[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
ONE YEAR AFTER WALTER REED: AN INDEPENDENT ASSESSMENT OF THE CARE,
SUPPORT, AND DISABILITY EVALUATION FOR WOUNDED SOLDIERS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY
AND FOREIGN AFFAIRS
of the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 27, 2008
__________
Serial No. 110-176
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
http://www.oversight.house.gov
----------
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
EDOLPHUS TOWNS, New York TOM DAVIS, Virginia
PAUL E. KANJORSKI, Pennsylvania DAN BURTON, Indiana
CAROLYN B. MALONEY, New York CHRISTOPHER SHAYS, Connecticut
ELIJAH E. CUMMINGS, Maryland JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts TODD RUSSELL PLATTS, Pennsylvania
WM. LACY CLAY, Missouri CHRIS CANNON, Utah
DIANE E. WATSON, California JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts MICHAEL R. TURNER, Ohio
BRIAN HIGGINS, New York DARRELL E. ISSA, California
JOHN A. YARMUTH, Kentucky KENNY MARCHANT, Texas
BRUCE L. BRALEY, Iowa LYNN A. WESTMORELAND, Georgia
ELEANOR HOLMES NORTON, District of PATRICK T. McHENRY, North Carolina
Columbia VIRGINIA FOXX, North Carolina
BETTY McCOLLUM, Minnesota BRIAN P. BILBRAY, California
JIM COOPER, Tennessee BILL SALI, Idaho
CHRIS VAN HOLLEN, Maryland JIM JORDAN, Ohio
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
------ ------
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
Lawrence Halloran, Minority Staff Director
Subcommittee on National Security and Foreign Affairs
JOHN F. TIERNEY, Massachusetts, Chairman
CAROLYN B. MALONEY, New York CHRISTOPHER SHAYS, Connecticut
STEPHEN F. LYNCH, Massachusetts DAN BURTON, Indiana
BRIAN HIGGINS, New York JOHN M. McHUGH, New York
JOHN A. YARMUTH, Kentucky TODD RUSSELL PLATTS, Pennsylvania
BRUCE L. BRALEY, Iowa JOHN J. DUNCAN, Jr., Tennessee
BETTY McCOLLUM, Minnesota MICHAEL R. TURNER, Ohio
JIM COOPER, Tennessee KENNY MARCHANT, Texas
CHRIS VAN HOLLEN, Maryland LYNN A. WESTMORELAND, Georgia
PAUL W. HODES, New Hampshire PATRICK T. McHENRY, North Carolina
PETER WELCH, Vermont VIRGINIA FOXX, North Carolina
------ ------
Dave Turk, Staff Director
C O N T E N T S
----------
Page
Hearing held on February 27, 2008................................ 1
Statement of:
Pendleton, John, Acting Director, Health Care, U.S.
Government Accountability Office, accompanied by Daniel
Bertoni, Director, Education, Workforce, and Income
Security, U.S. Government Accountability Office; Lieutenant
General Eric Schoomaker, Surgeon General/Commander U.S.
Army Medical Command, accompanied by Brigadier General
Reuben Jones, Adjutant General of the Army; Michael L.
Dominguez, Principal Deputy Under Secretary of Defense,
Personnel and Readiness, U.S. Department of Defense; and
Patrick W. Dunne, Rear Admiral, retired, Assistant
Secretary for Policy and Planning, U.S. Department of
Veterans Affairs........................................... 15
Dominguez, Michael L., and Patrick W. Dunne.............. 57
Pendleton, John, and Daniel Bertoni...................... 15
Schoomaker, Lieutenant General Eric...................... 47
Letters, statements, etc., submitted for the record by:
Dominguez, Michael L., Principal Deputy Under Secretary of
Defense, Personnel and Readiness, U.S. Department of
Defense, and Patrick W. Dunne, Rear Admiral, retired,
Assistant Secretary for Policy and Planning, U.S.
Department of Veterans Affairs, joint prepared statement of 60
Pendleton, John, Acting Director, Health Care, U.S.
Government Accountability Office, and Daniel Bertoni,
Director, Education, Workforce, and Income Security, U.S.
Government Accountability Office, joint prepared statement
of......................................................... 19
Schoomaker, Lieutenant General Eric, Surgeon General/
Commander U.S. Army Medical Command, , prepared statement
of......................................................... 50
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut, prepared statement of............ 11
Tierney, Hon. John F., a Representative in Congress from the
State of Massachusetts, prepared statement of.............. 5
ONE YEAR AFTER WALTER REED: AN INDEPENDENT ASSESSMENT OF THE CARE,
SUPPORT, AND DISABILITY EVALUATION FOR WOUNDED SOLDIERS
----------
WEDNESDAY, FEBRUARY 27, 2008
House of Representatives,
Subcommittee on National Security and Foreign
Affairs,
Committee on Oversight and Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:05 p.m. in
room 2157, Rayburn House Office Building, Hon. John F. Tierney
(chairman of the subcommittee) presiding.
Present: Representatives Tierney, Lynch, McCollum, Hodes,
Shays, Platts, and McHenry.
Staff present: Dave Turk, staff director; Andrew Su,
professional staff member; Davis Hake, clerk; Andy Wright,
counsel; Grace Washbourne and Janice Spector, minority senior
professional staff members; Nick Palarino, minority senior
investigator and policy advisor; Benjamin Chance, minority
clerk; and Mark Lavin, minority Army fellow.
Mr. Tierney. A quorum being present, the Subcommittee on
National Security and Foreign Affairs will commence.
This hearing is entitled, ``One Year After Walter Reed, An
Independent Assessment of the Care, Support, and Disability
Evaluation for Wounded Soldiers,'' because we always think of
such great titles for our hearings.
I ask unanimous consent that only the chairman and ranking
member of the subcommittee be allowed to make opening
statements. Without objection, that is so ordered.
And I also ask unanimous consent that the hearing record be
kept open for 5 business days so that all members of the
subcommittee be allowed to submit a written statement for the
record. Without objection, so ordered.
I want to thank all of you for being here today. About a
year ago, as we all recall, we saw that shocking expose in the
Washington Post that revealed appalling conditions and
unacceptable treatment of soldiers and their families at Walter
Reed, located just a few miles from here in Washington, DC.
The stories about what those injured heroes endured after
coming home from Iraq and Afghanistan obviously ignited a
public outcry and brought to light hundreds of revelations of
similar frustrations and disrespect faced by our injured
soldiers and their families.
This subcommittee chose to hold the very first oversight
hearing that it had this session on that topic, and we chose to
do so on the grounds of Walter Reed, itself, in full view of
the soldiers recovering there.
During the course of the year, we have had two other
subcommittee hearings, one full committee hearing, and
countless briefings and interviews, and during that time we
have learned about a maze of complex bureaucracies and hurdles
that face patients and their families.
I want to thank all the people who are here today, as well
as others, for assisting us with those hearings and briefings
and the interviews that we have had. It has been enormously
helpful, and I know it is sometimes difficult or burdensome on
you, but the only way we can work together on this is if we
have that sharing of information, and we appreciate your
openness on that, as well as your understanding that the spirit
of this entire oversight is a jointly shared goal that we have
of improving how this system works.
We have learned about the enormous challenges the soldiers
face with traumatic brain injury and post-traumatic stress
disorder. We have learned about an archaic, adversarial, and
burdensome disability evaluation process. At least that is how
many of the people going through it expressed their
understanding to us.
Since last February we have also had a host of
congressional, White House, Army, Defense Department, Veterans
Affairs, and independent commissions and investigations urging
a variety of reforms. If past is prologue, none of the work by
these groups will mean anything unless there is the political
will and the resolve to fundamentally improve the system and to
make difficult choices that are necessary to actually implement
some of the most wide-ranging recommendations.
Let me be the first to say that much has been done over the
past year to improve the military health care system. I think
the Government Accountability Office report is going to reflect
that, as well, and the public should know that there was great
energy and intensity put on this by the Army, in particular.
The Army has increased staff, as one example, by nearly 75
percent. I think that is commendable.
But, unfortunately, I think we all recognize it is equally
clear that we have a ways to go. So today we are going to hear
from the top directors of the Government Accountability Office
on their independent assessment of where things currently stand
with respect to providing those warriors and their families the
care and support they have earned and that they deserve.
The spirit of the GAO's extensive and independent analysis,
as well as this oversight more generally, is best captured, I
hope, by General Schoomaker's testimony. I am going to quote
out of that, General, if you will permit me. You note, ``We
know that there are obstacles and bureaucracies that still must
be overcome. We continue to face challenges that require blunt
honesty, continuous self-assessment, [and] humility. . . .''
Certainly humility is one thing we have all learned from this
process, but we are grateful that you have been gracious in
continuing the self-assessment and the bluntness.
What we are trying to do here today is provide that
independent assessment and robust critique in the spirit of
fairness and sustained and constructive oversight. I am a firm
believer that sustained oversight can be a powerful tool to
ensure that the needed reforms are actually implemented this
time around and to meet the long-term needs of growing yet
diverse populations of wounded soldiers who are likely going to
be in the VA system for a good part of their remaining lives.
In a few minutes the Government Accountability Office will
fully lay out what they found, but I want to take just a few
minutes to highlight some things.
First, according to the GAO, achieving adequate staffing
levels continues to pose difficulties, particularly for the so-
called PEBLOs, whose job it is to help soldiers navigate
through the confusing disability evaluation process.
Moreover, borrowing from other units to fill key positions
and utilizing JAG officers rotating in and out from the Reserve
component strike me as only temporary fixes. Our wounded
soldiers need long-term, permanent solutions, and if any link
in the support chain is weak, then the whole model cannot
succeed. Once again, it is the wounded soldiers and their
families who will suffer.
Second, if there is ever a time when we are actually going
to be able to fundamentally fix the overly complicated and
adversarial disability evaluation system, it seems to be now.
There have been complaints about the disability evaluation
system for decades, but over that period of time we have not
done enough. If we don't take advantage of this unique
opportunity now to fundamentally fix the system, I am concerned
that 5 years from now we will still be wringing our hands and
saying we had an opportunity to act and did not.
That is why the GAO's testimony about their concerns with
respect to the joint Defense Department/Veterans Administration
pilot program is so important. We need to make sure this pilot
has been created, is being rolled out, and is being evaluated
in absolutely the best manner.
But the GAO today will share concerns, among others, about
the lack of a control group and transparent criteria to assess
the success of the pilot and to evaluate whether to expand it
to other facilities.
We will hear all these concerns expressed in greater detail
in a few moments, and I hope our executive branch
decisionmakers present today will take them seriously and view
them as constructive. If the past is any indication, I am sure
you will.
Our goals are the same: we want to take care of our wounded
soldiers. We want to give them and their families the utmost
respect. We want to ensure that these heroes have the best
quality of life possible for the rest of their lives.
Just because the 1-year anniversary of Walter Reed stories
is passing, it does not mean that we should take our eye off
the ball. This subcommittee, for one, certainly will hold
additional hearings as long as is necessary to continue to
monitor this administrations' progress and subsequent
administration's progress and continue to ask all the questions
that need to be asked.
[The prepared statement of Hon. John F. Tierney follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. I yield now to the ranking member of the
subcommittee, Congressman Shays, for his opening remarks.
Mr. Shays. Thank you, Mr. Chairman.
Mr. Chairman, if I could, I would like to submit for the
record the statement of the ranking Republican member of the
full committee, Tom Davis.
Mr. Tierney. Without objection, so ordered.
Mr. Shays. Thank you, Mr. Tierney, for your unwavering
commitment to this subcommittee's ongoing bipartisan inquiry
into the administration of medical care for our injured men and
women returning from war. I commend you for your continued
commitment to holding hearings and keeping the light of
oversight on the Federal departments and responsibility for the
care of our military wounded.
Hearings have taught us well the many challenges that face
our wounded warriors under a system that was not planned to
give them the support, service, and treatment they need and
have earned, so here we are again today with the Departments of
Defense and Veterans Affairs witnesses to take stock of what
has been accomplished to date and what still remains to be
done.
Secretary Dominguez, Secretary Dunne, we look forward to
hearing what the joint Department of Defense/Department of
Veterans Affairs Senior Oversight Committee has accomplished
since our hearing last September. We look forward to learning
what you have done to carry out the recommendations contained
in the President's Commission on Care for America's Returning
Wounded Warriors, commonly known as the Dole-Shalala
Commission.
General Schoomaker, congratulations on your promotion to
Surgeon General of the Army. On TV today I still said you were
in charge of Walter Reed Hospital, but, at any rate,
congratulations on being Surgeon General. Your help with
individual soldiers that have come to this committee for
assistance has made a difference. We hope you are able to carry
this dedication to the individual when you implement the
policies of the Army medical action plan throughout the Army
bureaucracy.
The true test of what we are trying to accomplish with
sweeping process changes, new dedicated personnel and training,
and new forms of evaluation and treatment is to better serve
the individual wounded soldier. If we do not keep the
individual in mind, I feel we will be here again still looking
for solutions that work.
A year ago, Walter Reed Army Medical Center became a symbol
of dysfunction. Today we look for a detailed accounting of what
has been done not only to correct the problems there, but at
all medical treatment facilities. Are the new standards of care
that have been put into place working? Has service to our
wounded and their families improved in their eyes? We look for
the Department of Army and the Department of Defense to tell us
what system of oversight they have in place to monitor whether
or not every facility and every soldier is able to partake of
the new programs and services.
Along with Mr. Davis, Mr. Tierney, and Mr. Waxman, I still
hold deep reservations about whether or not the Department of
Army, the Department of Defense, and the Department of Veterans
Affairs initiatives and programs are mindful of the unique
needs of the Reserve components. Two weeks ago, Veterans
Affairs Secretary Peake told Congress that his Department had
not done enough for the National Guard and Reserve in the area
of mental health treatment. We look forward to hearing what the
Department is going to do to change that.
Although the rate of suicide among returning troops is no
higher than other groups of that age, it is shocking to hear
that the rate of suicide among returning Guard and Reserves is
at a higher percentage than active duty soldiers, which make up
a large number of those deployed.
As for the Department of Defense and the Department of
Army, I know congressional appropriations are being used to
fund new personnel at medical treatment facilities, but,
unfortunately, there is a lack of inclusion in funding for
mental health directors and transition assistance advisors that
serve the members of the National Guard when they return home.
Now pre and 30, 60, and 90-day post-deployment mental
health evaluations for the National Guard are only of value if
there are trained and competent personnel available in their
State administrative headquarters to help secure treatment and
other benefits needed for recovery and transition into
community and home life.
Today we will hear recruiting and retaining health care
personnel is problematic, but I am also concerned about whether
all caregivers and administrators are receiving comprehensive
training. The process, both old and new, is still vastly
convoluted and lacks the connectivity that supports real
patient service oriented change.
We will also hear about an update on a new disability
evaluation system pilot. Can we completely restructure the
disability and compensation systems of the Army, Navy, Air
Force, and Marine Corps, the Department of Defense, and the
Department of Veterans Affairs to better serve our Nation's
military heroes and veterans? And to what effect? Is joint
medical evaluation system streamlining, or is it just creating
a bigger bureaucracy between two departments? And which
department will be responsible if something goes wrong? How
successful have DOD and VA been in sharing essential data?
The Government Accountability Office has reported that
these departments have been working for almost 10 years to
facilitate the exchange of information without success. What
has been done in the last year that has been different from
past attempts? As long as paper is still part of the process,
errors and time lags will cause problems for the wounded and
their families.
Of all the Dole-Shalala Commission recommendations, this
integration will require a greater deal of cooperation and
continuous dedication of resources.
We look forward to hearing from our Government
Accountability Office witnesses on current Federal Governmental
efforts to address how our wounded warriors are treated. The
value of their independent assessment cannot be over-stated.
The President wants the Dole-Shalala recommendations
implemented within a year. I know this subcommittee is
committed to ensuring the Federal Government properly cares for
our wounded veterans and that this care stays a priority until
every person treated can say, I answered my country's call, and
when I was wounded my country answered my call for help.
Thank you, Mr. Chairman.
[The prepared statement of Hon. Christopher Shays follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Thank you, Mr. Shays.
Now the subcommittee will receive testimony from the
witnesses that are before us today.
I want to begin by introducing our witnesses. First, we
have two top directors from the Government Accountability
Office, Mr. John Pendleton, who is the Acting Director of the
Health Care Team, and Mr. Daniel Bertoni, who is the Director
of the Education, Workforce, and Income Security Team.
The subcommittee thanks you and everyone working on your
staffs for the enormous lift that was done to get this work. We
appreciate all the research and the conscientious work that
went into it. It took a considerable amount of talent and
travel and conversation with families and with injured
soldiers, as well, so we really, truly appreciate that.
We also welcome key officials from the Army, Defense
Department, and Department of Veterans Affairs. Lieutenant
General Eric V. Schoomaker, M.D., the Army Surgeon General and
Commander of the U.S. Army Medical Command. General Schoomaker
is accompanied today by Brigadier General Reuben Jones, the
Adjutant General of the Army.
Michael Dominguez is the Principal Deputy Under Secretary
of Defense for Personnel and Readiness for the U.S. Department
of Defense.
And Rear Admiral Patrick Dunne, Retired, is the Assistant
Secretary for Policy and Planning at the U.S. Department of
Veterans Affairs.
Your work and dedication on behalf of all of our men and
women in uniform is greatly appreciated. I want to particularly
thank General Schoomaker and Admiral Dunne for changing your
plans to accommodate our hearing schedule today. I know it is
inconvenient, but we greatly appreciate it.
It is the policy of the subcommittee to swear in all of our
witnesses before they testify, so I ask you to rise please and
raise your right hands.
[Witnesses sworn.]
Mr. Tierney. The record will please reflect that all of the
witnesses answered in the affirmative.
I can tell you that all of your written statements in their
entirety will be placed into the hearing record, so you needn't
feel compelled to repeat them word-for-word. We do offer 5
minutes for our witnesses oral statements.
Mr. Pendleton and Mr. Bertoni, I know that you are going to
be making a joint statement, so you may want to take some
license with that and go a little bit over. And I understand
there was some talk about a joint statement from some of the
other witnesses, but now people are going to take their
individual time, and we are pleased with that. We want to hear
everything that you have to say.
Mr. Pendleton, why don't we start with you and Mr. Bertoni,
please.
STATEMENTS OF JOHN PENDLETON, ACTING DIRECTOR, HEALTH CARE,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE, ACCOMPANIED BY DANIEL
BERTONI, DIRECTOR, EDUCATION, WORKFORCE, AND INCOME SECURITY,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; LIEUTENANT GENERAL ERIC
SCHOOMAKER, SURGEON GENERAL/COMMANDER U.S. ARMY MEDICAL
COMMAND, ACCOMPANIED BY BRIGADIER GENERAL REUBEN JONES,
ADJUTANT GENERAL OF THE ARMY; MICHAEL L. DOMINGUEZ, PRINCIPAL
DEPUTY UNDER SECRETARY OF DEFENSE, PERSONNEL AND READINESS,
U.S. DEPARTMENT OF DEFENSE; AND PATRICK W. DUNNE, REAR ADMIRAL,
RETIRED, ASSISTANT SECRETARY FOR POLICY AND PLANNING, U.S.
DEPARTMENT OF VETERANS AFFAIRS
JOINT STATEMENT OF JOHN PENDLETON AND DANIEL BERTONI
Mr. Pendleton. Mr. Chairman, Mr. Shays, and members of the
subcommittee, thank you for inviting us to testify before you
today as you continue your oversight of efforts to improve care
for service members who are hurt or fall ill while in service
to our country. Our work has continued since our testimony this
past September. That work is still ongoing, but we are pleased
to provide you with some interim observations today.
Our oral statement will be in two parts. First, I will take
a moment to update you on the Army's efforts to improve warrior
care. Then my colleague, Dan Bertoni, will describe our ongoing
assessment of efforts to improve the disability evaluation
processes at DOD and VA.
We have submitted a combined written statement for the
record.
First, an update on the Army. Mr. Chairman, I am pleased to
report to you that the Army has made progress in the 5-months
since our September 2007 testimony. Challenges remain, but the
trends are in the right direction.
As the centerpiece of its medical action plan, the Army has
established warrior transition units at more than 30 locations
to help service members and their families through what is
often an extraordinarily difficult time. When we testified in
September, the Army had filled roughly half of the key
positions authorized for those warrior transition units. The
Army still needed many highly sought-after medical personnel
like doctors and nurses, as well as enlisted leaders from an
Army already stretched thin by operations in Iraq and
Afghanistan.
Early this year the Army declared that its warrior
transition units had reached full operational capability. This
meant that senior commanders reported that the units had
sufficient personnel and other resources to perform the key
tasks assigned to them.
The Army's assessment is encouraging, but a closer look
reveals some challenges.
First, about a third of the locations still have staff
shortfalls in the warrior transition units. Most are minor,
only one or two staff needed at a location. But some are more
significant.
Also, to meet their growing needs in the short term, the
Army is still relying on borrowed staff to fill the warrior
transition units. About one in five staff are temporarily
borrowed from other units today, and this proportion has
changed little actually since we testified in September.
Another challenge is the 2,500 injured or ill soldiers who
are eligible for the warrior transition units but have not yet
been assigned to one. This is a complicated and fluid calculus
for the Army. Because these personnel are outside the warrior
transition unit, they are not considered when the Army
identifies its staffing shortfalls. Including them would
magnify the staffing challenge, because at some locations these
personnel represent 40 percent or more of the total warriors in
transition there. This group is at risk of getting lost in the
shuffle as they attempt to navigate a still confusing
disability process, which Dan will discuss in a moment.
Finally, Mr. Chairman, I had hoped to be able to report to
you about outcomes; for example, whether all of these efforts
have translated into more satisfied soldiers and families.
Until the Army obtains more reliable information, however, it
will be difficult to adequately gauge the overall progress of
their efforts.
Mr. Chairman, that concludes my statement. Thank you. I
will turn it over to Dan.
Mr. Tierney. Thank you, Mr. Pendleton.
Mr. Bertoni.
Mr. Bertoni. Mr. Chairman, members of the subcommittee,
good afternoon. I am pleased to be here to discuss efforts to
meet the critical needs of America's wounded warriors.
Thousands of service members have been wounded in Iraq and
Afghanistan, and many are now navigating the complex and
confusing disability process. In September we testified that
overhauling the disability evaluation system was key to the
reintegration and productive capacity of service members with
disabilities. My testimony today draws on our ongoing work for
this subcommittee and focuses on two key areas: current efforts
to improve the process, and challenges to further progress.
In summary, DOD's and VA's disability programs have been
plagued by longstanding problems. In following the unfortunate
events at Walter Reed, the Army developed several near-term
initiatives to increase supports for those in the disability
system. To address underlying systemic issues, DOD and VA
currently are piloting a joint disability evaluation system
with an emphasis on re-engineering the process for the longer
term.
To alleviate current pressures, the Army has established an
average case load target of 30 service members per Physical
Evaluation Board Liaison [PEBLO], and increased hiring by 22
percent. The Army has met its goal at 24 of 35 treatment
facilities. The Army is also increasing the number of attorneys
and paralegals to meet increasing service member demands, and
has established and mostly met its goal of one Medical
Evaluation Board physician for every 200 service members in the
system.
The Army also reports increasing education and outreach,
revising the informational guidance and handbooks, and
developing a Web-based tool for soldiers to track their claims.
Despite these many efforts, real challenges remain,
especially in regard to hiring staff to help service members
navigate the disability process. While average PEBLO caseloads
have improved, the Army has not met its goal of 30 service
members per liaison. Eleven of thirty-five treatment facilities
continue to face staffing shortages, and over half of all
service members currently in the evaluation process are located
at these same facilities.
The Army has also noted that the current number of legal
personnel are insufficient to provide support during both the
physical evaluation and Medical Evaluation Boards.
While the Army plans to hire additional legal staff,
current Government hiring policies and Army rotation policies
could impede its ability to maintain staff within in-depth
knowledge of complex disability issues.
Finally, despite having mostly met its goal for Medical
Evaluation Board physicians, some physicians are having
difficulty managing their workloads due to the increasing
volume of cases with multiple injuries and complex conditions
such as TBI and PTSD.
Regarding the pilot, DOD and VA conducted a tabletop
exercise using 33 previously decided service member cases to
evaluate four potential options. In November 2007 the pilot,
which includes a comprehensive medical exam and a single VA
disability rating, was rolled out in three Washington area
locations. DOD and VA selection approach followed a
predetermined selection methodology, captured a broad range of
metrics, and involved a number of expert stakeholders. While
the exercise yielded sufficient information to select the pilot
option, it required some tradeoffs in data collection and
analysis that could have implications down the road.
For example, the small, judgmental sample of cases selected
was not statistically representative of each military service's
workloads, and a larger, more representative sample could have
yielded different outcomes.
Further, a key selection variable, expected service member
satisfaction, was based on input from pilot officials rather
than input from service members, themselves.
While the pilot is expected to last 1 year, officials may
expand it to more sites outside the Washington area prior to
that time. However, very few cases will have gone through the
entire process at this and other critical junctures, and the
agencies will have limited data to guide their interim
decisions.
Further, current evaluation plans lack key elements such as
the criteria for determining how much improvement and
timeliness or consistency would justify full expansion, a
method for measuring the policy impact compared to the current
process, and an approach for measuring service member
satisfaction. All of these elements are critical to identifying
problem areas or issues that could limit the effectiveness of
any new system.
Going forward, it is important that focused attention be
placed on the challenges discussed today. For the Army,
sustained attention to addressing key staffing and workload
imbalances, and continued efforts to enhance the efficiency and
transparency of the process is essential. For the pilot, more
transparent articulation of the data that will be available at
key junctures, and the criteria that will guide decisions on
future expansion or modification is needed. Absent such an
approach, the performance and credibility of any redesigned
system could be in jeopardy.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions that you may have.
Thank you.
[The prepared joint statement of Mr. Pendleton and Mr.
Bertoni follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Thank you, Mr. Bertoni.
General Schoomaker, would you care to make some remarks?
General Schoomaker. Yes, sir.
STATEMENT OF LIEUTENANT GENERAL ERIC SCHOOMAKER
General Schoomaker. Chairman Tierney, Congressman Shays,
distinguished members of the subcommittee, thank you for
inviting me to discuss really a total transformation that the
Army has undergone in the way that we care for soldiers and
families. We are truly committed to getting this right and to
providing a level of care and support to our warriors and
families that is equal to the quality of their service.
Accompanying me this afternoon is my colleague, the Army
Adjutant General, Brigadier General Reuben Jones. As the
Adjutant General, General Jones has oversight of the Army's
Physical Evaluation Boards, the PEBs, and is actively involved
with improvements in the disability evaluation system. He is
here to answer any questions that you may have concerning the
Army's role in streamlining the disability evaluation process.
I appreciate the continuing efforts of the committee and of
the Government Accountability Office to help our wounded, ill,
and injured service members. Your attention to their problems
and your insights and observations play an important role in
our continuing progress.
Mr. Bertoni and Mr. Pendleton work collaboratively and
openly with our Army medical action planners to produce a good,
independent assessment of our progress to date. Before we delve
into the details of where we are today, I would like to
emphasize the unprecedented nature of what the Army has
accomplished over the last year.
We now have over 2,400 soldier leaders assigned as cadre to
35 warrior transition units that did not exist last February.
These are 2,400 small unit leaders in jobs where last year at
this time we had fewer than 400 cadre doing the work for almost
an equivalent population of patients.
The most significant feature of these warrior transition
units is a triad that consists of a primary care physician, a
nurse case manager, and the squad leader working together to
attend to the needs of each individual and their family.
In less than 1 year the Army has funded, staffed, and
written doctrine to establish these new organizations. This is
a truly amazing accomplishment. It is a true transformation in
warrior care.
Another improvement in the care of soldiers is that a year
ago our wounded, ill, and injured believed that their
complaints were falling on deaf ears within the Army.
Now, with the assistance of this subcommittee--and I know,
sir, that this was a specific interest that this subcommittee
had--we have established a MEDCOM-wide ombudsman program with
ombudsmen at installations across the Army, and we continue to
hire more. In fact, my Command Sergeant Major, Althea Dixon, is
not with me today only because she is addressing the newest
crop of ombudsmen that have been hired and are being trained in
San Antonio, Texas, many of whom are former NCOs who served in
uniform and are experienced in the medical system.
Every one of our treatment facilities knows who their
ombudsman is and how to find him or her. Many are retired NCOs,
as I mentioned, or officers that work outside the local chain
of command, but they have direct access to the hospital
commander, to the garrison commander, the senior mission
commander on our installations, and they know how to get
problems fixed.
We have also established a 1-800 wounded soldier and family
hotline. I believe your packets contain the card that we hand
out generously. In fact, in meeting with the VA recently we
showed them what we were doing, and they were so impressed that
they have started a similar hotline of their own.
This offers wounded, ill, and injured soldiers and families
a way to share concerns on any aspect of their care or
administrative support, and I emphasize that it can be any
aspect, not just inpatient medical care or outpatient care, but
housing, pay, accompaniment of the family member, whatever it
might be. We respond to these inquiries within 24 hours. So far
we have received in excess of 7,000 calls.
As you may well know, despite these successes, there is
much progress to be made. We are addressing concerns and
providing treatment for those soldiers with concussive injuries
and those with symptoms of post-traumatic stress.
We understand that these are great concerns to the American
public, as well as for our soldiers and their families. We
recognize the importance of prevention, timely diagnosis and
treatment of concussive injuries and post-traumatic stress, and
we are aggressively executing programs designed to educate, to
prevent, to screen, and to provide care for deployment-related
stress and injuries.
Congress jump-started us last year with supplemental
funding for post-traumatic stress and traumatic brain injury
research and care, and we are extremely grateful. We are
putting them to good use.
We must continue to look at the physical disability
evaluation system and ways to make it less antagonistic, more
understandable and equitable for soldiers and his or her
family, and to make it more user friendly. I applaud the
efforts to pursue changes in the disability evaluation system
as aggressively as possible.
The Army's unwavering commitment and a key element of our
warrior ethos is never to leave a soldier behind on the
battlefield or lost in the bureaucracy. We are doing a better
job of honoring that commitment today than we were at this date
last year.
In February 2009 I want to report back to you with GAO at
my side that we have achieved a similar level of progress as we
have over the last year, because, sir, I strongly agree with
your commitment to sustained oversight and continuous
improvement.
I am proud of Army medicine's efforts over the past 232
years, and especially over the last 12 months, to care for the
soldier and his or her family. I am convinced that, in
coordination with the Department of Defense, the Department of
Veterans Affairs, the Congress, we have turned the corner on
this issue.
Thank you for holding this hearing. Thank you for your
continued support for our warriors for whom we are truly
honored to serve.
Thank you.
[The prepared statement of General Schoomaker follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Thank you, General.
General Jones, do you care to make any remarks?
General Jones. No, sir.
Mr. Tierney. OK. Mr. Dominguez, if you would.
JOINT STATEMENT OF MICHAEL L. DOMINGUEZ AND PATRICK W. DUNNE
Mr. Dominguez. Thank you, Mr. Chairman, Congressman Shays.
I want to start off first by offering my condolences to you
on the loss of your colleague, Congressman Tom Lantos. I was a
graduate student in California when he was first elected to
Congress, and I had the privilege of having Tom Lantos as my
Congressman for a short while.
I am privileged to be here with Admiral Dunne, the
Assistant Secretary from Veterans Affairs, and our presence
together and our joint testimony symbolizes the close working
relationship that is now, I think, the single greatest
achievement of the work over the last year at the major policy
level within the Department. Our two departments are now welded
together in a goal of delivering seamless support to service
members as they transition into veteran status.
I want to acknowledge General Schoomaker's presence here.
While we have done a lot at the national policy level, the
policy coordination level, the military services, symbolized
here by these two gentlemen to my right, have really changed
the situation on the ground through their aggressive work and
enlightened leadership.
I want to recognize our GAO colleagues. We have endeavored
in our efforts from the first to be open. We have recognized we
needed help in understanding the problem and in trying to
devise solutions to that. That is where all those boards and
commissions came from. We have received that help. We are
thankful for it. We have acted on it. And extra eyes on this
problem continue to be needed, so GAO's involvement and
continued involvement is welcome.
Admiral Dunne and I have addressed in our written testimony
and we will cover today lots of specific initiatives that we
put in place since last year, but allow me please in these
comments to put those details in the context of some broad,
sweeping changes.
The first big change that I would like to call your
attention to is this integration of DOD and VA into a single
collaborative team of problem-solvers committed to delivering a
seamless continuum of care. It wasn't that way when we started,
but it is that way now, and I think that extends all the way
down through our organizations and out into the field.
The second major change I would like to highlight for you
is this fundamental shift in our approach to care and
management and support of armed forces member in long-term
outpatient status. General Schoomaker made reference to that.
That is a huge change. Outpatients are no longer a special
project of a first sergeant, but now they are organized into
units, into these warrior transition units, and their needs are
addressed comprehensively and holistically. That is a big
change in how we approach a problem.
Third, there has been a huge shift in our approach to
psychological health. There has been a recognition over this
last year that psychological fitness is as important to a
warrior's mission as is physical fitness, and staying
psychologically fit is part of the warrior's job, and it is
part of the commander's job to ensure the warrior remains fit.
That premise is changing a lot of what we are doing and
changing a lot of our approach to at mental health care in the
Department of Defense, and that is a huge difference now.
The fourth big change is recognizing the complexity of our
processes and the sense of powerlessness people in the system
can feel. We have placed a major emphasis on robust case
management, customer care, and communication, and a robust,
involved, ever-present military organization and chain of
command is an essential piece of that. That, also, is a huge
change.
So these are big changes that now have us moving in the
right direction. We have only just started work, turning our
institution in that direction, and much remains to be done.
The last big change we need, however, rests with the
Congress, and that is achieving the clarity and simplicity in
transition from service member to veteran requires a
legislative rationalization of the roles of the two
departments, DOD and DVA. I urge you to act on the President's
proposal implementing the recommendations of the Dole-Shalala
Commission in this regard.
Thank you. I look forward to your questions, sir.
Mr. Tierney. Thank you very much.
Admiral, do you care to make some remarks, as well, please?
Admiral Dunne. Mr. Chairman, members of the committee, I
appreciate this opportunity to appear before you today. The
Department of Veterans Affairs and Department of Defense
continue to make excellent progress toward ensuring today's
active duty service members and veterans receive the benefits,
care, and services they have earned. I would also like to take
this opportunity to thank the committee for its support for
these efforts.
I am especially pleased to be here today with Secretary
Dominguez. Over the past year, Mike and I have had a unique
opportunity to focus the attention of both departments on the
needs of those we serve. We concentrated attention on the need
for a seamless transition. I want to publicly thank him for his
leadership. The partnership between the two organizations and
the lines of communication are stronger than ever, as evidenced
by the establishment and success of the Senior Oversight
Committee.
The Senior Oversight Committee has been in operation since
May of last year. I note, however, that substantial high-level
cooperative efforts in the areas of health care and benefits
delivery predate the SOC. VA and DOD participated in the Joint
Executive Council since February 2002. The JEC was designed to
remove barriers and challenges faced by veterans and to support
mutually beneficial opportunities. The JEC succeeded in the
areas of benefits, health care, and joint ventures. The JEC was
instrumental in launching the benefits delivery and discharge
project, locating VBA counselors at military treatment
facilities and establishing the traumatic service members group
life insurance program. Through January 2008, TSGLI has paid
out more than 4,100 claims to the tune of more than $254
million.
The JEC was also successful in employing the joint
incentive fund. The fund supported 66 projects worth $160
million. The JEC championed the VA/Navy collaboration on a
North Chicago Joint Federal Health Care Facility, led the way
in data sharing initiatives, and helped extend dental care
benefits for the National Guard and Reserve members. In short,
the JEC provided the starting point for the SOC. The SOC
established the eight lines of action, which generally aligned
with the issues needing resolution.
The outstanding VA and DOD staff reviewed the
recommendations presented by the numerous reports,
investigations, and commissions to come up with a comprehensive
plan of action, and the SOC is overseeing the efforts to
implement that plan.
For example, the case management decision resulted in VA
standing up in office, hiring the first eight Federal recovery
coordinators, and assigning them to military treatment
facilities. The disability evaluation system pilot project is
underway and using a single medical exam from which DOD can
make fit/unfit to serve decisions, and VA may decide a claim
for disability benefits if the individual is found unfit.
But we realize we have more work to do. Data sharing, for
example, has presented challenges as we seek to transfer
patient data between our two systems. We are already
implementing the requirements for the National Defense
Authorization Act passed last session, but the issue of a new
disability benefits system as proposed by the President remains
an open item, and so VA contracted for two studies which will
prepare us to move forward in this area. The studies are due
for completion in August, and they will deal with transition
payments, compensation, and quality of life issues as
recommended by the Dole-Shalala Commission.
The issue of rehabilitation medicine continues to evolve as
we treat and evaluate the patients returning from the
battlefield, entering acute care treatment, and initial
rehabilitation in military treatment facilities before they
transition to VA poly trauma centers and medical centers.
Be assured the SOC is prepared to come together whenever
necessary to make decisions and eliminate the obstacles faced
by the dedicated VA and DOD staff which oversee the efforts on
each line of action. VA continues its commitment to address any
issues regarding cooperation between the two departments, and
our efforts continue to enjoy support at the highest levels.
This concludes my statement, and I look forward to your
questions.
[The prepared joint statement of Admiral Dominguez and
Admiral Dunne follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Thank you, Admiral.
Ms. McCollum, you are recognized for 5 minutes to begin the
questioning.
Ms. McCollum. Thank you, Mr. Chair. I have two questions. I
think one is quick, so I will go with that.
Are you aware if we are beginning to test soldiers prior to
being deployed for mental cognizant capability? In other words,
I have been told that there are tests available where you can
measure someone ahead of time and then find out later on if
they have received traumatic brain injury. Are we doing that?
Mr. Dominguez. Yes, Congresswoman, we have started that
program in the Department of Defense to apply a cognitive
baselining test to people deploying into the combat theater. It
is not comprehensive yet. We are not doing it to everybody, but
we are starting in both sessions and trying to get into the
deployment cycle. I think the 101st Airborne Division, if I am
right----
Ms. McCollum. If you could get my office and the committee
some more information on that, I would like it. And when you
see everyone being deployed having that available, that would
be great. Thank you.
Mr. Dominguez. Happy to.
Ms. McCollum. I would like to move on to another area. In
the report--and thank you, gentlemen, for your report-on page 5
under the disability evaluation system, item No. 1, your words,
``GAO continues to have concerns in the hiring, training
shortfalls,'' and goes on about lack of full utilization of
judge advocates. Later on in the report you are talking about
how the VA and the military still haven't come together on
coming up with a seamless disability evaluation process, so I
am concerned about that and I would like to hear from you in a
minute what they need to do to correct this error, and if there
is money in the President's budget to do whatever they need to
do with computer software or hiring people or whatever is going
to be required.
The reason why I am concerned, General Schoomaker, is a
couple of weeks ago, listening to National Public Radio, as I
do every morning, there was a story of Fort Drum in New York,
where the soldiers had been allegedly told by the VA that the
VA could not advise them through disability evaluation systems.
Now you have characterized that as a miscommunication now, but
the soldiers really felt that they were getting the short end
of the stick here. It is well established, VA ratings are often
higher than the ones that are given by the military service, as
was pointed out in testimony that we had here several months
ago.
But I want to walk through the facts, particularly in light
of GAO's testimony today that 20 percent of the eligible
service members at Fort Drum, approximately 105 wounded
soldiers, are not in a warrior transition unit. You established
an ad hoc group, Tiger Team, in 11 different hospitals and
installations to cover the quality of rehabilitative care for
our soldiers and the process of transitioning them from DOD to
VA.
As the NPR story relates, a Tiger Team went to Fort Drum,
New York and found the veterans benefit advisors at the
installation performing very well. In fact, they were
performing so well that the Tiger Team even qualified it as
almost a best practice. Yet, the message received at Fort Drum
from the Tiger Team was the complete opposite. Though you told
NPR there was no Army policy stating that a soldier could not
receive outside advice in filing disability paperwork, that was
exactly what your Tiger Team stated at Fort Drum. In fact, the
VA official who attended the meeting wrote a memo the following
day detailing the discussion under the heading ``Major
discussion points by attendees.''
The first point states that the colonel from the Tiger Team
said, ``The Veterans Benefit Administration should discontinue
counseling Medical Evaluation Board soldiers on the
appropriateness of DOD, MEB/PEB ratings and findings. There is
a conflict of interest. This activity should go on to any
service organization, military Purple Heart at Fort Drum. They
should assume the responsibility immediately.''
So, General Schoomaker, I want to know how you could
characterize this as a miscommunication. How is it that the
Tiger Team could tell you that Fort Drum was doing a laudable
job, but at the same time communicate to folks at Fort Drum, in
what appears to be a fairly ambiguous manner, that their
veterans benefit advisors should stop counseling injured
soldiers on medical evaluation processes, especially after here
in this committee there was an agreement that there was going
to be work done to solve this problem, and it was going to seem
seamless for the veteran?
General Schoomaker. Well, ma'am, let me just real quickly
review the facts in that case.
The team that you are referring to went to 11 facilities,
installations and hospitals, around March 2007, almost a year
ago, at the very outset of our problem at Walter Reed.
While we were standing up the Army medical action plan, the
then Acting Surgeon General of the Army sent this team on the
road. They were rapidly attempting to harvest best practices
around the country.
Fort Drum happened to be about the last place they went,
and their account of their encounter and their investigation of
what was going on at Fort Drum was exactly as you depicted. It
was one of the best that they had seen. In fact, they were
extraordinarily laudable about what they saw the counselors
doing and tried to harvest as many of those practices as
possible for use within the bigger system.
When we heard about the story that NPR was going to float,
I talked to, or my staff talked directly to people who were on
the Army team, as well as senior supervisors within the VA at
Buffalo who were at the meeting, and they recounted that no
such discussion took place, and that it was a very, very
collegial, very positive, very informative session in which
there were no contentious issues, and nobody could recall this
exchange taking place.
In fact, I talked personally to the colonel that is quoted
in the memo to ask her did anything to awry in this meeting,
and it was absolutely the opposite.
We tracked down as many members of the team as possible,
and they all recounted exactly as I said.
Unfortunately, the memorandum was not surfaced before the
story. It was not shared with the team before they left Fort
Drum or my office or my predecessor's office before. In fact,
that memorandum only surfaced the day after the story was
given, and after I had already made comments to the effect that
we weren't entirely sure how this could have happened this way
because everybody who was at the meeting recounted it was an
extraordinarily positive exchange, and we encouraged them to do
what the VBA counselors were doing on behalf of our soldiers.
But as soon as that memorandum was surfaced, a memorandum
written by a single attendee at that meeting, was never
verified, never ratified by the other members who were in
attendance there, I said, ``OK, clearly there has been a
miscommunication here and misunderstanding between them. Let's
prevent this from happening.''
We got a hold of Secretary Peake almost immediately.
Secretary Peake very graciously said, ``You know, there appears
not to be the standardization and understanding around our
counselors. Let's eliminate the possibility this could ever
happen again.'' We immediately sat down and wrote a memorandum
of----
Ms. McCollum. General, my time has expired here.
General Schoomaker. Yes, ma'am.
Ms. McCollum. I am very confused.
Mr. Tierney. I will give the gentlewoman more time if you
want it.
Ms. McCollum. Thank you. I am very confused on this,
because there was actually a followup story the second day, or
a couple days later, on NPR, and other people collaborated with
what had happened. In fact, if I am remembering correctly,
several of the men were actually kind of nervous about being
identified even because they didn't want to move forward.
I have a document--they tried to put it up on the screen,
sir, and they were unable to do so. If you need to see this, we
can make sure you can see it, as well.
General Schoomaker. Is this the memorandum, ma'am?
Ms. McCollum. Yes, it is.
General Schoomaker. I have the memorandum.
Ms. McCollum. Saturday, March 31, 2007, summary of Tiger
Team visits on March 30, 2007, at 3:45 p.m. On the first page,
Colonel Baker, item No. 1, ``Major discussion points by
attendees.'' So the attendees would be the soldiers who were
there, correct?
General Schoomaker. No, ma'am. Not that I recall. I was not
at the meeting, myself, but I understand----
Ms. McCollum. OK. But Colonel Baker says, ``VA should
discontinue counseling MED soldiers on the appropriateness of
DOD EMB/PEB ratings and findings. There exists a conflict of
interest. This activity should go to any service
organization''--and it recognizes Military Order of the Purple
Heart--``and Fort Drum should assume this responsibility
immediately.''
Now, that is in writing, and Colonel Baker says that major
discussion points by attendees. That means people were
discussing it, correct, if it is a discussion?
General Schoomaker. Ma'am, I----
Ms. McCollum. Are you saying Colonel Baker is totally
inaccurate in what he said, that he has fabricated what is on
here?
General Schoomaker. Ma'am, what I am telling you is that
Colonel Baker has said she never said that; that there were
discussions in the room about whose lane should--you know, what
work should be done by what counselors. The VBA counselors are
very gifted in their knowledge of benefits for veterans within
the Veterans Administration. They are not necessarily experts
in the Medical Evaluation Board process. Those were all sorted
out.
I mean, what I am telling you, not having been in the room,
one member who attended that meeting wrote those minutes, and I
said to Congressman McHugh from upstate New York and I said at
the NPR counsel I very much regret that the recorder of those
minutes didn't share it with anybody else until a year later
and a day after the story popped. Had they been shared, I think
we would have been able to, one, corroborate it, and, two,
validate it.
Ms. McCollum. Mr. Chair, I am very disturbed by this. Since
we are doing a lot of case work, way too much case work because
too many people have been injured in the war in Iraq, and we
thank them for their sacrifice, but I am hearing stories like
this in my office of people afraid of challenging the system
and that. I thought we had made it real clear after our last
set of hearings here that we wanted this solution fixed and we
wanted our veterans taken care of.
Thank you, Mr. Chairman.
Mr. Tierney. Thank you, Ms. McCollum.
Mr. Platts, you are recognized for 5 minutes.
Mr. Platts. Thank you, Mr. Chairman.
I first want to thank each of you for your testimony here
today, but especially for your efforts on behalf of our wounded
personnel who have been courageous in their service, and to our
two generals in uniform, as well as our civilian leaders in the
departments, as well as the GAO trying to oversee all that we
are doing.
Clearly, as we found a year ago, we had some significant
shortcomings in our system. I know each and every one of you
have worked diligently to address some in the last 12 months
and continue to do so. I want to express appreciation for your
efforts.
I regularly interact with families and wounded personnel
from my District, and what I often most clearly hear is
gratitude for the care they are receiving. The one thing that
came through last year and has been addressed in some of the
testimony here today I want to start with is that transition,
because that seemed to be what I took away from the hearing at
Walter Reed a year ago was the soldier coming right out of the
battlefield and the inpatient care was tremendous and the
medical care outstanding, but the transition to either
outpatient or from military to VA, from DOD to VA is where we
broke down, and a lot of this effort has been about trying to
address that.
Some of it is technology related, and I guess I would start
with both of our Secretaries. That hand-off from DOD to VA, my
understanding is that, while we are working on it, we still
have some significant IT challenges of allowing it to be
seamless so that the VA physicians get the up-to-date,
reliable, accurate data. Can the two of you give me an update
from your two different perspectives those handing off the
material, and then VA with receiving it, where you see us today
and where we are heading?
Mr. Dominguez. Thank you, sir. I would be happy to start.
I hope we don't have two different perspectives on this,
because we have established a joint organization, you know, to
drive this forward all the way across, not just in health care
but in the administrative benefits, personnel information
exchange, as well.
The physicians on the medical side are making enormous
progress--and there is a table included in our testimony that
highlights that--on sharing information now and electronic
media, so it describes the information that is already now
being exchanged.
More importantly, I think, in terms of the greater journey,
we are committed to in our two Departments to building
interoperable systems, so that the exchanges we have now with
viewable information, so you can see the notes I took and what
I wrote, but what we would like to do is move that into where
it is computable data, inasmuch as we possibly can.
The MDA put us on that journey or ratified that journey,
and we are on it.
Admiral Dunne.
Admiral Dunne. Just to add on what Mike said, we are in
accordance with NDAA, about to set up a program office which
will look at how we put a program together to continue on what
we are doing. We are on track for, by the end of this year, to
have completely viewable health and personnel records that are
needed to work with all our soldiers and veterans, and, as Mike
said, we are working together. We don't have two different
perspectives on it. We have two senior members of the SOC on
each side, DOD and VA, whose job is to coordinate this efforts,
to get our records first viewable and then interoperable.
Mr. Platts. Now, in the hearing last year the one issue was
just a legal barrier of whether you could share the records. It
sounds like you have overcome that. There was a concern
expressed last year whether HIPAA and some other laws allowed
you to share, but it sounds like that is not an issue today?
Admiral Dunne. I think from time to time someone will raise
that flag and question whether HIPAA or some other rule is an
impediment. Most times so far we have been able to answer those
questions and move on.
Mr. Platts. Because I am going to run out of time and I
have several issues I want to cover, the next one deals with
National Guard. With such a huge percentage of our troops being
deployed being Guard or Reserves, and in Pennsylvania huge Army
Guard, Air Guard units that have been deployed, and I have had
the privilege of visiting them in theater and they are doing
remarkable work, but when they come home, they don't come home
to a typical base. They come home to communities across the
State of Pennsylvania, across this country.
I know there has been the effort with the transitional
assistance advisors that has been stood up, and really from the
Guard side, but one of the challenges is how we are funding it.
I joined with the ranking member and the Chair of the
subcommittee as well as the Chair and ranking member of the
full committee earlier this week in a letter to Dr. Chu asking
for DOD to look at dedicated funding for this transitional
assistance. I know it is a letter we just sent out the
beginning of this week. Is there any position you can share
today of looking at this funding need, because from my
understanding the TAA system is being critical to helping Guard
who are coming back to their home communities with some
significant needs. Has DOD taken a position thus far on that
request?
Mr. Dominguez. I would say, first, we are looking at this
whole integration of reintegration for the Guard and Reserve.
We set up a major task force under Assistant Secretary for
Reserve Affairs Tom Hall to really take the Yellow Ribbon
programs that Congress sponsored and that we were doing
experiments in 15 States, and we are going to expand that to
all 50 States now. So Tom Hall is leading that effort, working
in close cooperation with Lieutenant General Steve Blum and the
chiefs of the Reserve components.
With regard to the funding, this is a tougher issue
because, while there is some level of funding that should be in
the baseline for ongoing, sustained family support programs for
the Guard and Reserve--and there was before and maybe that
needs to be increased--the major requirement, the major
increase in requirement is really driven by the fact that we
are taking National Guard brigades and deploying them into
combat and then bringing them home. So that challenge, the way
we are now structured in the way we do the budgeting really is
supplemental funding issue.
Now, I know that the appropriations committees are working
with the administration and the Comptroller of the Department
about moving away from supplementals and moving things into the
base budget, so those things will get resolved, I think, in
that discussion.
What I am sharing with you is some initial reactions. In
terms of the Department's or the administration's position on
this, we don't have it. I will certainly ensure we take a quick
look at it. I deeply appreciate the problem we have in funding
this long-term, sustained care need with money that comes from
month to month almost.
Mr. Tierney. Thank you, Mr. Platts.
Mr. Platts. If I could conclude real quick----
Mr. Tierney. We have to, only because we have votes to go
and I want to give everybody an opportunity to question.
Mr. Platts. OK.
Mr. Tierney. So 2 seconds or less.
Mr. Platts. I just wanted to emphasize that, whether it be
Guard, Reserve, or active duty, the bottom line is baseline
supplemental is that we get it done, and I appreciate your
efforts.
Mr. Tierney. Thank you, Mr. Platts.
Mr. Platts. Thank you, Mr. Chairman.
Mr. Tierney. Mr. Hodes, you are recognized for 5 minutes.
Mr. Hodes. Thank you, Mr. Tierney. Thank you very much. And
I thank the panel for coming. I thank you all for your efforts
to make things better.
I would like to address, Mr. Dominguez, a question to you.
I just came back from Iraq last week, where I heard with great
concern of an uptick in the level of suicides and other mental
health problems in theater. I note in your written testimony
that the Army has incorporated neurocognitive assessments as a
regular part of its soldier readiness processing in select
locations, and select Air Force units are assessed in Kuwait
before going into Iraq.
How quickly do you plan to expand the program of
neurocognitive assessments to everybody who is being deployed
in theater? What do you know about the problem? My sense was
that the extended deployments are taking an unimaginable toll
on our brave troops, and we are seeing it in mental health
problems and suicides in theater. I would like you to address
that, if you would.
Mr. Dominguez. Direct, I first want to separate the two
issues. The neurocognitive assessments won't give us any
insight into tendencies to suicide and depression and those
kind of issues. The neurocognitive assessment is really about
brain function. It is intended to give us a baseline for how
you respond in these different parts of brain function so that
if there is a concussive injury or something like that we have
a baseline to measure it against and see if we can document
that.
Mr. Hodes. Let me just followup. Understood. Does that mean
that you are also assessing pre-deployment mental health status
in terms of depression, tendency to depression, and any non-
neurocognitive deficiencies which might lead to the magazine of
health problems which we are now seeing.
Mr. Dominguez. Sir, the Surgeon General of the Army is much
more qualified, I think, to deal with that, because it is his
troops implementing his procedures that deal with that.
General Schoomaker. Yes, sir. I completely concur with what
Mr. Dominguez said. The neurocognitive assessment that is being
done that was referred to earlier by Congresswoman McCollum
refers to baseline assessment for concussion.
We have been and continue to assess symptoms of depression
and the like prior to deployment and then immediately upon re-
deployment, and then 90 to 180 days after re-deployment in what
is known as a post-deployment health reassessment [PDHRA]. That
derives from studies that we have conducted now that symptoms
of post-traumatic stress arise in the 90 to 180-day window
after re-deployment, not immediately upon re-deployment.
Mr. Hodes. I appreciate that. In Iraq I learned that there
are approximately 100 mental health professionals dealing with
our troops there spread throughout the country. What attention
is being paid by you to the uptick in mental health problems
and suicides in theater?
General Schoomaker. Sir, we can take the question for the
record, but I think the number is closer to 200 mental health
providers in Iraq, but the concern about suicide has gotten a
lot of attention from the theater command, as well as the Army
as a whole, and we have sent assessment teams down-range to
look at root causes for the problem and continue to track
suicide risks as they return from theater. The Army, with the
lead by the Army G-1, Chief of Personnel for the Army, and with
me in support, and our Chief of Chaplains and others are
looking at a comprehensive suicide prevention program and are
dealing with or advising our leadership as we speak about what
we will do about this suicide risk.
Mr. Hodes. How soon do you plan to deploy the suicide
prevention program? And do you have any conclusions yet about
why we are seeing this sharp uptick of suicide rate in theater?
General Schoomaker. Sir, I am not qualified to talk about
the in-theater suicide risk right now, nor how quickly.
Clearly, the Army has had an ongoing and continues to have an
ongoing suicide prevention program and has for many, many
years. It has been very successful. We see the trends that you
described. It has alerted us to the issue and we are taking a
very fundamental root cause and comprehensive approach to this,
using a public health model to see if we can turn the tide.
Mr. Tierney. Mr. Hodes, thank you very much.
Mr. Hodes. Thank you, Mr. Chairman.
Mr. Tierney. Gentlemen, let's see if we can get through
this so we don't have to bring you back after the votes. I have
essentially three categories here that I want to cover. The
rest of it I think we have in the written documentation that
you have been kind enough to provide.
The first has to do with personnel. What I would like to do
is ask a question about a particular nature of personnel and
then get the response from whoever feels qualified to answer,
then reaction from Government Accountability Office and what
you might add as a recommendation to how the situation gets
addressed.
Legal staff--we have a problem there. The process is slow,
according to the reports on that, very difficult to try and get
it through so that we can hire people up in time. What are we
doing about it and what does Government Accountability Office
recommend we do about it?
General Jones. Sir, let me take the legal question. First
of all, each soldier has access to counsel.
Mr. Tierney. I am going to say yes, we know, because we
read the reports. Just what are we doing about it and go.
Otherwise, we are going to have to have you back.
General Jones. Bottom line, sir, we have 57 members that
the Army is planning to distribute to the field.
Mr. Tierney. Right. And do you have them all hired up and
ready to go, because the information reports that we are
falling short on the numbers, and one of the problems was that
the process was so formal and so slow that you were having
difficulty.
General Jones. No, sir. The plan has not been approved, but
I was informed yesterday that it is at the Army level for
approval.
Mr. Tierney. Is that a satisfactory response from GAO's
point of view?
Mr. Bertoni. I would acknowledge that is the condition. I
guess I don't know, sitting here, exactly what the fix is, but
I would acknowledge that, of the 57 that are needed, I know
there has been recent approval for 30 more. Half of those are
civilian sector; the other half are military sector. On the
civilian side I think we point to just the general Federal
hiring policies for bringing in civilian sector employees.
There may be some room there to look at those and see if there
is some way to get some dispensation within those guidelines to
fast-track the civilian sector.
On the military side, the biggest concern we have is that
the Army's own policies of rotation is 12 to 18 months.
Disability is very complex. It takes a long time to sort of
overcome their learning curve. You could get an attorney in
place who has been there for 12 to 18 months, very good, very
adept at the issues, and they're gone. So, again, that is
within the Army's control. I know there are needs all over the
organization, but to the extent that they are losing brain
power and disability expertise, that is something that they
should look at.
Mr. Tierney. General, could you address those and get back
to us in writing as to what you think ought to be done with
those?
General Schoomaker. Yes, sir.
Mr. Tierney. I think they are both valid points, and I
would like to hear what you recommend as to how we are going to
address each of those and how quickly it can be done.
General Schoomaker. Yes, sir.
Mr. Tierney. Thank you.
In terms of most case managers, it seems to be going as
well as any of the positions on that, but we have a problem
with doctors with a current ratio of 200 to 1. There were some
comments from the doctors that they were overwhelmed because of
the complexity of the issues they were dealing with, as well as
the volume when surgeries occurred, and a recommendation from
some of them that the number be reduced to 100 patients per
doctor. How realistic is that, General? Are we moving in that
direction, or can we not move in that direction? What is GAO's
response to that?
General Schoomaker. Sir, I would have to say that the ratio
of 1 to 200 was taken as a very, very conservative, that is
protective kind of ratio. I mean, our normal primary care
provider ratios are in the range of 1 to 1,000 or 1 to 1,500,
so we felt, in setting the goal at 1 to 200, that was very
generous. I think we need to go back and look at that, based
upon what we heard from the GAO.
Mr. Tierney. Thank you.
And, gentlemen with the GAO, is that just your repetition
of complaints that you heard, or was that an in-depth analysis
of GAO agreeing with the complaint?
Mr. Bertoni. I would say the noise we heard out there, I
wouldn't say it is projectable to the force, as a whole. What
we are trying to bring to the table is that, when we went to
these various facilities, there were concerns about that ratio.
Most of the time, that concern was based on when there were
surges, particular units coming in during a surge of activity
or individuals coming in to the process.
One of the things I do know that the military is doing is
putting together these traveling med units where they can go
ahead and deal with these surges. Perhaps that is one way to
just expand these units and, at least for a short time, stop-
gap measure, to alleviate the pressure. But, I think, certainly
looking at that ratio, I don't know what it is, but there is
some concern out there at times, and it behooves the military
to look at it.
Mr. Tierney. Thank you. General, we appreciate your
willingness to take a look at that. Next time we get together
maybe we will have a response of what you found out on that.
The evaluation board liaisons are having some difficulty
there. The goal has yet to be met. Are we on track to meet that
any time soon, or is there a particular issue?
General Schoomaker. Sir, I think the shortages were
accurately reported and portrayed by the GAO. We have hiring
actions out on all of them. Our populations of WTUs, as the GAO
report describes, and as you have seen over the last year, we
have continued to grow, to move the population into the WTU in
a very, very deliberate and rational fashion. In fact, I think
your packets contain the decision matrix we used to decide
whether a soldier should remain out in a unit and not a part of
the WTU or moved over.
As the unit gets larger, then we add additional PEBLOs, but
I think GAO captured it. These are tough hiring actions, and
the training is difficult.
Mr. Tierney. Just briefly, the apparent issue of getting
eligible service members into the transition units, what are we
doing about that? Do you agree with GAO's assessment on that?
And if so, what are we going to do?
General Schoomaker. I think we have been very responsible
about this, to be candid with you. Let me just go back and put
it into context, the fact that the Army and the services have
always had soldiers with a variety of injuries and illnesses,
and I need to emphasize at this point what the Secretary said
earlier, that these are wounded, ill, and injured soldiers.
These are not just all combat wounds. In fact, the majority of
our soldiers, I would say, across the WTUs, are not as a
consequence of wounds in combat. They are illnesses and
injuries on training ranges and motor vehicle accidents,
cancers, heart disease--all the things that we are prone to.
The Army has always had soldiers distributed out through
its companies, platoons, battalions who are in a range of
recovery and treatment, and what we have done is to
systematically move them in in accordance with whether they are
going to be in it a long time, whether it doesn't look like
they are going to get back immediately to that unit, whether
that unit is going to deploy or not deploy. We don't want to
leave a deploying unit with a large number of these soldiers.
We have done it very systematically. Those that have
remained out there I think, if you look at our decision matrix,
are generally soldiers who are not going to be in long-term
recovery. They are not in any unit that is going to deploy.
They are not at risk for alcohol problems or family violence or
suicide, and so we have left them out there. Frankly, this is a
decision made with the consent of the commander of the unit.
They are very receptive to that.
Mr. Tierney. Do you want to add anything to that, GAO, Mr.
Pendleton?
Mr. Pendleton. Yes, sir. The Army put some guidance out
about this in December which said that this is envisioned to be
the exception rather than the rule, that someone would stay
outside their warrior transition unit. There are 40 percent or
more folks that are outside at a couple locations.
Mr. Tierney. Did you say 40 percent?
Mr. Pendleton. Yes, which doesn't sound like the exception
to me. However, I have to tell you this number is not going to
be zero. I mean, as General Schoomaker points out, some people
probably ought to stay with their unit. They might have had a
severely injured knee but they can do desk work, that kind of
thing. But I think the Army needs to stay on this, sir.
Mr. Tierney. OK. Maybe, General Schoomaker and Mr.
Pendleton and Mr. Bertoni can work on that. Next time we come
back we will see whether that 40 percent number is a bit high
and what it is made of. We will go a little deeper into that.
General Schoomaker. Yes, sir. I think, Mr. Pendleton, you
depicted a regional thing. I think across the Army it is
probably under 10 percent.
Mr. Pendleton. I think it is 22.
General Schoomaker. Never argue with an accountant.
Mr. Pendleton. Right.
Mr. Tierney. But I am interested in knowing whether the 22
percent number is a good number for us or not. I would
appreciate you digging down a little deeper on that at GAO and
let's be certain that they are getting them over there if they
need to be put over there on that.
Just very quickly, on the squad leaders, are we having any
difficulty getting people to go into that position, or do they
feel they are on a promotion track and being respected in the
military if they take that assignment?
General Schoomaker. Yes, sir. The feedback we get back, the
Army is very aggressive about getting very well-qualified NCOs.
We now have a special pay for them. We have sent all the right
signals, I think, that this is a career-enhancing and not a
career-ending step for them.
Mr. Tierney. OK. And last--my question may take a little
longer than that--is the evaluation process, itself. We have
the Medical Evaluation Board, we have the Physical Evaluation
Board. I am always curious to know why they can't be done as
one. I look at the pilot program, which still separates them
out as separate entities on that and then moves on to the
Veterans Administration evaluation from there.
Would you quickly go through for me what it is you are
doing in the pilot program exactly on that, why you chose that
model as opposed to any of the others that you could have, why
we only have one pilot program going, what happens if that
doesn't pan out. Have we lost all that time? And why are we
having a problem with the matrix or indices as a way of
measuring that, no comparative group to work against, or
whatever, and what about all the other services. Is it just the
Army, or are we dealing with everybody, and where are we going
on that?
Mr. Dominguez. Sir, the pilot involves all the services.
Mr. Tierney. Good.
Mr. Dominguez. With regard to the input from the GAO on the
evaluation criteria, I will be happy to look at that. We were
going to spend a couple days here in mid-March diving through
where they are in that pilot and what the next steps might be,
so we will put that on the table to wrestle through.
I would also ask the Director of Program Analysis and
Evaluation to give me his own look at how our experiment is
constructed to see whether it is adequate to the decision.
The key elements of the pilot are that we do in the Federal
Government one comprehensive medical examination, one
disability rating from the VA. In both of those cases they are
VA provided to VA standards. We do enhanced case management and
communication on steroids, so a lot of----
Mr. Tierney. That is not a good word for this committee.
Mr. Dominguez. Sorry. So there is an enhanced case
management aspect of it.
There is an early engagement of the VA in the case which
helps them reach early conclusions and rapid delivery of
benefits, so those are the aspects of the pilot.
We didn't do the MEB and PEB and try and combine them,
because they are, in our view, two separate processes, and they
are different parts of this winnowing process.
Many people are referred to a MEB that are not referred to
a Physical Evaluation Board, so the physicians look at them and
say, ``Yes, you are going to be good to go. Go back to work.''
Mr. Tierney. The definition people keep giving me on these
is that the Medical Evaluation Board evaluates in order to
identify a medical condition that may render a service member
unfit, and then the Physical Evaluation Board determines if the
member is fit or unfit. It seems to me there is not a lot of
leap between one and the other one.
Mr. Dominguez. Well, there is. Maybe General Jones can add
on this. But the Physical Evaluation Board is where you get in
commanders in the personnel community, and this is where you
look. This is the people who make judgments about whether we
can find you a place in our service to continue to serve, in
spite of the fact that you are not able to meet the demands of
your grade and MOS. So there are lots of those calls. Eighty of
800 amputees have been returned to service that way. That is
not a physician's call; that is a commander and a personnel
chief's call.
Mr. Tierney. I understand. Thank you.
The questions that you saw in the GAO report that were
raised about having an example to compare against all of those,
are you wiling to work with the GAO in trying to address those
concerns?
Mr. Dominguez. I am certainly going to address those
concerns they raised. We will look at them. I will have to
satisfy myself and my boss, our two bosses, about whether we
need to take that extra diligence necessary for the kind of
decision that we are approaching here.
You know, one of the things to keep in mind is what we did
so far was simple. We just took two steps out of the process
that were redundant within your same Federal Government, and we
were doing those two steps separately because we happened to be
two separate Federal agencies. So just pulling that out, which
is the core piece of the change in the process, seems to me to
be relatively straightforward and unobjectionable. But I will
look at what they have suggested and will evaluate it and----
Mr. Tierney. The concern out here is that we are going to
end up down the road at the end of the pilot program back at
the beginning.
Mr. Dominguez. Yes.
Mr. Tierney. I think that would be very disconcerting to
you and Members of Congress and particularly the individuals
involved on that, so we may have some written questions. I know
Mr. Shays is going to have some written questions and I may
have some additional also in terms of why we are not running
more than one pilot and why we are not doing some of those
things with all of you gentlemen on that.
Mr. Dominguez. Right.
Mr. Tierney. I want to thank you for coming in here today,
again, Admiral Dunne and General Schoomaker, for changing your
schedules, all of you for the diligent work that you have done
and the cooperative effort with looking at that and the
willingness to sit here and respond to our questions. We are
all trying to get on the same page with this. We will have
additional hearings. Some of you will probably be participants
in that, as well, and we look forward to it.
We thank you all for your great work and service. Thank
you.
Meeting adjourned.
[Whereupon, at 3:25 p.m., the subcommittee was adjourned.]
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