identified by your command and fixed while you have been in
charge of this part of the Army?
General Kiley. I do believe that that is one of the things
that we want to look at through our iterative analysis of the
medical board process, is how can we better computerize this
program and pass it to the PEB. I agree with you. Why we cannot
do that, I do not know the answer why we do not have that in
place now.
Senator McCaskill. Ultimately, the culture of command is
incredibly important here. It is incredibly important in terms
of how people feel about complaining and whether they think
their complaints are going to go anywhere. I must respectfully
say, General Kiley, I think that belongs at your doorstep.
Thank you very much, Mr. Chairman.
Chairman Levin. Thank you, Senator McCaskill.
Senator Chambliss.
Senator Chambliss. Thank you very much, Mr. Chairman.
General Schoomaker, as you wind down your career I want to
join the sentiments of everybody up here. Thanks for your
service to our country.
There is another General Schoomaker who is going to be
coming to Walter Reed as our new commander there. General Eric
Schoomaker happens to be somebody that I know very well, having
served at Eisenhower Medical Center at Fort Gordon. He is a
good soldier, a good outstanding physician, a good
administrator, and I have every confidence that he is going to
be able to address the situation at Walter Reed as we move
forward.
Gentlemen, a failure on the battlefield brings disastrous
results. Here we are seeing a failure off the battlefield that
brought about disastrous results that none of us are happy
about, obviously, including you. This is not the first time
this has happened. In 2003, we had a very similar situation
that took place in Fort Stewart, Georgia, with our Iraq Walter
Reed veterans as the Guard and Reserve soldiers in the medical
holdover unit were waiting months for follow-up treatment and
the facilities and the living conditions which those men and
women were put in were horrible.
At the time, although we were horrified at how our heroes
were being treated, the Army was very responsive and
implemented immediate changes at Fort Stewart. In fact, the
Army staff and the Pentagon assured us, and I quote: ``What we
learned from this incident is going to help the Army when we
have other major units returning from Operation Iraqi
Freedom.''
Given this response, the Army's recognition of the problem,
and the commitment from the Army at its highest levels, and
even the implementation of new policy from then-Acting
Secretary of the Army Les Brownlee, I have to wonder what the
Army actually did learn and take away from the situation at
Fort Stewart. Basically, it concerns me greatly and it should
concern all of you that we have seen this problem before and
apparently we did not learn enough from it to stay ahead of the
issue.
In relation to the issues that came up in Fort Stewart in
2003, can you share what were the lessons learned there and how
and who were they shared with, and who were the take-aways
communicated to, and what changes were actually implemented?
Dr. Chu, let us start with you.
Dr. Chu. Let me start with an issue General Schoomaker has
already addressed, which is the adequacy of our housing
facilities for our personnel. I think one of the important
issues at Fort Stewart was that with the mobilization of
significant numbers of Reserve personnel, the higher training
needs for this conflict, we needed more and better housing
facilities.
The Department had already embarked on a course of action
to improve those facilities before the Fort Stewart concerns
were raised. That was one of the hallmarks of his initial
decisions as President, the President's decision to direct the
Department to do so. We have put substantial money into it, but
I am with General Schoomaker. It is not a problem,
unfortunately, and I think this is ultimately the source of the
Building 18 immediate issue, that can be rectified overnight.
There is a limit to how fast you can do this.
We have made enormous progress in both family housing and
barracks housing. We have been spending a billion dollars a
year or so on barracks housing in the Department during the
course of this administration. Have we caught up in all areas?
No, sir. Are we committed to catching up in all these areas?
Yes, sir. But it is a major challenge to take the Department,
which had not invested, I regret to say, in earlier decades in
the housing stock the way it should have, to get to the right
place.
Now, in the short run--and one of the earlier questions
dealt with this. In the short run, it has been complicated by
the commotion over--Senator Inhofe raised this question--the
MILCON appropriation for fiscal 2007. I am very hopeful we can
get that straightened out because that is indicative of how we
do fall short. As one of the other questions emphasized, when
we do not get the funding you cannot execute. So it is
important to keep that funding train, the BRAC funding train,
on track, if not, as Senator Warner suggested, accelerating
somewhat.
I think the major lesson, one of the major lessons that
came out of Fort Stewart, was this question of the adequacy of
our billeting for our troops across the board. We did not have
enough for the expanded operations today. We have put money
into that. It does take time. It was not all done in 1 year and
there are still issues to be addressed.
Senator Chambliss. Anybody else care to comment?
General Schoomaker. Sir, I will comment because the Fort
Stewart situation was one of the first things that confronted
me when I was brought back into the Army. It was one of the
first challenges I had. I went down there and visited. The
lessons learned from Fort Stewart were many. There were over
600 soldiers down there in the Fort Stewart deal. The reality
is is that was a mobilization issue. Very few of those soldiers
had deployed and been injured. In fact, I think something like
14, or less than 20 anyway.
Nevertheless, we have a responsibility once bringing
soldiers on Active Duty to correct and to return them
corrected. So it is a different issue in many respects, yet the
same issue in terms of the administration--the housing, the
chain of command, the administration of medicine and the MEB/
PEB process and all the rest of it. What we largely learned was
to mobilize soldiers and prepare them with their pre-
mobilization training, medical readiness, et cetera, before we
mobilize them and brought them on Active Duty. That was one of
the big lessons.
We obviously learned a lesson in chain of command. We
learned a lesson in having adequate housing and capacity, et
cetera. The problem that we are dealing with here on the back
side of this is an additive problem, and that is many of these
soldiers that we are now dealing with have very serious war
wounds, multiple wounds, all of the issues we have heard on TBI
and PTSD, and all the rest of that. That complicates it
enormously as this process arbitrates it. So it magnifies way
over what Fort Stewart was the challenge that faces us here to
do right by these soldiers.
Nothing I have said is an excuse. It is that this is by far
a more complex problem that we are facing here than Fort
Stewart was. So Fort Stewart did not have all of the answers to
the dilemma that we face today. No excuse for either one of
them.
Senator Chambliss. General Kiley, in your testimony you
talk about the fact that between 2001 and 2005 more than
$400,000 in renovations were made to this Building 18. In 2005
$269,000 in renovations were made. Who made the decision to
spend that money on Building 18?
General Kiley. Sir, I believe my predecessor at Walter Reed
made a decision in 2001 to do some renovation. While I was the
commander, the numbers that I remember--I was reminded that we
put $40,000 into the building for new carpets and curtains.
Then in 2005, I believe General Farmer made the decision to
do a major renovation at the $260,000.
Senator Chambliss. During the process of your making the
decision to spend money on this building, did you go in that
building?
General Kiley. No, sir.
Senator Chambliss. Did you know what you were spending the
money on at the time?
General Kiley. Yes, sir. That was not a patient billet in
my command. It was a standard barracks. The commander came to
me and said: Look, we could use a little bit of help in
Building 18; I have some student detachment soldiers over there
and I would like some money to replace the carpets and the
curtains. I do not remember the specific conversation, but I
approved the money.
In retrospect, would it have been good to go over and take
a look? Certainly. Certainly, now with what we have seen, I
erred in not doing that. But I trusted my colonel commander and
the garrison commander that that is what it needed.
Senator Chambliss. Who made the decision to convert this
into a building to house patients?
General Kiley. Sir, it is my understanding that General
Farmer made the decision to do that, because of the load of
soldiers that he was having to care for.
Senator Chambliss. Is it standard operating procedure to
make a decision like that without examining the building? Is
that part of the bureaucracy issue that we are talking about?
General Kiley. No, sir, I do not believe that is true. I
honestly do not know whether General Farmer examined that
building before he made the decision with his chain of command.
I certainly think that part of our error and certainly my error
in counseling my commanders, I clearly failed in this regard,
is in anywhere that we are putting patients, soldier patients,
despite the fact that we have worked very hard on that from day
1 at Fort Stewart until a couple of weeks ago when the papers
revealed our shortfalls, that patient care and patient
billeting areas should have the highest priority.
That was part of the problem we found with Building 18, and
I failed in that regard.
Senator Chambliss. Thank you, Mr. Chairman.
Chairman Levin. Senator Clinton is next. There is a vote
on. We are going to work right through this vote. Senator
Clinton, when your time is up will you recognize the next
Senator in order. You will be given that list. I will try to
get back here in about 10 minutes. If no one is here, could you
just recess it until one of us returns.
Senator Clinton. Yes, sir.
Chairman Levin. Thank you.
Senator Clinton. Obviously we are here today because we are
all distressed by the problems that are facing our wounded
soldiers. I think we all agree that these men and women are the
best we have and they deserve a lot better from our government
and our country.
I have tried to focus in on the needs and treatment of our
wounded and sick soldiers, and over the last 2 years I was
disturbed by reports about pay problems that wounded soldiers
were confronting and had an amendment accepted in the last
year's DOD authorization bill. My office was recently briefed
on the result of a study that I commissioned in that amendment,
an audit that found that 24 percent of wounded soldiers
requiring inpatient care had underpayments. That is, they were
not paid on time.
The Army I know is working to fix the problem, but the
number is still too high. Now we have learned that wounded
soldiers are living in substandard conditions, trapped in
bureaucratic red tape. This is just the latest incident. If all
we were here to talk about would be the problems in Building 18
and the other problems that have emerged, not only at Walter
Reed but other of our facilities, that would be disturbing
enough. But there is a pattern here that somehow we are just
not focused on what needs to be done to help these young men
and women.
I am deeply concerned that the problems they are
confronting could be, frankly, overlooked again if we just
focus on who made what decision to put in new carpeting in
Building 18 and what else needs to be done. This is a systemic
problem.
When I was out at Walter Reed on Friday I had an
opportunity to visit with a number of our wounded and sick
soldiers from New York, as well as seeing Building 18 for
myself. One of the common denominators of the complaints I
heard remains the disjointed and unfair MEB/PEB process, the
untrained and overworked PEB liaison officers, the various
stops along the process, the lack of legal counsel during
appeals, the prolonged period either to start or complete the
process.
We have already heard about the disconnect between the VA
schedule for rating disabilities that does not adequately
address the current nature of wounds like TBI and PTSD and
amputations and hearing loss and diseases. In the audience is
Steve Robinson. He and I worked together a couple of years ago
in trying to get a pre- and post-deployment physical exam done
so that we could actually tell what was the condition of a
soldier before being deployed and the condition of that soldier
when he returned. One of the things we could not get through
was a mental exam assessment before someone was deployed.
We are now hearing that people who are reporting with TBI
and PTSD are being told it was a preexisting condition. If the
proposal that I had made and that others had lobbied before had
been accepted we might have a baseline to figure out what
actually happened to these young men and women during their
deployments.
The problem that I heard over and over again is a
perception that Walter Reed was concerned with releasing
soldiers from Active Duty at a greatly reduced disability
benefit level, as quickly as possible, a lump sum solution,
cheaper than a lifetime of financial retirement care.
I have a number of soldiers whose specific cases I would
like to present to you and to get your response to. A
specialist from Grand Island, New York, appealing his PEB
disability benefit rating of 20 percent, has chronic pain
conditions and without medical retirement will not qualify for
lifetime insurance. The pain condition is debilitating. He does
not believe that is being taken into consideration.
Here is the dilemma he faces today. He has been offered a
new treatment, but if he accepts the new medical treatment he
loses his opportunity to appeal. If he proceeds with his
appeal, he loses his opportunity for the new medical treatment.
There is just something wrong with that kind of Hobson's choice
to present to this young specialist.
A major from Manhattan. He was injured in Operation
Enduring Freedom in 2001, but stayed on Active Duty, deferred
treatment until finally he could not, and now he has been at
Walter Reed for 26 months. He did not feel he was being well
taken care of at Walter Reed, so he sought treatment at
Bethesda, where he was able to appeal the Walter Reed prognosis
and receive the surgery his injury required.
He began the MEB process in December 2006, but has not been
able to meet with his liaison officer because she cancelled his
first four appointments and now is too busy to meet with him.
He is trying to get legal assistance. His requests have gone
unanswered.
Finally, a staff sergeant from the Bronx, also appealing a
PEB disability percentage, because he believes that the case
mis-evaluated his pain and did not give him a high enough
return. When he met with me, he denied himself his medication
so that he could meet with me and feel like he was in full
control of his faculties, and it was totally evident to me that
he was suffering from pain on an ongoing basis.
So it is really important that we take on this MEB and PEB
process. But again, I think we have to do more to try to clean
up the system now. I know we have to approach the longer term
problems, but it does strike me as totally unacceptable that,
according to press reports, there are three lawyers and one
paralegal to handle a 750-case caseload to deal with these PEB
appeals.
General Schoomaker, we have over 4,000 Judge Advocate
General (JAG) lawyers in the Active, Reserve, and National
Guard of the Army. Can we please get some help to try to clean
up this backlog and get people some legal assistance as they
are trying to go through this process?
General Schoomaker. We are going to gang-tackle that out
there. I am not familiar with the numbers you just said.
General Kiley. I agree with the Senator that we have to get
this stuff fixed. I agree with the Chief; we are going to take
that on. This is my reference earlier. There are things or
actions we can take--more JAG officers, more caseworkers. I do
think that the first case, the young soldier with the 20
percent disability, Senator, does not rise to the 30 percent
which is the medical retirement. Frankly, it is not the fault
of the doctors or the case managers and it is not the fault of
the people in the PEB who are just being stingy with the
dollars. It is more based on what our regulations and our
policies have in place.
To me, even if it is a temporary medical retirement until
the soldier heals up more, I think we should be much more
aggressive in recognizing that. The VA is very quick to
recognize the whole man or woman and reimburse at a much higher
rate. But as we have said earlier, that does not get you the
medical retirement, it does not get you the care for your
children and your spouse. There is clearly a financial impact
over the long haul to the Department and to both Departments in
terms of that. But I think it is the right thing to do.
The individual obstacles about getting appointments, et
cetera, we are taking that on right now, as the Chief has said.
Senator Clinton. Obviously we need, as General Schoomaker
often does very memorably say, to gang-tackle this problem and
let us try to get it on a faster track. Obviously, we have
systemic problems.
I just want to end with two additional points because I am
going to have to recess and go vote. Or maybe, Senator Dole,
can you go next?
Senator Dole. Yes.
Senator Clinton. Let me just conclude by saying, number
one, I am deeply concerned about the impact that the BRAC
Commission order had on Walter Reed. It was I believe
demoralizing. I do not know that we can put an exact frame
around what did not happen because people were either of the
opinion that they were going out of business in a few years
anyway or they were pulled off of caring for patients and
dealing with the important issues right in front of them
because they were involved in planning for the eventual end of
Walter Reed. I really hope--and I told Secretary Gates this--
you got to take a look at this. I do not have an answer for it,
but I think it has undermined an already fragile system.
Finally, these independent contractors. It is a problem.
Our government is outsourcing important services to people who
we are not accountable for. This idea that yet again
Halliburton, and it raises its head by being a former
Halliburton official who got a contract to do in-house
maintenance at Walter Reed--I tell you, folks, this has to end.
Somebody has to be responsible, and all this contracting out of
the important work that we are doing and then we try to turn
around and find out who in the chain of command is responsible.
Well, let us start by making it clear that we are just not
going to turn over important jobs to people that we are not
directly responsible for.
So with that, I am going to have to run to vote. But I am
going to leave it in the good hands of my friend and colleague,
Senator Dole. I want to commend your husband, Senator Dole.
Former Senator Dole and Secretary Shalala are going to be
heading up this commission and I think the President has made a
very good choice of the two to do that.
Senator Dole. Thank you very much. I agree with what you
just said.
Gentlemen, we know that Walter Reed has a reputation for
providing world class care for our wounded soldiers. Doctors,
nurses, and other medical personnel at Walter Reed provide
extraordinary care to the servicemembers at this facility. It
is this excellent reputation that makes these recent
revelations all the more appalling. I have to believe that a
profound failure of leadership at many levels is responsible
for these deplorable conditions.
Everyone from the top down, from the people overseeing
Walter Reed to the nurses aides, must above all else think
first of the patient. If that concern is compromised, even the
best facility in the world can quickly become cold and
inhospitable, potentially undermining the quality of care.
This committee has the responsibility to our servicemembers
and to their loved ones to thoroughly examine what has happened
at Walter Reed and to ensure that every mistake is corrected
and every wrong is made right, so that our Nation's heroes are
always treated with the dignity and care they so richly
deserve.
General Schoomaker, let me ask you, how do we go about
selecting our senior leaders to command at institutions such as
Walter Reed? Have we been doing something wrong? Are there ways
in which the selection process can be improved?
General Schoomaker. I think the ways in which leaders are
grown and developed is very complex. There is actually training
and education, et cetera, that goes into all that. But there is
also statutory board processes that select people for promotion
under the law. When you get to positions, commander positions,
we have boards of officers that sit and look at people's
credentials. Obviously, in the case of medical credentials, the
Surgeon General is involved in that, and we select people based
upon not only their specialty, but based on the
responsibilities, the broader commandership, leadership, and
demonstrated performance previously.
It is one of the most important responsibilities we have.
We call it growing the bench. We selected a new commander at
Walter Reed who happens to be my brother.
Senator Dole. Right.
General Schoomaker. You need to know that I recused myself
from that process, rightfully so, and allowed the proper people
to look at who was best out of who was available.
By the way, everybody was available out there. This was not
just who is closest and we can grab by the shirt sleeve, but
taking a look across the whole inventory of people that could
help solve this problem. In this case, Major General Eric
Schoomaker ended up being the one that surfaced, which I agree
was a very good choice.
So I tell you, I think leader development is one of the
most important responsibilities we have. You can see what
happens when we have a failure in these systems and why it is
so important that we reinforce the chain of command and hold
people accountable and do the things we have to do. These are
very, very complex commands we are talking about.
Senator Dole. General Schoomaker, General Matthew Ridgway
in his history of the Korean War observed that there is never a
shortage of physical courage on the battlefield, but that there
is often an absence of moral courage when and where it is
needed most. I cannot help but conclude that we confront a
similar situation today.
Do you believe that we are observing an instance of leaders
failing to speak up because they believe they must operate
within a fixed top-line budget?
General Schoomaker. No, I do not. I believe that obviously
that is a factor, but I believe in this case there is just a
failure in performing their duties and to ask the right
questions, look in the right places, and to take the right
kinds of action based on what they saw. I think that is what
this is.
I also think it is an extraordinarily complex system that
they are having to deal with. If you think about what the
commander at Walter Reed has to deal with, it is not just the
administration of this very complex process we are talking
about, but he is running a small city. He is concerned with the
health and welfare of all the people that are there, the
scheduling and the patients and all of the things that go on,
the physical security and maintenance--very, very complex.
So the financial aspect is an important factor, but there
is no reason, there was no financial impediment to do what was
right here. We, as I said upfront, have been spending hundreds
of millions of dollars correcting inadequate barracks,
inadequate conditions in all of the rest across the Army, and
we certainly should have not had them at Walter Reed.
Senator Dole. Thank you.
Mr. Chairman, I understand I am going to miss the vote if I
do not leave immediately, so thank you very much.
Chairman Levin. Thank you, Senator Dole.
Senator Ben Nelson. Again, our thanks to you, Senator
Nelson, for your accommodation.
Senator Ben Nelson. Thank you. Thank you, Mr. Chairman. I
want to thank the panelists for being here today as well.
General Kiley, to be in charge of a hospital, in many cases
it is the person who has an MBA or a hospital administrator's
experience or management experience that is used as a base for
determination of somebody who would be qualified to run a
hospital. This is not pejorative. It is just an inquiry. Do you
have an experience like that, an education in hospital
administration, or any particular qualifications other than
your rank, which I am not going to challenge?
General Kiley. I do not have an MBA in hospital
administration, Senator. My experience in a series of positions
inside the Army medical department over the last 20 years,
really longer, both as a practicing physician and as a senior
executive inside the Fort Bragg Medical Center, and then as a
hospital commander at Landstuhl from 1994 to 1997 I would say
or characterize prepared me for further assignments, to include
command at Walter Reed and the North Atlantic Regional Command.
We have a system, as the Chief has referenced, of leader
development inside the Army medical department. It is not just
doctors that command hospitals. We have had, we have nurses
commanding, medical service corps, medical specialist corps. We
have had a nurse, Major General Pollock, commanding at Tripler,
and Brigadier General Rubenstein commanded Landstuhl as a
medical service corps officer. We are seeing a nurse command
Landstuhl.
I am very comfortable that the system leader develops our
officers of all corps. Now, dentists do not command hospitals
because they command dental, and the veterinarians do not
command because they command veterinarians.
There is one small point that is not a small point, and I
think General Schoomaker referenced this, that unlike the
civilian community, a hospital commander is more than just a
manager or leader; he is a commander or she is a commander.
There is part of understanding what command is about,
accountability for command, executing the mission, completing
the mission, being held accountable morally, physically,
ethically for your performance. Not that they do not do that in
the civilian, but there is real authority vested in commanders
that I do not know that there is necessarily a counterpart in
the civilian. That is also part of the career development and
the leader development inside the Army medical department. We
certainly have courses--CGSC that we now have, it is called. It
has changed its name. We have the War College. We have courses
in medical administration. We do have officers who have gotten
advanced degrees in hospital administration. We have the Baylor
program which graduates classes every year.
Senator Ben Nelson. Do you think that having some specific
education, specific experience in information technology might
have led to finding a solution to the problems of the
bureaucracy and particularly the paperwork? I have heard of 22
forms that had to be filled out with 8 different commands, to
the point where a staff sergeant, after moving to outpatient
status, had appointments for 2 weeks and nothing. ``I thought,
should they not contact me? I did not understand the paperwork.
I would start calling phone numbers, asking if I had
appointments. I finally ran across someone who said: I am your
case manager; where have you been?''
That is a combination of a lack of coordination of the care
command and the garrison command, as well as the paperwork.
Would information technology help in that area?
General Kiley. Yes, sir, it would. We have evolved an
electronic medical record inside not only the Army medical
department, but the entire MHS, that we call ALTA. It is not
complete yet. There are parts and pieces of it, as they say,
that still need to be developed. It is a very big and complex,
privacy protected program that is worldwide. That is part of
the solution.
Moving the MEB and PEB process to a totally paperless
process would improve it. But if we still have 22 forms that
have to be filled out electronically, that is still 22 forms
that need to be filled out.
Senator Ben Nelson. Or fill out one and transfer it to 20
different locations.
General Kiley. Yes, sir, but it is about 20 different forms
with potentially 20 different pieces of information on it. It
is very cumbersome, and we want to challenge the complexity of
that.
Senator Ben Nelson. Secretary Chu, I have the American
Legion coming in today, the VFW coming in today, the Nebraska
Veterans Home Administrators coming in today, and the VFW
coming in tomorrow. What should I tell them?
Dr. Chu. I think you should tell them that we are committed
to correcting the shortcomings here, we are committed to
looking at the fundamentals of the system, and that we are and
we will get on top of the issues that have been raised.
Senator Ben Nelson. Can I tell them that we are going to
work toward seamless care and seamless transfer from Active
Duty status to the veterans care, so that we do not have people
stranded somewhere in between or trying to choose which one
works better for them?
Dr. Chu. Absolutely. We have made, I think as you are
aware, significant progress on that score in the last several
years. We have a system now which alerts the VA, particularly
when someone is going to go on the temporary disability
retirement list, that this patient is coming so they can begin
the reception process and so that there is not a seam in the
process.
We have sent several million records electronically to the
VA in the last several years so that they have that evidentiary
base. A much stronger relationship I would argue, sir, between
the two agencies now than there was 5 or 6 years ago.
Senator Ben Nelson. As much as we commend, and I think we
should commend, the inpatient care, the acute care facilities,
and the care that the soldiers get is outstanding and second to
none, and the care that is provided by the caregivers, whether
it is the physicians or the nurses or the other personnel and
staff, is outstanding. But it does break down, as we have
talked, about outpatients. It is not just the outpatients that
have been there on the campus or across the street from Walter
Reed. People get stranded when they are sent home.
I met with, a little over a year ago, a soldier, a wounded
soldier in Nebraska who was sent home with floating ribs and
the kind of care that was going to require somebody who had--a
bone surgeon, it was going to have to have something in the
orthopedics. The follow-on care was so inadequate that when I
met with that patient and her parents that they had not been
able to get calls back, they had not been able to get referred
to a physician in Nebraska in the middle part of the State, 200
miles from Offutt with the hospital and care that might be
available there.
I just picked up the phone and called the nurse at Walter
Reed who was assigned to this patient. This nurse was
apparently very overworked and asked me why I was butting in. I
got to thinking, if a United States Senator has trouble trying
to cut through the bureaucracy, why would you not expect the
average family might have a very serious problem cutting
through that follow-on care, that aftercare, when somebody is
sent home to convalesce, as you said, General Kiley, the
healing process.
Well, this healing process I think was interrupted by the
lack of follow-on care. Fortunately, by the end of that day we
were able to get an orthopedic physician assigned to that
patient, that hero, that wounded soldier, who was otherwise
unable to get it done.
We are going to have to do a great deal more to make sure
that the follow-on care, the aftercare, because there is a
stranding that can go on once they are that far away from
Walter Reed or from wherever the facility is.
So I guess, Dr. Chu, can I tell them that we are going to
do a better job for follow-on care and follow-up care and to
make sure that the aftercare that they get is first rate just
like the acute care that they get at the hospital?
Dr. Chu. Yes, sir. If I could reiterate, that is one of the
reasons we created this military severely injured center, as a
backstop to the service programs. We recognize that people may
not get satisfaction at the first level. We need another level
of intervention. So to that individual now or in the future who
has those issues, if he or she is not satisfied with what was
done, that telephone number is there 24 hours a day with a
masters degree level person who is trained to intervene in the
bureaucracy, figure out what is the issue, and get it resolved
and provide a warm handoff to another person for the resolution
of that problem.
So I invite those who feel that--and I think that is part
of the issue here. There are going to be individuals who are
not satisfied with the first level response. If they are not
satisfied, that backstop is there and that safeguard is there
to try to make sure we do not have these situations.
Senator Ben Nelson. That might help avoiding the situation
that I had with the near-Nurse Ratchett situation. Thank you.
Dr. Winkenwerder. Senator, if I might also say, that just
should not be the experience that someone should have. I happen
to believe----
Senator Ben Nelson. I did not think I should have been
treated that way, but I was not the patient.
Dr. Winkenwerder. Absolutely. Not you or the soldier. It
just should not happen.
I think that from where I look at this across the entire
system, people need to understand, we take care of across the
entire system 110,000 patient visits a day. This is a very
large system. This is not a large number of people that we are
talking about who have these issues and concerns. We ought to
be able to have case managers who could follow these
individuals and ratios so that we ensure that everybody gets
touched and helped when they need to.
I would just add one other thing that we have done that I
think is making a difference. It is the 4- to 6-month post-
deployment health reassessment process that started 2 years
ago. Everybody, not just when they come back, but 4 to 6 months
down the line--and this is when many problems do occur, not
necessarily for everybody--but we reach out, and it is a
requirement. Every single person is supposed to have that, that
touch and evaluation, not just a questionnaire; personal,
professional evaluation: How are you doing? How is your family
doing? What do you need?
So that hopefully is another step to reach out to people.
Senator Ben Nelson. We sure know more than we knew before.
Thank you.
Chairman Levin. Thank you, Senator Nelson.
Senator Webb.
Senator Webb. Thank you, Mr. Chairman.
I believe that, gentlemen, the opinions of this committee
have been pretty forcefully stated today. I am going to resist
the temptation to pile on in a lot of anecdotal ways here. I
would like to thank the chairman, first of all, for committing
to further hearings, particularly with the Veterans Committee.
I am also on that committee. I think it is probably the best
way to address some of these overlapping issues.
Dr. Chu, always good to see you. I have been privileged to
work with Dr. Chu for more than 20 years, 4 years inside the
Pentagon on a daily basis. We were sort of fellow data dinks
and I know how hard it is to scrub some of these numbers.
I approach this issue from two different perspectives, one
as a lifetime recipient of military medicine. I grew up in the
military. I was very fortunate to be the recipient of a great
deal of compassionate care while I was on Active Duty, after I
was wounded, when I was recuperating, and I have been able to
use the system since then because I was medically retired from
the Marine Corps following that experience.
I also have worked on these issues as a committee counsel
on the Veterans Committee when we were looking at a number of
these issues nearly 30 years ago, some of them. Particularly,
one comment, Mr. Chairman, with respect to the questions about
the military evaluation of PTSD. I served as counsel for a good
percentage of those hearings when we were attempting to fully
understand PTSD back in the late 70s. One of the challenges
with PTSD is that it does not always manifest itself when you
are on Active Duty. It is a very difficult thing, I think, for
military medicine to get its arms around.
What we were seeing when we were looking at the data--and
we went back to all war eras when we were looking at PTSD--is
that in many cases it will not manifest itself until typically
8 to 10 years after someone goes through the experience, and
then again more than 20 years after someone goes through the
experience. So this is an area that in my view should be a
principal focus of the VA with correlation with DOD.
With respect to BRAC, just having listened to some of these
hearings, one of the things that I have observed over my
lifetime is the continuing consolidation of medical facilities.
It is difficult to recruit physicians. It is difficult to keep
them on Active Duty. When I was on Active Duty, we had a full-
up hospital in Quantico. I was treated there. We had medical
facilities down here at 23rd and Constitution Avenue that I
used when I was in the Marine Corps. They are gone.
So when we talk about eliminating yet another facility,
even though I take the point with respect to the consolidation
of research information and the ability to have the National
Institutes of Health (NIH) across the street and all the rest
of that, I am very concerned whenever we start eliminating
military medical facilities, given not only the people on
Active Duty, but also the retiree population that frequently is
served by military medicine.
But I also look at this and cannot help but look at this
issue with the perspective of someone who spent a good bit of
time in command and also civilian responsibilities. Uniquely in
the military, there are the responsibilities and the
obligations of command. One of those responsibilities is to
show up and to supervise any facility that is under one's
jurisdiction. When I would visit ships when I was Secretary of
the Navy, the first thing I would do would be to go down to the
engineering spaces down in the boiler rooms, and one of the
first questions I would ask them was: When is the last time the
commanding officer visited you down here in the boiler rooms,
where the 1,200-pound steam boilers were going? That was a
pretty good indicator, I think, of command, of command
responsibility and the attention that command was paying.
To borrow another metaphor here, General, this is sort of
the boiler room. This is the boiler room of Walter Reed. People
needed to be showing up and talking to the troops and asking
them how they were doing.
What I have been seeing from the veterans side and also
from the military side on these issues is that we seem to be at
a clear breakdown at the point of transition, with DOD on the
one side in a number of these problems, how you process these
people after they have been given undoubtedly some of the
finest medical care in the world, how we process them, evaluate
them, either return them to duty or get them into the veterans
network.
Also on the VA side, we have a 400,000-case backlog in the
VA in terms of evaluating people's claims. These transitional
programs go beyond medical. They go to disability evaluation.
Dr. Chu, I want to ask you a question about this in a minute.
They also go to such areas as how we are rewarding service,
which is one of the reasons that I introduced a good GI Bill, a
World War II type GI Bill, for these people who have served
since September 11, which seems to be resisted in some cases
because potentially of the cost. Well, how do you evaluate the
price of service and how do you evaluate the value of service?
What I am seeing here in many cases is an indication of
where leadership is putting its priorities, civilian and
military. We know we have to put priority on the battlefield.
But we need a greater expression from this administration and
from military leaders about these kinds of priorities, the
sorts of things that we are focusing on.
I have a question--and again, Dr. Chu, you and I love data.
This is a March 20, 2006, GAO report on the military disability
system. It has been around for a year. Its title was ``Improved
Oversight Needed to Ensure Consistent and Timely Outcomes for
Reserve and Active Duty Servicemembers,'' and it goes through
the evaluations of individuals and how their disability claims
were processed.
One of the things that jumps out at me--I am not going to
ask you to answer this in detail today, but it is just a real
point of curiosity. It is on page 50 of this report, where it
gives the statistics for disability evaluations from 2001
through 2005. On the face of it, it is an Active Duty versus
Reserve component evaluation. But here is the thing that jumps
out at me, and it goes along the line of questioning here about
perhaps pushing these people out of the system, or maybe it is
just the inability to collect the right kind of data.
What it shows here is that on the Active Duty side there
were in 2001 6,378 total people evaluated, in 2002 6,632 people
evaluated. By 2005, with the war going on, there were only
6,465 people evaluated. That just seems implausible to me when
you consider the casualty flow from these operations from
woundeds and also from people who were injured but not wounded.
I would greatly appreciate a clarification of this data
before we can jump into trying to figure out where solutions
might be needed.
Dr. Chu. Delighted to.
Senator Webb. Good. Thank you very much.
Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator Webb. You are looking
for that for the record?
Senator Webb. Yes, I would appreciate a response for the
record. We can provide you with a follow-up letter with the
data on it.
[The information referred to follows:]
The data on page 50 of the Government Accountability Office report
is incorrect. The Department asked the Army to verify their data, and
the Army provided corrected data for disability dispositions, as shown
below. These revised data show an increase in the number of soldiers in
the Disability Evaluation System (DES), especially for the years 2004
and 2005. In 2006, there were 7,665 Active component soldiers in the
DES, which is a significant drop from 2005, but is still significantly
higher than in 2001. For the Reserve component, the increase was
significant across the last 5 years, from 567 in 2001 to a high of
4,213 in 2004, and with 2,784 in 2006.
UPDATED NUMBERS FROM THE ARMY
March 5, 2007
------------------------------------------------------------------------
Physical
Disability Case
Case Count by Calendar Year Processing
System Total
------------------------------------------------------------------------
Active component:
2001............................................... 6,557
2002............................................... 6,907
2003............................................... 6,094
2004............................................... 8,277
2005............................................... 9,297
2006............................................... 7,665
------------------------------------------------------------------------
Reserve component:
2001............................................... 567
2002............................................... 773
2003............................................... 1,624
2004............................................... 4,213
2005............................................... 3,221
2006............................................... 2,784
------------------------------------------------------------------------
Chairman Levin. That would be great.
Senator Webb. Thank you, Mr. Chairman.
Chairman Levin. Thank you so much.
Senator Kennedy.
Senator Kennedy. Thank you, Mr. Chairman. I think all of us
are grateful to you for having these hearings and, as others
mentioned, enormously troubled by all of this situation.
Let me just mention--I know you have heard these stories
before, but just in my own State of Massachusetts we have story
after story of the soldiers who are wounded: Bilad, Iraq,
November 2003, changing a tire on an Army helicopter, accident
resulted in the loss of both arms; working with the USO, our
office facilitated the soldier's family's travel to Washington,
DC, so they could visit at Walter Reed. Then the family
contacted us because it appears that the soldier was falling
through the cracks. He received adequate care at Walter Reed,
then experienced difficulty receiving care at a VA facility
because the discharge paperwork was delayed. Ultimately,
because of administrative problems he needed assistance in
receiving his annuity pay, as well as receiving care at the
Brockton VA hospital.
We have instance after instance of that type of thing,
which we must avoid.
But let me come back to the central issue, and it is not
unrelated to what Senator Webb has mentioned. A month ago the
DOD reorganized the way it releases the casualty figures from
Iraq and Afghanistan. On January 29, the Department's Web page
listed a total of more than 47,000 non-mortal casualties. The
next day, on the same Web page the category of non-mortal
casualties had been replaced by one titled ``Total Medical Air
Transported,`` and the figure was slightly more than 31,000.
This new figure excludes more than 16,000 wounded or
injured servicemen and women whose conditions were deemed not
serious enough for evacuation. On the Department's press
resources Web site, only those who are wounded in action are
mentioned, about 23,000 troops. So we have these figures. These
differences are both confusing and raise questions that we hope
that you can answer. They have implications in both the short-
and long-term about care of our troops, about allocations of
resources, about what the needs are when you have these kinds
of disparities.
Dr. Winkenwerder, why has the DOD suddenly felt the need to
cut in half the number of soldiers who needed the care?
Dr. Winkenwerder. Senator, thank you for that question.
There was confusion. I think we within the Department created
that confusion unnecessarily. Let me assure you and others that
there is no intent other than to accurately and properly inform
everybody of what casualty figures are and what they are not,
just to be absolutely candid about this.
What had arisen was the term--it gets to the term
``casualty.'' The individuals that were being moved from the
theater for the last 3 or 4 years for whatever reason--and
early on there were quite a number of people because there was
not medical care there--that might have been moved for a
routine exam, a female exam, whatever, these were not
casualties. These were just people moved for routine care. That
is called medical air transports.
People had taken that information, I think because we had
expressed it improperly, and had concluded that these were war
injuries or war wounds, and they were not. So it was just an
effort to clarify that. We should not have misled people in the
way that we did in the first place. So that is what it is, that
is what it was. The figures are what they are, and it would be
crazy, absolutely insane, to try and imply that the figures are
any different than what they are. That is it, that is the
answer.
Senator Kennedy. Thank you, but how--what were your--did
you have the estimates of what you thought were going to be the
casualties? Did you make the estimates now of what you thought
were going to be the casualties, say for March of this year?
Did you make those estimates a year ago or a number of months
ago, so that you would know whether there is going to be the
allocations of personnel and the allocations of resources and
the training of different personnel and trying to anticipate
that? Are these, the numbers that we have now, the same as
those? Are they different? How are they different?
Dr. Winkenwerder. The casualty estimates, going back to
even the beginning of the conflict, are generated by, and any
projections of those and therefore what sort of medical
resources in theater do we need, are made by the Joint Staff.
They are really military estimates. We review them and assist
it with ensuring that the right level of medical care was in
theater.
As things have progressed, obviously, over the last 3, now
4 years, we observe and track, and I know General Kiley and the
other surgeons general and the other service leaders are
tracking the casualty flow to ensure that all the resources not
only are there in theater, but when people get back. That is
how it is done, and so there is a constant look at it.
Senator Kennedy. Dr. Chu, did the career professionals in
DOD estimate the number of military personnel who would need
health care services as a result of service in Iraq and
Afghanistan?
Dr. Chu. The Department has conducted a thoroughgoing
analysis of what the size of its capacity needs to be for all
our contingencies, including the ongoing challenges in Iraq and
Afghanistan. Based on that, we have sized the present and
future medical establishment.
I also want to note the Department has transformed--this is
an extraordinary achievement by the medical community--how we
deal with war casualties. Our prior model, as you are aware,
was to try to take forward the care apparatus. That is bulky,
it does not necessarily get the best clinical care for the
complex wounds we are seeing today. The transformation in these
two conflicts, Afghanistan and Iraq, is that the role of the
forward medical community is to stabilize the patient, to act
as a safeguard against any surge in casualties, but that our
objective is to bring the casualties back to the United States,
where we can concentrate the best clinical talent on their
recovery, their recuperation.
That is the great achievement in the last several years. It
is an enormous tribute to the skill of the medical personnel in
theater, to the skill of medical personnel who are manning this
in-transit system. As you have seen in the press reports,
people are accurately reporting that they have gone from the
battlefield to Walter Reed or Bethesda, often in 36, 48 hours,
and they are the better for it.
It allows us, among other benefits besides the sheer
medical benefit of the transformation, to bring the family to
the bedside in a way that the previous model did not. Really
quite an extraordinary change in how we do business.
Senator Kennedy. Secretary, no one is complaining about
that. We are full of admiration for that service. It is heroic
efforts, every single day, the people. That is not our issue
that we are talking about here. We are talking about an
entirely different situation, what is happening to these
individuals over their experience of their lives.
I mentioned--I will give you another. Here is soldier
number two, a paraplegic, served two tours in Iraq and
Afghanistan, due to injuries sustained in combat ended up at
Walter Reed, transferred to West Roxbury VA facility, did not
have specific problems with the care, but once transferred to
the VA facility the Army, specifically Walter Reed, lost track
of him, resulting in lack of pay for the soldier and his
family.
Our office was contacted to help out in October. We talked
to Walter Reed. The paperwork was incomplete, leaving him in a
troubling grey area where he is not on Active Duty, not
officially discharged. This is the situation that is repeated,
where people are being left out and effectively dropped.
Another patient received psychiatric treatment at Walter
Reed, had been at Walter Reed for 21 months. He came to our
office, he was getting transferred to a VA hospital. Once he
got transferred to the facility, his family was told that he
was being discharged because he was technically still Active
Duty and his discharge documents were waiting on signatures.
Due to the fact that he was no longer at Walter Reed, yet not a
veteran, he was unable to receive any kind of benefits.
This is instance after instance. I am not going to take the
time, but that is the great gap that we are seeing, and that is
both in treatment and in care and attention and focus. As was
mentioned, I think, earlier during the course of the hearing,
getting an advocate, the advocate that is going to speak and
follow for the individuals, is something which is enormously
valuable and very helpful in the health care system in any
event, and is something that we certainly ought to consider
with regards to the veterans.
I thank the chair.
Chairman Levin. Thank you, Senator Kennedy.
Senator Sessions.
Senator Sessions. Thank you, Mr. Chairman.
As is so often the case, I had another hearing, but I have
benefited from what we have heard today. I believe Secretary
Gates has an awesome responsibility and he has ultimate
responsibility for everything in DOD. I think he has shown
courage and leadership and he has insisted on strict
accountability, and I am sure that some might feel that that
power may not have been wielded perfectly, but I believe he
wielded it effectively and I think it has helped us begin to
emphasize the need to revaluate what is going on in the health
care of our soldiers.
The care that they receive I agree with Senator Lieberman
should be commensurate with the risks we have asked them to
undertake for us. We have asked them to give everything they
have to execute our policies. Therefore we should do everything
we can to make sure that their health and safety are taken care
of, particularly if they are injured while serving their
country. I think we all understand that, but obviously we have
not met the high standards that we would like to meet.
One article I believe in the Christian Science Monitor of
recent days noted that a Colonel Garibaldi had warned that,
``Patient care services are at a risk of mission failure,'' due
to a privatization effort that had left the hospital short-
staffed. General Kiley, could you give us your insight into
that troubling comment?
General Kiley. Yes, sir. That is part of the A-76 study
that actually started when I was in command at Walter Reed,
following the law and the requirements of the Army to identify
capabilities on the installation. In this case, it was the
garrison operations, the personnel actions, the Director of
Public Works.
Senator Sessions. Explain the garrisons for those who are
listening.
General Kiley. A garrison is the command that is
responsible for essentially running the town or city. So every
one of our installations has a commanding officer accountable
to the senior mission commander and to General Wilson, except
for Walter Reed because it is a separate installation to date.
Senator Sessions. Are those uniformed personnel?
General Kiley. Yes, sir.
General Schoomaker. City manager is what it is.
General Kiley. Yes, sir, city manager.
In this case, the MEDCOM had Walter Reed, Fort Dietrich,
and Fort Sam Houston and had undergone an A-76 at Fort Sam
Houston and was directed to undergo an A-76 analysis, which
would require the government employees to compete against the
contractor. They began that process. In the process of appeals
and re-appeals, Colonel Garibaldi realized that he was at risk
to dip below a functional capability to manage the city, not
necessarily for clinical----
Senator Sessions. It is one thing to have an A-76 study
about privatization for cutting the grass at a military base.
It is another thing when you are dealing with entrusting the
health care of our soldiers. Is that correct?
General Kiley. The health care was not part of that A-76.
It was just the installation support, to include maintenance.
Senator Sessions. But that is why that is relevant to
maintenance at the facility.
General Kiley. Yes, sir, and particularly to Building 18.
That same capability was at risk and that was part of Colonel
Garibaldi's challenge.
He sent that memorandum up through General Weightman, to my
resource manager with a series of requests. We analyzed that
and concurred that he needed support and resources and provided
those to him. His challenge was that because of the nature of
the pending shift to the contractor, there were people that
were not interested in coming to work for a couple of months
and that made him struggle a little bit in completing the
mission because of the lack of personnel to complete the
mission.
Senator Sessions. I think it indicates that we have had
some knowledge of our danger earlier. I do believe that perhaps
all of us in Congress could have done a better job of
maintaining oversight. I just must say that. We have had
oversight over prison treatments. We have had half a dozen
hearings on Guantanamo and how we are treating the terrorists.
Perhaps we should have had some hearings on how to treat our
own soldiers, or maybe a lot more hearings on it.
Tell me about this deal of this situation in which a
soldier who has been severely injured, they need a good bit of
reconstructive surgery, and then they are eligible to go back
home, or perhaps when do they go back and receive care where
their families may be, and when do they stay here, and are we
confident we are making the right decisions about that?
General Kiley. Yes, sir. We have two populations. We have
the Active Duty population med hold. We have Reserve and
National Guard in the med holdover. I believe it was in 2004 we
began a program called the Community-Based Health Care
Organization (CBHCO), where we recognized--and some of this
came out of our experiences at Fort Stewart--that we had
soldiers who had injuries, combat injuries, and were going to
require long-term, not low level, but not high risk health
care, physical therapy, occupational therapy, care they could
receive in their communities where they lived. They simply
asked the question: Why can I not go home and see a doctor or a
therapist in my hometown, and then I will remain on Active Duty
while I do that, under the control of a CBHCO command and
control?
So we established that. We have been running that for a
couple of years. We presently have about 1,300 soldiers around
the Nation at home getting their health care. At some point as
they heal up, they either become fit to be released from Active
Duty, or if they need an MEB/PEB we begin to do that. We have
done that for the last couple years.
Senator Sessions. How would you evaluate the success of
that program?
General Kiley. In general, I think that program has been
very successful.
Senator Sessions. Now, is that the problem we are dealing
with?
General Kiley. No, sir.
Senator Sessions. What is the difference in that?
General Kiley. The difference is that many of the soldiers
that are at Walter Reed--and by the way, Walter Reed has almost
by an order of magnitude got a larger number of soldiers in
outpatient status around Walter Reed than most of the rest of
my medical facilities, although I have sent the teams to them.
These soldiers have very complex, very complex multi-system
injuries--we heard a soldier last week--with PTSD, and TBI, and
orthopedic injuries, sometimes amputations, and the need to
develop prosthesis, sometimes multiple prosthesis, sometimes
requirements for sequential surgeries over time.
Senator Sessions. I am aware of that.
General Kiley. We and often the soldiers would like to stay
at Walter Reed and get their care done and then reach a final
decision, maximum therapeutic care, and make a decision about
return to duty. Some of them would like to come back to duty
even with amputations and prosthesis. Some are ready to be
medically boarded and discharged.
So we make a decision almost on a case-by-case basis, or we
should be, that says, you should stay here, I want to stay
here. If we have soldiers that would like to go, for example,
from Walter Reed to Brook Army Medical Center because they are
from Texas or from San Antonio or Fort Lewis, we will make
arrangements to transfer them there.
Senator Sessions. My time has expired. I would note that
there is an article, op-ed I guess, in the New York Times by
retired General Paul Eaton that said ``Soldiers have long
joked''--I guess, Dr. Winkenwerder, I will ask you this--``long
joked, `If you are really sick or injured, Army medical care is
okay. But if you are hurting only a little, especially if it is
not visible, you are in big trouble.' ''
General Eaton goes on in a critical piece here, he does go
on to say, ``The American soldier still receives the best
trauma care in the world, especially at Walter Reed. The
problem there has been with deplorable outpatient care
management. The system, the military health system, is
seriously undermanned and underfinanced for the number of
casualties coming home.''
Let me ask you to comment on those remarks.
Dr. Winkenwerder. I do not know how familiar General Eaton
is with things that have been done in the last 4, 5, or 6
years, the advances, not just in battlefield care, which he
alludes to and does not have a concern about. Just based on the
evaluations that we do, from the clinical quality and the
satisfaction across the system, would not support his
conclusion about that.
Senator Sessions. Is that on the question of money or the
question of----
Dr. Winkenwerder. On the question of whether people get and
are satisfied with their care as outpatients or for everyday
kinds of care. In fact, the survey work--and again, our goal is
to have no bias. That is why we benchmark to the private
sector, and that is where I spent my career, so I have some
sense of this--is that the satisfaction is very good with
everyday routine care. The issues that we have been talking
about now I think are for the special population of people who
have the--it is outpatient care, but it is the long-term
rehabilitation population, not someone who is coming in for
cold or flu or for a sprained ankle.
That may have been the case--and General Schoomaker or
others can comment--historically within the Army, but I think
there have been dramatic improvements in satisfaction, and we
have very good data that can show that. Are we satisfied? No,
we are never satisfied. We can always be better, and I think
that is the culture, that is the idea that we need to embrace:
Never satisfied, always get better, always compete to get
better.
General Schoomaker. Sir, if I could add something. I do not
mean--this is not meant to be flippant, but I said earlier this
is not about comparing to other things. This is about what is
right and what should be expected and what the standard should
be for these soldiers. If you look at the Gallup Poll in 2005
and 2006, health maintenance organizations in this country were
at the bottom of everything on the list, and I would not
measure military medicine against civilian medicine in any form
or fashion. Our soldiers and their families deserve far better
commitment than the standard that is out there in the civilian
thing.
I personally object to the business attitude about all of
this. This is a bigger commitment than that. So I am not
lecturing you, but I want to go back to this business about
what the right price for things are. You cannot put a price on
what these young men and women are doing and the responsibility
we have for them for the rest of their lives.
I was just looking at the figures. Just of the Army, 31,581
soldiers were evacuated out of the area of responsibility
(AOR), just Army, since October 7, 2001, and those figures are
good as of March 3 of this year. So it is very new information.
Seventy-two percent of those evacuated are outpatients. That is
22,738.
This is what our difficulty is here. The 8,843 that are
inpatients are getting the finest care in the world. But we
have to bring this standard to the people in the outpatient
business. We cannot compare it to business and to civilian kind
of stuff and all these people because it is not respected out
there on the civilian side, according to the Gallup Poll. I do
not know because I do not go out there.
I will tell you, just of the 31,581 people that have been
evacuated out of the AOR--these are the people who have been
evacuated now, not the ones who have been returned to duty--
4,000 of them are battle-injured, and 8,843 are non-battle
injuries. Over twice the non-battle injuries than battle
injuries, and 18,633 are disease. So 59 percent of all those
evacuated were disease, 28 percent non-battle injury; 13
percent were battle injuries.
I guess what I have been trying to say throughout this
testimony here is this is another layer on top of a system that
is already dealing with a baseline of families and soldiers and
all the rest of it here. Much more complex. So again, I am
sorry to sound pedantic here, but I do feel passionately about
this Nation's responsibility, not only to resource our
soldiers, sailors, airmen, marines, and everybody else that is
serving this country when they are well and how we put them
into battle, but we damn sure ought to be doing better than we
are doing on those that have been injured or diseased or hurt
while we are doing it.
So I hope our baseline is against what should be and could
be, not about some kind of what is happening out there in small
town America.
Senator Sessions. Thank you, General Schoomaker, for your
magnificent service to your country. I have to tell you, I
understand your brother has many of the qualities of integrity
and commitment that you do and I am confident that he will make
progress for us.
General Schoomaker. Thank you, sir.
Chairman Levin. Thank you, Senator Sessions.
Senator Akaka.
Senator Akaka. Thank you very much, Mr. Chairman.
Let me welcome Secretary Chu, Dr. Winkenwerder, General
Schoomaker, and General Kiley to the Senate committee this
morning and tell you, General Schoomaker, you were right on
target in what you just said about our commitment, and the
commitment is with you as well as us here in the Senate to give
the best to our troops as they continue to serve us.
We are here to look at the problems with patient treatment
at Walter Reed and our effort here is to find out what it is
all about, what we are dealing with, and to try to find
solutions to do that. For that reason, I really am grateful for
your responses today.
One of the things that the chairman mentioned--and I want
to thank the chairman for this hearing--was that the Veterans
Affairs Committee and the Armed Services Committee should work
together on this and to meet together in a joint hearing as
well. We have talked about it and I do look forward to that
happening, Mr. Chairman, and all for the effort of trying to
find solutions to the problems that we are facing. We can do no
less than the best that we can.
One of the concerns that I have had, and I have mentioned
this before, has been about BRAC and what impact that BRAC has
had on all of this. We all know that in 2005 the BRAC
Commission did name Walter Reed as a facility that would be
closed by 2010, in a 10-year period. I just would like to have
a comment from Dr. Chu and Dr. Winkenwerder about what they
feel about that, the decision that was made by the BRAC
Commission, and whether that has had an effect on what is
happening now?
Dr. Chu. Let me speak to the decision and allow General
Schoomaker and General Kiley to speak to any effects at Walter
Reed as a campus. It is a decision the Department supports. We
think it will further advance the cause of military medicine
because we bring these two great institutions together on a
single campus with the revamped state-of-the-art facilities
they ought to have to meet the standard General Schoomaker just
outlined.
Both buildings, both institutions, need their physical
plant refurbished. Walter Reed is the more urgent, the current
Walter Reed building is the more urgent of the two, but
eventually Bethesda needs the same thing. The Bethesda location
that was selected by the commission we think has great
advantages because it is also the campus for the Uniformed
Services University of Health Sciences and, as you appreciate,
right across Wisconsin Avenue is NIH.
So we have charged the President of the Uniformed Services
University with improving the partnership with NIH as a prelude
to what we hope will really be a truly extraordinary national
asset.
I want to emphasize one of the important additional
elements in the BRAC decision and that is the call to increase
our capacity at Fort Belvoir. If you look at where our people
live in this region, they are mostly south, west, however you
want to call it, of the Potomac River. So therefore it is very
important that we have a better primary care capacity at the
principal inpatient location in the region, that is Fort
Belvoir. So a very important piece of this is Fort Belvoir and
what it will give in terms of primary care capacity.
Dr. Winkenwerder, would you like to add something?
Dr. Winkenwerder. I just agree with everything you have
said. I would also just add to that that our message coming
certainly from my office is we have a critical mission. It
continues right until the day of that transition. We have
continued to invest in the Walter Reed campus. There is a new
amputee center that a decision was made about in 2005, $10
million. It is going up. It will be completed later this year.
If there are more issues or more needs, we continue to invest.
We cannot underfund, and we will not underfund, and have
not underfunded what is going on today and that has to
continue. That will be what takes place. Maybe from the other,
day-to-day aspect, I do not know if, General Kiley, you would
want to comment from your vantage point.
General Kiley. Just two quick comments. I made a comment
earlier. After the Washington Post article was released, I was
asked the question, did BRAC cause this. My answer was no from
the basis of my position as the MEDCOM commander, in that I was
not making any funding decisions nor was I restricting any
funding to Walter Reed because of the BRAC. The intent was to
maintain Walter Reed as robustly as we could and with all the
resources that they needed.
Subsequent to that, in my discussions with General
Weightman, it is clear that, even though I went out probably a
couple months ago with the Navy Surgeon General to reassure the
professional staff at Walter Reed that the new National
Military Medical Center at Bethesda would carry on all the
great traditions at Walter Reed, there is clearly still a
psychological impact on the organization. I do not believe it
impacts on the health care of the soldiers, but it has some
second and third order effects downrange in terms of recruiting
and retention that I am not real sure what that impact is.
So from a financial perspective, from an operational,
OPTEMPO perspective, it did not impact and should not have
impacted. But culturally and emotionally, I am not sure how
much it impacted on Walter Reed.
Then of course, the analysis of the soldiers and the
soldier flow is still something that we need to take a look at.
Senator Akaka. Thank you for that. I have worried about
that and I am grateful for your responses.
One of the problems that we think has affected what has
happened has been the budget for treatment. You just mentioned,
General Kiley, that this did not happen as far as Walter Reed
is concerned. But the Boston Globe reported yesterday that the
Pentagon is concerned that the cost of health care could erode
our military readiness and that is very important to us.
Dr. Winkenwerder, you are quoted in the article as saying
``Without relief, spending for health care will divert critical
funds needed for warfighters, their readiness, and their
critical equipment.'' The focus on the article is on the impact
of health care on military readiness and therefore it is very
critical that we deal with that. I am concerned about whether
or not budgetary constraints are forcing our military to take
tough measures to address rising health care costs and whether
these measures are a contributor to the systemic problems as we
are finding at Walter Reed.
Dr. Winkenwerder. Thank you, Senator. That is an excellent
question and I am glad to address it. The issue is that we do
have a growing cost challenge for health care broadly. But I
would like to put into perspective where most of those dollars
go. Over 60 percent of our entire budget goes for retiree
health care, not for today's Active Duty and their families. It
is that retiree portion within which we have experienced the
greatest cost growth.
So I do not believe we have had any issues to date that
have affected necessary investments in the direct provision of
health care at Walter Reed or other institutions or anything
that we are doing today. My concern was as I look forward and
look out that there has to be pressure, growing pressure, with
these costs and it has created and will create more pressure in
the future for the entire DOD. So there is a challenge out
there that we have to address and recognize and deal with.
I would invite Dr. Chu or General Schoomaker to comment as
well.
General Schoomaker. I am a retiree and I am about to be
released from Active Duty and to be one again. I just remind
you that the retirees we are talking about fought World War II,
they fought Korea, they fought Vietnam, they fought the global
war on terror, and they have earned this. We are about to have
in my view, as has already been alluded to, a growing
population from the global war on terror and the long war as we
go of many very seriously injured young men and women that are
going to become older men and women with these very serious
injuries and all the complicating factors. I think that if it
is not a problem today, it will be a problem, and that what we
ought to be doing is anticipating it.
It is no surprise to anybody here because I have been
saying it a long time: This Nation spends too little on
defense, and part of defense, a big part of defense, are the
people that volunteer to man our formations. So I have heard it
back on some other committees what I have said before: We ought
to be spending 5 percent at least of gross domestic product
(GDP) on defense. We ought to be taking care of people, who are
our most valuable asset. We ought to be putting the very best
equipment on these people when we ask them to go in harm's way,
and we ought to take care of them after they perform their
service. That is where I stand and I am at odds with lots of
people that think they are managing some kind of checkbook and
that some how our priorities ought to be in other areas. I just
disagree with them.
Senator Akaka. Thank you, General Schoomaker. You are right
on target.
Thank you, Mr. Chairman. My time has expired.
Chairman Levin. Thank you, Senator Akaka.
Senator Thune.
Senator Thune. Thank you, Mr. Chairman.
I appreciate that last comment. I also agree. In World War
II we were spending a third of our GDP on military. Korea and
Vietnam, it dropped down in the 10, 15 percent range, and then
Cold War, post-Cold War period, continued to drop, and it is
about 3.8 percent of our GDP today. We are at war, we are in a
war.
I think that these are all symptoms of a bigger problem.
That is that we are not putting enough into making sure that
when we fight wars we are able to fight and win, but second
that when we have people coming home from those fights that we
are taking the appropriate care of them.
I have been to Walter Reed Hospital on five different
occasions visiting with soldiers. I have been to Landstuhl in
Germany, and I think in every case when I have been there and I
have visited with people who have been treated there,
particularly in the inpatient setting, there is a high level of
satisfaction with the quality of care. At least that has been
my observation in visiting, interacting with soldiers who have
been injured.
It does seem that this is a function more of a very
different type of war and one where we are having a lot more
injuries. Fortunately, people are living because of the body
armor, but it creates a very different strain on the military
health care system.
But I guess I have a question with regard to outpatients.
Perhaps, General Kiley, you can answer this. There have been, I
am told, nearly 4,000 outpatients that are currently in the
military's medical holding or medical holdover companies which
oversee the wounded. What is the average length of time a
wounded soldier spends in a medical hold or holdover status and
are we keeping soldiers in that status longer than is
necessary?
General Kiley. Sir, I would have to take the--I do not know
the answer to the average stay across the entire MEDCOM. I can
report that back to the committee. I think the answer to ``are
we keeping them too long'' clearly identifies one of the
challenges we have, because we have soldiers that want to get
on with the process of going through the MEB and the PEB,
working their way through that bureaucracy, and we have other
soldiers who are concerned that all of their concerns will not
be diagnosed and properly cared for. So we have this tension
between how long is too long.
[The information referred to follows:]
The average length of stay in medical holdover for Reserve
component soldiers is 172 days when they remain at a Military Treatment
Facility. The average length of stay in Community-Based Health Care
Organizations (CBHCO) is 291 days. The average length of stay for
Active component soldiers in medical hold status at Army hospitals is
176 days. The average time in medical hold begins when the treating
physician initiates the Medical Evaluation Board and ends with final
disposition by the U.S. Army Physical Disability Agency.
It is important to note that the medical hold (Active component
soldiers) does not include time spent healing after injury or illness.
Most Active component soldiers remain assigned to and working within
their units during this phase. Duty limitations for medical hold
soldiers are specified in temporary profiles issued by the treating
health care provider. Medical holdover and CBHCO averages stay includes
healing or rehabilitation time.
General Kiley. I hear occasionally allegations or concerns
that soldiers, they are rushing us out the door, they are
rushing us out the door. So we continually give guidance to the
commanders all the way down to the CBCHOs and to the hospital
commanders who oversee the medical board piece of this that,
you have to take the time to examine all the issues that
soldiers have and properly take care of them.
Where we are at risk and where we are going to redouble our
efforts so as not to delay the processing of soldiers is in
that area where we are down to one or two conditions, as an
example, and we have one or two more consultations and then we
can begin to type up the summaries and do the 22 pages of
paperwork and there are delays. A clinic appointment is
cancelled or it takes another couple of weeks to get a test.
Those are case-by-case, but they start to mount when you have
4,000 individuals in med hold and med holdover.
We need to go back and take a look at that, and I think
part of that has to do with again the complexity of the
conditions, requiring multiple consultations instead of a
single one. Part of it has to do with making sure that we have
the ancillary support staffs that we need, properly
proportioned to the numbers of soldiers, so that we can in
exactly the right timing work them through this very
bureaucratic process.
Senator Thune. Secretary Chu, in the National Defense
Authorization Bill last year there was some report language
that directed the Department to look at--in fact, the language
says, ``The conferees continue to learn of instances in which
returning members of the Armed Forces have been delayed in
receiving needed health, mental health, and rehabilitative
services both in military hospitals and in medical holdover
status. The conferees believe that a wounded, injured, or ill
soldier, airman, or marine deserves the highest priority for
care. Should sufficient resources in the military hospital
system not be available, civilian resources must be made
available without delay.''
There was a requirement in here that there be a tracking of
these wounded soldiers as they come back and that you prepare a
report regarding that. I am curious to know what the status of
that report is.
But second, is this a capacity problem and do we need,
particularly in this outpatient setting, where we have a lot of
these injuries, to be referring more to a civilian resource if
that is necessary? That was the last observation of the
conference committee last year in the National Defense
Authorization Bill. What is the status of the report?
Dr. Chu. The report should be to you within the next couple
of months. We have begun working on the issues that the
conference report language raised.
On the capacity issue, broadly I think the answer is no,
there is not a capacity issue. That is not to say that we
should not advantage ourselves of the best care in the country
for the particular conditions the person might have. So I do
not want to rule out the use of the civil sector. Indeed, you
see an example of our partnership with the non-DOD sector in
using the VA's four major polytrauma centers for TBI. We
recognize this is not going to be something that every facility
can offer.
It does raise, and I think General Kiley has touched on
this already, a tension for our people. They often do want to
go home and that was the purpose of the Army's CBHCO effort. We
must recognize sometimes that there will not be quite the same
level of care in some communities for the tertiary type
situations as there might be at a major medical center, and
that is a choice the individual has to make.
But we are committed to devoting the resources necessary to
get these people well. I do think a place that we may yet put
additional resources--and this is an evidentiary matter,
although the Army has already put a good deal of resources in
this effort--is in the staffing for case management. It may be
that, as several members have noted, it is the importance of
the advocate for the patient that will bring the bureaucratic
process together in a way that is more effective, especially
for someone who is trying to understand where is he or she
going with his life, what is the future going to look like
here.
But the bottom line, I would argue, is I do not think we
have an important capacity issue per se.
Senator Thune. I want to commend you for acting quickly and
decisively with respect to the Building 18 issue. I do think
that these men and women who serve our country are heroes and
they deserve the best of care, whether that is in the inpatient
or outpatient setting.
The other thing we are going to be dealing with at the VA,
if you look at the statistics from Vietnam or Korea, there were
three injured soldiers per one dying soldier. World War II it
was two injured per one dying. In this current conflict it is
16 injured for 1 dying, which I think points to down the road
as these soldiers get on with life they are going to have
ongoing medical needs that are going to put additional strains
and stresses on the VA, and I think that is something that we
have to be prepared to deal with as well, and it is a cost of
war.
But these people who serve our country are heroes and they
deserve the very best of care, and I appreciate the fact that
you responded quickly and are trying to shore up some of the
shortcomings that we have in the system today, and particularly
with regard to the outpatient setting. So thank you for your
testimony and I am sure this will not be the last time that we
discuss this issue, but clearly this committee wants to act
quickly as well and make sure that we are doing everything we
can to see that you are resourced to deal with these problems
and challenges. Thank you.
Thank you, Mr. Chairman.
Chairman Levin. Thank you, Senator Thune.
Senator Graham.
Senator Graham. Thank you, Mr. Chairman.
Chairman Levin. Excuse me for interrupting you, Senator
Graham. But if you are the last Senator to have an opportunity
this round, we will not be able to go to a second round, given
the hour, and I just want to announce that. But the record will
be kept open for questions.
Senator Graham. I am sure they will want to stay and hear
my questions, but I do appreciate your letting everyone know
that. If I could go I would, but I have to actually ask them.
General Kiley, should you resign?
General Kiley. Sir, that is a difficult question to answer.
I certainly serve at the pleasure of the senior leadership of
the Department and would respect their decisions. I am
accountable for what happened at Walter Reed, as I am
accountable for Landstuhl and accountable for Brook and the
Center for the Intrepid, for the quality of the doctors and
nurses that go to the combat zone.
If I could step away from myself, I think at this time,
with us still at war, we have had some changes in the
leadership already in the MEDCOM. I still think I have the
right skill sets and the right experience to fix these
problems. But as I said, I stand ready for decisions.
Senator Graham. It seems to me that Building 18 is one part
of the problem, obviously, and the system problems are large
and complicated. Mr. Chairman, we need a whole hearing about
retiree health care in the DOD and what we can do to get a grip
on it. Because you are going back into retirement, General
Schoomaker; do you believe that you were promised as part of
your contract lifetime health care in retirement free, without
any shared responsibility?
General Schoomaker. No, because it is not free.
Senator Graham. Well, it is not. There are copayments, and
we have to figure out what is fair to the retirees.
General Schoomaker. Sir, I do believe that there is an
expectation that that was very much a part of the compensation
for service, because as you know we are not compensated in
fiscal terms.
Senator Graham. Do you have a problem with a retiree having
to make a copay for TRICARE services or a premium payment?
General Schoomaker. No, I do not, because we do now.
Senator Graham. That is right, and we need to look at that
system over time and see what is fair. I want to work with
everyone on this panel to do it.
But about the building itself, could you provide us,
General Kiley, the names of the first sergeants--and I do not
speak Army, so I do not know what organizational--I know one
thing, that people in the Army complain a lot less than they do
in the Air Force. I cannot imagine people in the Air Force not
complaining about this building, and apparently no one
complained. Is that true? No one that lived in that building
ever complained to anybody?
General Kiley. Sir, I think Specialist Duncan yesterday in
his testimony clearly stated he not only complained to his
leadership at Building 18, he made his concerns known to
Sergeant Lester, who is the NCO in charge.
But sir, that whole thing, if I may, is still under an
official investigation, and I can certainly provide for the
record the names of the individuals.
Senator Graham. I do not want you to provide--I would like
with the chairman to work on a list of people who are
responsible for that building at every level of command for as
long a period of time it was in a state of disrepair, so that
eventually at an appropriate time we could talk with them. I
would like to know how a building could be in that state of
disrepair that long and it not percolate up.
How long do you think the building was in a state of
disrepair that would be unacceptable? Do we know the time
period in question?
General Kiley. Sir, as I understand it the building
underwent a $260,000 renovation, to include paint and repairs
of exactly the kinds of things that were addressed in the
article. That happened in 2005. I cannot tell you at what point
Room 205 started having mold behind the wallpaper. I think it
is an old building. I think it has had a series of continuing
repair jobs. I think there is a humidity issue in this
building, I am told.
But I think it has had renovations. People have attempted
to pay attention to it. Clearly what changed the calculus was
that we were putting patients in there, and there is no excuse
to have soldiers in moldy rooms like that. But I think our
sense of urgency was not heightened at that point and we should
have been more aggressive.
Senator Graham. Right. I guess what I am trying to find out
is, when we start assessing who is responsible I would like to
know who was closest to the problem, and we can go up to the
President if we want to, but I do believe in the military that
command responsibility is a shared obligation, and if I am a
commander I do expect my subordinate commanders to be out there
doing their job and I want to look at the whole, how did
Building 18 get to become Building 18. I think it would be
helpful for us to know that.
General Kiley. Yes, sir.
General Schoomaker. Sir, let me, if I could add to it. I
agree with that track. I think that is exactly the right way to
go. But just for clarity sake, every room in Building 18--and I
know you have been through it--was not moldy.
Senator Graham. No, I have not been through it, and that is
what I need to learn.
General Schoomaker. There is a leak, the roof leaks on the
east side of that building on the fourth floor. There is a
humidity issue there. It has been through several renovations.
There are many rooms--and I talked to soldiers over there--they
are perfectly happy with the rooms, they are dry, they are
clean. They have their TVs in there. They are doing some stuff.
But it is not the standard for the whole building that we
should expect to have soldiers in.
Senator Graham. The only reason I mention each room by room
is that what we have in this war is a capacity problem. We are
looking at every building we can get our hands on and we are
throwing as much duct tape as we can, and what you see in the
health care area you see in other areas of military. We are
asking a lot. Nobody anticipated this war lasting this long,
causing this many casualties, and we are playing catch-up.
General Schoomaker. Sir, there is another issue here, and
this is what we are investigating, going down through the chain
of command. But we had empty rooms in Building 14 on the campus
over there, which is a state-of-the-art one-plus-one, standard
wonderful place. We had Building 18 that was not full. Only
two-thirds of the rooms or something like that were being
utilized. There were rooms that were open there and some of the
rooms that were in the worst shape, obviously, were not being
occupied.
Senator Graham. What we need to take from this whole
exercise is that our military is under stress at every stage.
Abu Ghraib was about people not being trained to do a job and
being asked to do a job they were not trained about, a prison
that had 200 or 300 people in it that wound up with 6,000. We
have to get ahead of some of these problems.
So what I want to learn from this is how did each room go
bad and for how long and why no one caught it. But look at the
bigger picture: What do you need? Is this a management problem
or is this a resource problem? Is Building 18 a result of bad
management or just we are having to take every resource, no
matter how delapidated, and put it into play?
General Schoomaker. Sir, my quick look at it, it is a
leadership problem, it was a management problem, and it was
also a resource problem in that the A-76 thing that went on for
6 years went from 300 maintainers to 60 maintainers on the
installation and therefore ended up with some of these issues.
So it is all of the above and it is not acceptable, and we
are going to hold everyone accountable for it.
Senator Graham. Including us here in Congress. I will say
that. You do not have to.
But now let us talk about very quickly what happens to a
person who is injured in Iraq, and you are taken out of the
line because your injuries are so substantial that you have to
come back. Dr. Chu, the first thing that happens to that
injured soldier is a determination as to whether or not they
can ever go back to Active Duty; is that correct?
Dr. Chu. Yes, sir, that is the first bureaucratic step in
that regard. But of course, our first priority is getting the
soldier well.
Senator Graham. No, I understand that. I am talking about
now we are past the health care.
Dr. Chu. Once it is decided that the individual may not--
and I underscore the word, ``may not''--meet retention
standards because of physical issues, then the so-called
medical board is held, MEB. A narrative summary is dictated
that describes the case, describes the situation.
Senator Graham. How long does that normally take?
Dr. Chu. It can take a long time.
Senator Graham. I know my time is up, Mr. Chairman. I am
just trying to walk through this very quickly.
Dr. Chu. Our standard is 30 days. It is not a standard
Walter Reed was meeting, although that is understandable given
the complexity of the conditions.
It then passes to the PEB, which decides on disposition of
the case. First there is an informal board, essentially based
upon the documents, and if the soldier is agreeable to the
finding of that informal board that is the end of the process.
If, however, the soldier wishes to continue, there is a formal
board. The soldier can be represented at that board. Again, if
the soldier is not comfortable with the conclusion the soldier
may appeal, so there is appellate review.
Our standard is 40 days for that whole board process. The
Army on average meets that standard, although not typical at
Walter Reed, I should admit. The majority of the Army's cases
stay within the 40-day limit, although the distribution does
spill outside that limit.
I should emphasize that the cases that go to the PEB, if I
remember the Army's numbers correctly, about 20 percent or so
the soldier is returned to duty. So this is not a black and
white situation.
Senator Graham. And the 80 percent do not?
Dr. Chu. And 80 percent do not.
Senator Graham. They have to go to the VA and start all
over again, basically, do they not?
Dr. Chu. No. We have changed that process. If we anticipate
that you are going to be on the temporary disability retirement
list, we notify the VA right away that Smith is coming and we
start opening a case file at the VA, so that when the
individual arrives under the VA's aegis the VA is better
prepared to deal with him or her. So for the most seriously
injured this is handled differently from a more routine
situation in that regard.
As General Schoomaker just said earlier this morning or
today, we have all sorts of cases in this physical evaluation
system peace or war.
Senator Graham. Thank you.
Chairman Levin. Thank you, Senator Graham.
Senator Graham has suggested that we get the names of the
people directly in charge of the maintenance and repair at
Building 18 and that we would then talk directly to those
people. We do not need them to be stated publicly here, but for
the record if you will get us their names, Senator Graham's
staff, our committee staff, will work together to interview
those people to get the kind of picture which Senator Graham
has talked about.
If you also for the record--there will be other questions--
tell us what the role of privatization either has been or will
be in this process. There is some privatizing going on. Is that
going to create even more uncertainty, confusion, and possible
gaps? The record will be kept open until tomorrow afternoon for
additional questions for all of you.
[The information referred to follows:]
Walter Reed began an A-76 competition for Base Operations in 2000,
which reached initial decision in September 2004. The final decision
report was submitted to Congress on June 5, 2006. Proposed
congressional actions called into question whether Congress would allow
fiscal year 2007 funds to be used for performance of this contract.
These proposed congressional actions caused the medical command to
delay the contract award and start of the 90-day transition to full
contractor performance until November 2006. iAP Worldwide Services
(iAP) began full performance of the contract on February 4, 2007.
In 2004, a Residential Communities Initiative to privatize family
housing took effect. A total utility privatization effort began prior
to the Base Realignment and Closure (BRAC) 2005 announcement, but this
effort was stopped following the BRAC recommendations.
An Enhanced Use Lease (EUL) privatization contract was planned in
May 2004 for Building 40, which had been empty for over 4 years at that
point. The EUL on Building 40 did not have any personnel impact,
because the building was empty.The effective date of BRAC was estimated
to be over 6 years from the time it was announced in 2005.
The Department of the Army provided to the committee the names of
individuals who filled key leadership positions at Walter Reed Army
Medical Center with responsibility for oversight of maintenance and
repair at Building 18:
Brigade Commander
COL Ron Hamilton............................. July 2006-present
COL Rosaline Cadarelli....................... 2004-2006
COL Dorene Hurt.............................. 2002-2004
------------------------------------------------------------------------
Brigade Command Sergeant Major
CSM Monshi Ramdass........................... July 2006-March 2007
CSM George Sosa.............................. 2004-2006
CSM Santiago................................. 2002-2004
------------------------------------------------------------------------
Med Hold Company Commander
CPT Aaron Braxton II......................... 2006-2007
MAJ Carzell Middleton........................ 2004-2006
CPT Matthew Bowles........................... 2002-2004
------------------------------------------------------------------------
MED Hold First Sergeant
1SG Donald Walker............................ 2005-2007
SFC Warren-Clark............................. 2004-2005
1SG Andrew Patterson......................... 2002-2004
------------------------------------------------------------------------
Med Holdover Company Commander
CPT Arthur Jenkins........................... 2007-2007
CPT Sheri Swandal............................ 2006-2007
MAJ Carzell Middleton........................ 2004-2006
CPT Matthew Bowles........................... 2002-2004
------------------------------------------------------------------------
Med Holdover First Sergeant
1SG Angello Gordon........................... 2007-2007
1SG John Zelch............................... 2006-2007
SFC Carol Warren-Clark....................... 2004-2005
1SG Andrew Patterson......................... 2002-2004
------------------------------------------------------------------------
Student Company Commander (occupied Bldg #18 in
02-04)
CPT Tonia Ashton............................. 2002-2004
------------------------------------------------------------------------
Garrison Commanders
COL Bruce Haselden........................... July 2007-present
COL Peter Garibaldi.......................... 2005-2007
COL Jeffrey Davies........................... 2003-2005
COL Randy Treiber............................ 2001-2003
Chairman Levin. We thank you again for your testimony and
we will stand adjourned.
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator Daniel K. Akaka
command pressure
1. Senator Akaka. General Schoomaker, a report in the Army Times
states that some of the Walter Reed patients thought they were being
punished with morning inspections and being made to clean their rooms
as retribution for the Washington Post article. Moreover, patients were
told that they could only talk to media after getting permission from
the chain of command, if they were going to be interviewed on
government property. They were further told that they could go down the
street to a coffee shop, if they did not want to seek permission to
speak with the media first. From the outside world, this would seem
like the Walter Reed leadership is applying pressure on the patients to
prevent them from talking to the media.
These are very serious allegations. It's my understanding that in
General Kiley's testimony before the House National Security
Subcommittee on Monday, March 5, he stated that you had discussed the
allegations from the Army Times article with the brigade commander,
Colonel Hamilton, and that his sense was that the troops were not being
pressured to keep quiet. Is that correct?
General Schoomaker. Lieutenant General Kiley and Major General Eric
Schoomaker both discussed the allegations in the Army Times with
Colonel Hamilton. An investigation of the allegations has not been
completed. Colonel Hamilton did hold a formation during which he
reemphasized his open-door policy and encouraged soldiers to bring
their problems and concerns to the chain of command so the command
could address those issues. The chain of command exists to help
soldiers with problems such as those uncovered by the Washington Post,
and commanders should be available and approachable so soldiers can
bring problems to the command's attention without fear of retribution
or reprisal. Additionally, the Army has established the Wounded Soldier
and Family Hotline, to connect callers directly with staff in the Army
Operations Center. These issues will be briefed weekly to the Army
leadership.
2. Senator Akaka. General Schoomaker, I cannot help but notice that
there is a significant disparity between the allegations made in the
Army Times and the results of General Kiley's discussion with Colonel
Hamilton. Did you or any of your staff discuss these allegations with
the troops themselves in order to understand what is causing these
perceptions by the patients at Walter Reed?
General Schoomaker. The Army leadership has frequent personal
contact with soldiers, patients, families, and others expressing
concern about medical care and leadership concerns, among other issues.
My staff reviews those complaints, forwards them to the appropriate
Army command for investigation, and provides a response to the soldier/
patient. However, these specific allegations were not raised in my
discussions. I am confident that the Commander at Walter Reed Army
Medical Center will conduct a thorough review of the allegations and is
very sensitive to the perception created by the article. If additional
information comes out that substantiates the allegations in the
articles we will take appropriate action.
3. Senator Akaka. General Schoomaker, has it been your policy for
you or your staff to discuss complaints of this nature from patients
directly with the patients?
General Schoomaker. Yes. The Army leadership has frequent personal
contact with soldiers, patients, families, and others expressing
concern about medical care and leadership concerns, among other issues.
My staff reviews those complaints, forwards them to the appropriate
Army command for investigation, and provides a response to the soldier/
patient.
contractor oversight
4. Senator Akaka. General Schoomaker, how did the Walter Reed
command ensure that renovations conducted on Building 18 since 2001
were conducted correctly? What oversight of the contractor was
conducted?
General Schoomaker. The current contractor took over responsibility
of performing maintenance on Building 18 on February 4, 2007. All
previous renovations to Building 18 were the responsibility of the
Government. Currently all work performed by the contractor is inspected
in accordance with the Quality Assurance Surveillance Plan by the
Continuing Government Organization before it is accepted.
5. Senator Akaka. General Schoomaker, how was the contractor
selected to perform the work, and what type of contract was awarded?
General Schoomaker. The contractor was selected based on a public/
private competition in accordance with Office of Management and Budget
Circular A-76. As the private sector contractor chosen to compete
against the government bid, the private sector contractor was selected
based on a competitive formal source selection process conducted in
accordance with the Federal Acquisition Regulation, Part 15, Negotiated
Procurements. Part 15 procedures are designed to foster an impartial
and comprehensive evaluation of offerers' proposals, leading to
selection of the proposal representing the best value to the
government. The resulting contract was a 1-year cost-plus award fee
contract, with four 1-year option periods.
6. Senator Akaka. General Schoomaker, did the contractor have a
record of performance on government contracts? If so, how had they
previously performed?
General Schoomaker. The Government performed an extensive check of
past performance prior to award. The evaluation process included
checking references provided by the contractor, checking Department of
Defense (DODI-wide performance databases, and performing three on-site
evaluations at the following DOD facilities where the contractor was
performing the work: Forts Gordon and Polk, and Jacksonville Naval Air
Station. All findings were positive. The contractor had extensive
facility operations experience at several locations where the
government contract administrative staff gave the contractor overall
excellent ratings.
determining service connected disabilities
7. Senator Akaka. General Schoomaker, as chairman of the Veterans'
Affairs Committee, and as chairman of the Armed Services Committee's
Subcommittee on Readiness and Management Support, I find myself looking
at the issue of determining disability for wounded or injured
servicemembers from two different perspectives.
Please explain why it seems that DOD uses a different standard for
determining service connected disabilities than the VA. After all, we
are talking about one servicemember with one set of medical problems.
General Schoomaker. The DOD is required to use the statutory
standards found in chapter 61, U.S.C. Specifically, title 10, U.S.C.
1201 indicates servicemembers can be compensated for impairments
incurred or aggravated while entitled to basic pay. This has been
interpreted by past Comptrollers General opinions to be the ``date or
onset of a disease or occurrence of the injury.'' The VA is bound by
title 38, U.S.C. 105 and definitions found at title 38, U.S.C. 101. The
VA defines ``service-connected'' as any injury or disease incurred or
aggravated during active military service determined to have been in
line of duty.
There appears to be little difference in how the VA and DOD define
eligibility for disability compensation. However, the Services can
compensate for non-service incurred or aggravated impairments when the
servicemember has over 8 years of Active Duty (10 U.S.C. 1207a), while
the VA cannot, and the VA has statutory presumptions regarding when
certain diseases are presumed service-connected where the Services do
not. There might also be some disparities as the result of different
views of the evidence by individual reviewers.
8. Senator Akaka. General Schoomaker, to follow-up, I understand
that there is a big difference between the percentage of retired
disability that separating Operation Iraqi Freedom and Operation
Enduring Freedom servicemembers have received from DOD versus what they
later received from the VA. Please explain how this can happen. Also,
please provide statistics on the numbers of percentages of retired
disabilities awarded by DOD versus the VA. Please break out the
statistics to show Active, Guard, and Reserve Forces separately.
General Schoomaker. The VA rates every service-incurred condition,
whereas the Army rates only those conditions that make a soldier unfit
for further duty. Although there may be specific conditions the VA
rates higher than the Army, the Army does not have visibility on VA
ratings. The Veterans Disability Benefit Commission results should
provide that information.
Fewer than 15 percent of Army soldiers are separated or retired
through the Army's disability system with combat-related injuries. The
vast majority of soldiers wounded in action are returned to duty--a
testament to our great medical care. From the beginning of October 2001
to 1 April 2007, the Army placed 18.48 percent on disability
retirement; Active component 17.97 percent; U.S. Army Reserve 18.97
percent; and National Guard 20.80 percent.
budget concerns
9. Senator Akaka. Secretary Chu, Dr. Winkenwerder, and General
Schoomaker, at the hearing on Tuesday, March 6, I raised a question
regarding an article in the Boston Globe. Specifically, the Boston
Globe reported on Monday, March 5, that the Pentagon is concerned that
the cost of health care could erode our military readiness. Dr.
Winkenwerder is quoted in the article as saying, ``Without relief,
spending for health care will . . . divert critical funds needed for
warfighters, their readiness, and for critical equipment.'' I raised my
concerned about whether or not budgetary constraints are forcing our
military to take tough measures to address rising health care costs,
and whether these measures are a contributor to the systemic problems
we are finding at Walter Reed. I was assured by you all that it was
not.
I note that several times during the hearing, you all stated your
belief that budgetary issues were not the cause, or part of the cause,
for the problems at Walter Reed. However, at the same time, General
Schoomaker repeated his statement that the Army has been historically
underfunded. We heard during the hearing that the problems at Walter
Reed are systemic and have been occurring throughout the military
medical system for quite some time.
How can you be sure that the military medical community is not
feeling pressure to keep costs down, potentially contributing to the
problems at Walter Reed?
Dr. Chu and Dr. Winkenwerder. We do not believe available resources
were the cause for the facility issues at Walter Reed. In the Defense
Health Program, the Military Health System leadership (including the
medical department senior leaders) collaboratively determines the
programmed budgets. As with any appropriation, emerging requirements
during a fiscal year can exceed available funding. However, since
fiscal year 2001, we have been able to restore enough funds during our
midyear review budget adjustments to meet, and in some years exceed,
projected annual requirements in the areas of facility sustainment,
restoration, and modernization. The ultimate uses of those funds are at
the discretion of the individual Services' medical departments.
General Schoomaker. The U.S. Army Medical Command (MEDCOM), like
the entire Military Health System, is under pressure to keep costs down
but budgetary constraints were not the root cause of all the problems
that have surfaced at Walter Reed Army Medical Center. The Assistant
Secretary of Defense for Health Affairs (ASD(HA)) has funded our
immediate requirements as we have identified them. Historically, MEDCOM
begins the fiscal year with sufficient resources as identified in our
President's budget request. Any additional military health service
unprogrammed requirements or higher execution of programmed needs
compete for funding at mid-year. Routinely, by year's end, the AD(HA)
funds all reasonable requirements to support the global war on
terrorism and other high priority requirements.
10. Senator Akaka. Secretary Chu, Dr. Winkenwerder, and General
Schoomaker, what budgetary guidance have you given the Army medical
community? Have they been given everything they have requested in each
year's Army budget dating back to fiscal year 2001?
Dr. Chu and Dr. Winkenwerder. The medical community (including
Army) begins the budget process by making adjustments to the previous
year's Defense Health Program President's Budget. This base line amount
is then adjusted for programmatic changes, such as new or discontinued
missions, planned military to civilian conversions, savings assumptions
associated with cost reduction initiatives, changes in managed care
support contracts, and other similar items. This revised amount is then
inflated at standard DOD rates to establish the next year's budget
proposal.
As with all Federal agencies, proposals can exceed funding
availability within the top line budget guidance provided for the
Defense Health Program by DOD leadership. When this occurs, the
Military Health System leadership (including medical department senior
leaders) collaboratively decides what areas of the budget risk may be
taken without harming patient care.
Actual budgets, of course, are determined by Congress. In
execution, the mid-year budget review reallocates funds to areas of
need. Since fiscal year 2001, we have used this review to ensure we
meet or exceed projected requirements for medical facilities
sustainment and modernization.
General Schoomaker. The Army received adequate Defense Health Care
Program funding by year's end to accomplish our core missions. However,
we start a typical fiscal year with an inadequate budget and compete
for additional resources from the TRICARE Management Activity
throughout the year. This resource uncertainty precludes a stable
business environment and creates inefficiencies.
11. Senator Akaka. Secretary Chu, Dr. Winkenwerder, and General
Schoomaker, if these problems at Walter Reed Army Medical Center were
not a result of lack of funding, then what do you believe is the root
cause? Is it due to a lack of judgment?
Dr. Chu and Dr. Winkenwerder. The DOD Review Group and the other
reviews by the Army will assist the Department in understanding the
root causes of the issues at Walter Reed. It would be premature to
speculate before their reports are rendered.
I would respectfully point out, however, that while there are many
factors involved, it would not be fair to conclude that the A-76
competition had a destabilizing effect on Walter Reed. Although the
Army should have proceeded with its public-private competition in a
more timely manner, Army data does not show a precipitous drop in the
number of employees providing base operating support during the
competition. In fact, I understand the number of employees remained
relatively constant during the competition and up through May 2006 when
congressional actions delayed the formal award of the contract and the
transition to contract performance. In the final analysis, competitive
sourcing allowed the Army to reach a sound management decision for the
efficient and effective performance of maintenance at Walter Reed.
Under the Army's supervision, the contractor will be required to meet
the same quality standards, at a minimum, as would have been applied to
the in-house team. The contract will save resources--estimated at more
than $32 million over 5 years, which is $17 million more than would be
realized if the work were retained in-house that can be applied to
other Service needs.
General Schoomaker. I want to emphasize that the quality of medical
care provided to our soldiers at Walter Reed is absolutely superb.
There are problems with billeting and administrative processes for
medical hold and medical holdover soldiers and we are fixing those
problems. Several factors contributed to the infrastructure problems at
Walter Reed Army Medical Center. First, a prolonged A-76 competition
had the effect of attriting the garrison workforce that maintained the
infrastructure. The BRAC decision resulted in infrastructure and
capital improvement projects being down-scoped or cancelled, along with
enhanced use lease projects for Building 18 and the old Walter Reed
Army Institute of Research Building to be placed in abeyance. In
general, the aged infrastructure at Walter Reed requires intensive
maintenance. The war resulted in a significant increase in medical
hold/holdover outpatients, stretching the ability to serve and support
this population.
[Whereupon, at 1:36 p.m., the committee adjourned.]