<DOC>
[110th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:36999.wais]
IS THIS ANY WAY TO TREAT OUR TROOPS? PART II: FOLLOW-UP ON CORRECTIVE
MEASURES TAKEN AT WALTER REED AND OTHER MEDICAL FACILITIES CARING 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
FIRST SESSION
__________
APRIL 17, 2007
__________
Serial No. 110-16
__________
Printed for the use of the Committee on Oversight and Government Reform
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36-999 PDF WASHINGTON DC: 2007
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COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts CHRIS CANNON, Utah
WM. LACY CLAY, Missouri JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts DARRELL E. ISSA, California
BRIAN HIGGINS, New York KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of VIRGINIA FOXX, North Carolina
Columbia BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota BILL SALI, Idaho
JIM COOPER, Tennessee ------ ------
CHRIS VAN HOLLEN, Maryland
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
David Marin, 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
TODD RUSSELL PLATTS, Pennsylvania
Dave Turk, Staff Director
C O N T E N T S
----------
Page
Hearing held on April 17, 2007................................... 1
Statement of:
Dominguez, Michael L., Principal Deputy Under Secretary of
Defense (Personnel and Readiness), U.S. Department of
Defense; Major General Gale S. Pollack, Army Surgeon
General (acting) and Commander, U.S. Army Medical Command
(MEDCOM); and Major General Eric Schoomaker, Commander,
Walter Reed Army Medical Center............................ 52
Dominguez, Michael L..................................... 52
Pollack, Gale S.......................................... 72
Schoomaker, Eric......................................... 86
West, Togo D., Jr., former Secretary of Veterans Affairs and
former Secretary of the Army; Jack Marsh, former Secretary
of the Army; Arnold Fisher, senior partner Fisher Brothers
New York and chairman of the Board for the Intrepid Museum
Foundation; Lawrence Holland, senior enlisted advisor to
the Secretary of Defense for Reserve Affairs; Charles
``Chip'' Roadman, former Air Force Surgeon General; and
General John Jumper........................................ 17
Marsh, Jack.............................................. 19
West, Togo D., Jr........................................ 17
Letters, statements, etc., submitted for the record by:
Davis, Hon. Tom, a Representative in Congress from the State
of Virginia, prepared statement of......................... 15
Dominguez, Michael L., Principal Deputy Under Secretary of
Defense (Personnel and Readiness), U.S. Department of
Defense, prepared statement of............................. 54
Pollack, Major General Gale S., Army Surgeon General (acting)
and Commander, U.S. Army Medical Command (MEDCOM), prepared
statement of............................................... 75
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut:
Prepared statement of.................................... 12
Various bills............................................ 95
Tierney, Hon. John F., a Representative in Congress from the
State of Massachusetts, prepared statement of.............. 5
West, Togo D., Jr., former Secretary of Veterans Affairs and
former Secretary of the Army, and Jack Marsh, former
Secretary of the Army, prepared statement of............... 21
IS THIS ANY WAY TO TREAT OUR TROOPS? PART II: FOLLOW-UP ON CORRECTIVE
MEASURES TAKEN AT WALTER REED AND OTHER MEDICAL FACILITIES CARING FOR
WOUNDED SOLDIERS
----------
TUESDAY, APRIL 17, 2007
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 10:05 a.m. in
room 2154, Rayburn House Office Building, Hon. John F. Tierney
(chairman of the subcommittee) presiding.
Present: Representatives Tierney, Yarmuth, Braley,
McCollum, Cooper, Van Hollen, Hodes, Welch, Shays, Burton,
Turner, and Foxx.
Also present: Representative Cummings and Delegate Norton.
Staff present: Brian Cohen, senior investigator and policy
advisor; Dave Turk, staff director; Andrew Su and Andy Wright,
professional staff member; Davis Hake, clerk; David Marin,
minority staff director; A. Brooke Bennett, minority counsel;
Grace Washbourne, minority senior professional staff member;
Nick Palarino, minority senior investigator and policy advisor;
and Benjamin Chance, minority clerk.
Mr. Tierney. Good morning, everyone.
A quorum being present, the Subcommittee on National
Security and Foreign Affairs' hearing entitled, ``Is This Any
Way to Treat Our Troops? Part II,'' will come to order.
I ask unanimous consent that only the chairman and ranking
member of the subcommittee make opening statements. Without
objection, so ordered.
I ask unanimous consent that the hearing record be kept
open for 5 business days so that all members of the
subcommittee will be allowed to submit a written statement for
the record. Without objection, so ordered.
I ask unanimous consent that the following written
statements be placed on the hearing record: Dr. Allen Glass, a
military physician who has worked at Walter Reed for 20 years;
Gary Knight, a former patient at Walter Reed; Patrick Hayes, a
police officer who has worked at Walter Reed for almost 20
years; Dr. Richard Gardner, who worked at Winn Army Community
Hospital at Fort Stewart in Georgia; Specialist Stephen Jones,
an Iraqi veteran; and Corporal Steve Schultz and his wife,
Debbie. Without objection, so ordered.
I ask unanimous consent that the gentleman from Maryland,
Representative Cummings, and the Delegate from the District of
Columbia, Representative Eleanor Holmes Norton, members of the
full Oversight and Government Reform Committee, be permitted to
participate in the hearing. In accordance with our committee
practices, they will be recognized after members of the
subcommittee. Without objection, so ordered.
We will proceed to opening statements.
I want to just say good morning to everybody here on the
panel and all of our witnesses on both panels here today. On
March 5th, you will recall that this subcommittee convened our
first ever hearing on the care of wounded soldiers at Walter
Reed Army Medical Center. I think it is fair to say that all of
us were appalled by the heart-wrenching stories from Staff
Sergeant Dan Shannon, Annette McCleod, and Specialist Jeremy
Duncan. They spoke of living with mold, being lost in the
bureaucratic abyss, and being treated with a shameful lack of
respect.
But their stories are not, unfortunately, isolated
incidents. After our first hearing, we created a special
hotline, an e-hotline. We heard from hundreds of people, and
the problems went well beyond Walter Reed.
A doctor who had come out of retirement to help out at Winn
Army Community Hospital at Fort Stewart, GA, said that there
they were understaffed, overextended, and ``much worse than at
Walter Reed.''
A soldier who fought in both Gulf wars spoke of cuts in the
soldier advocate program at Darnall Army Medical Center in Fort
Hood, Texas, and that traumatic brain injury patients were
being un- or under-diagnosed.
Someone at 29 Palms Marine Base witnessed examples of post
traumatic stress disorder going undiagnosed, untreated, and
purposefully ignored to return soldiers to active duty. She
told us about one navy psychiatrist who said ``clearly he did
not believe in PTSD.''
We also, unfortunately, heard additional troubling stories
about Walter Reed.
A 20-year police veteran there wrote of cockroaches and
mice at their police station. He also wrote, ``The [police]
station is not handicapped accessible, which is ironic
considering we have a large number of handicapped veterans here
that may need to come to our station for police services.''
A Walter Reed JAG lawyer spoke of a broken disability
review process that under-rates wounded soldiers, a system in
which there were only three JAG officers and one civilian
counselor available to represent all wounded soldiers at Walter
Reed; a system so overburdened there was no time to get an
outside medical opinion or to adequately prepare for these
absolutely vital hearings.
We also heard in the media about computer programs that
can't talk to each other, a growing backlog of VA disability
claims, and egregious allegations of still-injured soldiers
being returned into battle.
At our March hearing, with the committee's support, I made
the commitment that this subcommittee would perform sustained
and aggressive oversight, and as a first step we would followup
with a hearing in 45 days.
Today marks the 43rd day, and I hope we will hear across
the board from our witnesses that the Department of Defense
acknowledges the seriousness and pervasiveness of these
problems; that we are rapidly fixing the broken bureaucracy,
knocking down the institutional walls across the services and
with the VA Administration, and ensuring that each soldier and
his or her family is treated with the utmost respect. That is
what we hope we can hear.
We will hear today from the Independent Review Group, led
by distinguished former Army Secretaries Togo West and Jack
Marsh. Their report, released yesterday, examines the problems
at Walter Reed and elsewhere and offers a series of
recommendations.
I want to thank all of the IRG members and your staff for
your work, and welcome those members here with us today. I
don't know if staff is here or not. At some point you may want
to acknowledge them. They certainly did a great job, as did
you, and we are really indebted to them and you for your
service.
As I suspect all these members will likely agree, we have
heard many, if not the vast majority, of these findings and
recommendations from testimony before Congress, from the
Government Accountability Office auditors, even from the
President's own 2003 Task Force to Improve Health Care Delivery
for Our Nation's Veterans. But the problems have not yet been
fixed.
In February, this subcommittee asked the Defense Department
for documents on the problems at Walter Reed. These documents
show a rash of complaints about the now-infamous Building 18,
including mold, mouse droppings, roaches, and flea bites so
severe they required medical attention.
There is a slide over there that indicates one of the
complaint forms that we received.
What is shocking is that these documents don't recount the
recent problems that were exposed by the Washington Post in
February. What is remarkable is that these complaints happened
in the summer of 2005, well before the Post investigation. The
documents show that, as a result, Building 18 was shut down. In
the words of the Walter Reed Inspector General at that time,
``Building 18 was not up to standards for occupancy, and it has
been temporarily evacuated of all personnel.''
But then Building 18 was reopened. Specialist Jeremy Duncan
and others moved in; and inexplicably the same exact thing
happened again.
I hope that we don't do here with respect to the broader
problems identified by the IRG Group and others is to
``Building 18'' them; that is, to simply paint over the
problems. We literally and figuratively need to knock down some
walls, to roll up our sleeves, and to work together to
completely overhaul the disability ratings process and to
figure out how best to deal with traumatic brain injuries. Put
simply, we need to tackle head-on the most difficult problems
instead of once again simply covering them over with half-
measures.
The fundamental question we all have to ask ourselves now
is: what is going to be different this time around in order to
actually solve these problems?
I am encouraged that the Independent Review Group has
assigned specific responsibility to specific officials for
specific recommendations, so that 2 years down the road
officials can't just claim that solving a certain problem was
somebody else's responsibility.
Many of those who will be responsible and accountable going
forward will testify on our second panel today. What I want to
know is very simple: what is going to be different this time
around under your watch to solve these problems once and for
all?
Be assured that as you continue your work, this committee
will be right there with you--offering constructive advice and
support where helpful, but also ready to hold people
accountable where necessary.
Our mutual goal of ensuring the proper care and respect for
each patient at each step of the recovery process demands
nothing less. The American people don't want to hear any
excuses or empty promises. Our Nation's soldiers and their
families deserve better.
These are difficult challenges and it will take our
cooperative efforts, all of us working together, to make sure
that this broken system is fixed, fixed quickly, and fixed
permanently.
I recently led a bipartisan congressional delegation to
Afghanistan and met with our soldiers there, including some
from our Commonwealth of Massachusetts, a young man from
Waltham, MA, there on the monitors. If, God forbid, any one of
them gets injured, they deserve to come home to a hero's
welcome and to the best care and utmost respect we can give
them, not to a building with mold and mouse droppings, not to a
maze of impenetrable bureaucracy, and not to a system that
works against the very soldiers it should be supporting. That,
to me, and I think to members of this panel, is the job that
faces us today.
[The prepared statement of Hon. John F. Tierney follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Mr. Shays.
Mr. Shays. Thank you very much, Mr. Chairman and my
colleagues. Mr. Chairman, I thank you for your commitment to
this subcommittee's bipartisan inquiry of medical care for our
men and women returning from war. If an American injured on the
battle field in Afghanistan or Iraq arrives quickly to a major
surgical facility, the chances are he or she will be kept
alive. If the wounded are transferred to Walter Reed Hospital,
the medical care they receive is unparalleled.
But it is after the soldier is treated and then transferred
into outpatient care that breakdowns occur, both in the
delivery of outpatient services and with the outpatient
facilities, themselves. We have seen the deplorable conditions
of Building 18 and the Byzantine bureaucracy through which
wounded warriors and their families are subjected.
These breakdowns, in and of themselves, do not define the
medical care offered at Walter Reed; however, they are clear
indications of systemic failings in the outpatient program. No
one should have to live in conditions like those reported in
Building 18, and it goes without saying that an outpatient
should be treated with the same care and focus as an in
patient. The medical treatment of our wounded warriors is non-
negotiable, and our servicemen and women have earned the right
to a continuum of care that sets standards.
Central to the military creed is the promise to leave no
soldier or Marine on the battlefield, but by subjecting our
recovering soldiers and their families to appalling outpatient
conditions we have done just that. We have failed in our
responsibility to ensure the care of our brave men and women,
and our task today and into the future is to ensure our war
wounded are being cared for completely and for as long as they
need care.
This committee's oversight into these matters, which
started under Chairman Tom Davis, has been long and protracted.
We have heard excuses and promises of improvements, promises of
changes, and promises that this time things are really going to
get better. What is different is the imprint of the graphic
representations of Building 18 and the accompanying calls for
action have forced action.
We want to hear what actions to correct these failings have
been taken and what actions are planned. We also want to hear
what we collectively need to do to ensure this does not happen
in the future.
The Wounded Warrior Assistance Act of 2007, which was
passed unanimously out of the House, provides a good start
toward the comprehensive reform of military medical programs,
but it does not go far enough. Toward that end, a number of us
advocated for comprehensive legislative proposals designed to
streamline processes for our war wounded and their families
caught in the Department of Defense's never-ending bureaucratic
maze. These proposals were based on the work of this committee
and subcommittee and were vetted through patients we have
helped in the past. These proposals included establishing
medical holdover, MHO, process reform standards to create
comprehensive oversight of all military medical facilities,
patients, and hospital staff, and a patient navigator's program
where independent navigators serve as representatives for
patients and families.
Our committee should support legislation supporting a DOD-
wide ombudsman to assist wounded military and their families
24/7 and establish the standard soldier patient tracking system
to help family members, installation commanders, patient
advocates, or ombudsmen office representatives locate any
patient in the medical holdover process.
We look forward to hearing other solutions today. We view
this hearing as an opportunity to identify the best possible
policies and legislation as required to rehabilitate Walter
Reed. Goodwill and faith in our military medical system will be
replenished not by excuses and promises but by solutions and
actions. We support you, General Schoomaker, and each of our
witnesses in this process.
Nearly 150 years ago Abraham Lincoln closed his second
inaugural address with the following words: ``Let us strive on
to finish the work we are in, to bind up the Nation's wounds,
to care for him who shall have born the battle, and for his
widow and his orphan.'' To care for him who shall have born the
battle, such was our duty 150 years ago and remains our duty
today.
I look forward to our witnesses' testimony today and thank
each of them for their hard work over the past few months.
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.
We are going to hear testimony from our panel at this point
in time, but I want to begin by introducing the witnesses on
our first panel who look to be almost all of the entire
Independent Review Group. A few are missing. Two are missing,
Mr. Schwartz and one other.
I am going to introduce them in the order in which they are
sitting to help people.
To my far left is Mr. Lawrence Holland, senior enlisted
advisor to the Secretary of Defense for Reserve Affairs. Next
is the Honorable Jack Marsh, the former Secretary of the Army,
who is the co-chair of the IRG; Togo West, former Secretary of
the Army and former Secretary of Veterans Affairs, the other
co-chair of the IRG; Mr. Charles Chip Roadman, formerly an Air
Force Surgeon General. We have Arnold Fisher, the senior
partner of Fisher Brothers New York and chairman of the Board
for the Intrepid Museum Foundation, amongst other
responsibilities; and last General John Jumper, General, the
U.S. Air Force, retired, who was the Chief of Staff of the Air
Force from 2001 to 2005.
I want to welcome all of you and thank you again for the
work that you have done and the report entitled, Rebuilding our
Trust, which is a significant piece of work, considering we
only had about 43 or 45 days to do it.
It is the policy of the subcommittee to swear you in before
you testify, so I ask you to please stand and raise your right
hands. If there is anybody else who is going to be asserting
answers to any of your responses, I ask that they also stand
and be sworn in.
[Witnesses sworn.]
Mr. Tierney. Note that the witnesses answered in the
affirmative.
I understand that one of two of you will be giving a single
opening statement. I remind you that our opening statements are
generally about 5 minutes. We won't hold you exactly to that
line, but if you would summarize it to 5 minutes then we will
have more time to ask questions and elicit as many responses as
we can.
Mr. Shays. Mr. Chairman, before we begin could I just
insert in the record the statement of Tom Davis, who is
visiting with family because of the horrific tragedy yesterday
at the campus in Virginia. So he has a statement, and I would
like to submit that for the record.
Mr. Tierney. Without objection. Thank you.
[The prepared statement of Hon. Tom Davis follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Secretary Marsh will start.
STATEMENTS OF THE INDEPENDENT REVIEW GROUP CHAIRMEN AND
MEMBERS: TOGO D. WEST, JR., FORMER SECRETARY OF VETERANS
AFFAIRS AND FORMER SECRETARY OF THE ARMY; JACK MARSH, FORMER
SECRETARY OF THE ARMY; ARNOLD FISHER, SENIOR PARTNER FISHER
BROTHERS NEW YORK AND CHAIRMAN OF THE BOARD FOR THE INTREPID
MUSEUM FOUNDATION; LAWRENCE HOLLAND, SENIOR ENLISTED ADVISOR TO
THE SECRETARY OF DEFENSE FOR RESERVE AFFAIRS; CHARLES ``CHIP''
ROADMAN, FORMER AIR FORCE SURGEON GENERAL; AND GENERAL JOHN
JUMPER
STATEMENT OF TOGO G. WEST, JR.
Mr. West. There are two of us that will give statements,
but we will meet your 5 minute requirements.
Mr. Tierney. I have read your statements. I think you can
do it. If you have to go over, go right ahead.
Mr. West. Thank you.
I would like to add that seated immediately behind us in
the first row is Rear Admiral retired Kathy Martin, former
Deputy Surgeon General of the U.S. Navy and a member of our
panel. She stood for the swearing in.
Mr. Chairman, members of the committee, let me offer just a
few comments with respect to our report and to what we at the
IRG did.
Walter Reed Army Medical Center bears the most
distinguished name in American military medicine. It and its
colleague to the north, the National Medical Center at
Bethesda, set the standard for DOD medicine. Our review
suggests, however, that, although Walter Reed's rich tradition
of flawlessly rendered medical care of the highest quality, as
you have pointed out, remains unchallenged, its highly prized
reputation has, nonetheless, been justifiably but not
irretrievably called into question in other respects. Fractures
in its continuum of care and support for its outpatient service
members have been reported and are being reviewed. We have
reviewed them.
Failures of leadership virtually incomprehensible, in
attention to maintenance of non-medical facilities, and a
reportedly almost palpable disdain for the necessity of
continuing support for patients and their families have led the
growing list of indictments against this once and still proud
medical facility.
Our recommendations cover a wide range. I have tried to
lump them into four quick questions. Firstly, who are we as a
country, as a military, as health care centers here in the
Nation's Capital? Unfortunately, if one considers the reports
you and we have received from service members and their
families, we would conclude that we may be answering that
question in ways that are not attractive to us as military
services or as a Nation. We say much about ourselves by the
attitudes we display toward those who look to this Nation for
support at their most vulnerable time.
A number of findings and recommendations involving the
assigning and training of case workers, increases in the
numbers of case workers, adjustment of the case-worker-to-
patient ratio, assignments of primary care physicians, and
attention to the nursing shortages consequently have been
included in our report.
Second, who are we and what are we to become? The base
realignment and closure process and the A-76 process have
caused incalculable dislocations in Walter Reed operations, and
they threaten the future of both installations.
We concluded that BRAC should proceed for a host of
reasons, but we also concluded that the transition process is
lacking, important coordinating efforts between the two
installations need to be improved, and increased pace for the
transition is urgently needed.
Third, how are our service members doing? At every turn we
encountered service members, families, professionals,
thoughtful observers who pointed out the impact of TBI,
traumatic brain injury, and PTSD, post traumatic stress
disorder, and how challenging they have become, challenging in
terms of DOD and Department of Veterans Affairs diagnosis,
evaluation, and treatment, challenging in terms of the ability
of our system to respond to them.
We offer detailed recommendations with respect to both a
center of excellence for the treatment, research, and education
with respect to these challenges, and increased attention to
cooperative efforts by both Cabinet departments.
And finally, fourth, how long? The IRG has operated with
what is, for me, a rare sense of unity and cooperation for
organizations of this sort. But if there is one thing that we
are most unified on, it is the need to put the horrors that are
inflicted upon our service members and their families in the
name of disability review and determinations, bring those
horrors to an end.
So our recommendations are several, but our thrust is one,
and that is that the process needs to become one single
process.
It is no surprise to you nor to us that Government and its
various parts can offer rationalizations, good ones, in fact
let me say reasonable arguments as to why each part of that
process needs to be reserved for a specific purpose, but we are
a Nation that values the sense of common Americans. We call it
common sense, and common sense tells us that, from the patients
and the service member and the families' point of view, it is
an incredible maze.
Thus, virtually every finding leads back to those four
things: leadership and attitude; the transition from Walter
Reed Army Medical Center to Walter Reed National Military
Medication Center; the extraordinary use of IEDs--improvised
explosive devices--and the current wars in the current two
areas of conflict, and their impacts on the brains and psyches
of our service members; and the longstanding and seemingly in
tractable problem of reforming the disability review process.
To be sure, it was the degradation of facilities that first
caught the eye of media reporters, but that is not our bottom
line at the Independent Review Group. That bottom line is this:
we are the United States of America. These are our sons and
daughters, our brothers and sisters, uncles, and an occasional
grandparent or two. We can and must do better.
Thank you.
STATEMENT OF JACK MARSH
Mr. Marsh. Mr. Chairman, thank you for conducting this
hearing. It is very, very important. All of the departments,
all of the services have been extremely cooperative in
assisting us in this review, and members of our panel are very
outstanding resource people, and some of your questions really
should go to them, because they have backgrounds in medicine
and hospital management and areas that we do not have.
So we have had great experience and help from the
Department, and I would tell you that under the leadership of
the new commander at Walter Reed, General Schoomaker, who is
here, and the new Acting Surgeon General, Gale Pollack, I think
you are going to see some real progress.
But, by way of background, I am a veteran of World War II,
served and retired as a National Guard officer in the Virginia
Guard, former Member of the U.S. Congress from Virginia. Both
of our sons were called to active duty and took part in combat
operation in the Persian Gulf. Our oldest son, a doctor, was a
surgeon for the Delta Force, and was severely wounded in
Mogadishu, but it gave us an insight to what families must go
through in these circumstances and how important it is.
We also saw the magnificent medical care that our son
received, and also I am eternally grateful to the U.S. Air
Force for the airlift capabilities that they have. Go down to
Andrews some evening when one of the cargo flights carrying
people come in these litters and you will come away with an
enormous admiration and respect for our medical community and
the Air Force.
I make a point of that because I believe there is a part of
the American ethic, and that American ethic is that America
takes care of its wounded. I knew that when I was in the
service, myself, I have seen it since, and I observed it, as
did Togo when he was Secretary of the Army. Incidentally, he
brought to our panel an enormous capability in his background
with the Veterans Administration. Veterans Affairs has been
exemplary and very, very helpful.
You are focusing on families, and I encourage you to do
that, not just to the active, but focus on the Guard and
Reserve. Their family support systems are different, and it
also imposes different requirements.
It has been said that at Walter Reed it was a confluence of
circumstances that became the Perfect Storm. The combination of
A-76, the requirement to contract out some 300 plus jobs, it
took over 5 years to address. So we had not only A-76, you had
the BRAC. Then you had enormous increase of the number of
casualties. So it came into a confluence in a way that was very
difficult to deal with.
There are problems that you have identified and which you
hear on the disability evaluation system. The standards are not
clear inside the Army, and they are not clear between the Army
and the Air Force or with the Navy or with the Department of
Defense. The medical community in many areas is in a sea of
bureaucracy and red tape that is creating enormous problems for
these service people. If you want to move quickly, move there.
Look at that red tape, the bureaucracy.
There is beginning to develop problems in recruiting for
the medical community. I would suggest you also look at
amending the statute that permits the recruitment of doctors
who are over 50 but do not impose on them the 8 year obligation
rule. It is a rare opportunity to avail yourselves and the
armed services of the kind of medical attention they need and
deserve.
Now, finally, as a Member of the Congress at one time I am
aware that only the Congress of the United States can fix and
address the real systemic problems that we are looking at here.
I suspect that the systemic problems that have been evidenced
at Walter Reed you are going to find evidenced in other places.
It was not our task to look at those, but I think they were
there.
But the Congress has the constitutional authorities,
article 1, section 8, to raise the Army's and Navy's and to
provide and maintain their support. Please, I beg of you, have
the commitment and the perseverance to see through that
legislative challenge. It will not be easy, but it is vital to
our country and it is vital to those who bear the brunt of war
and who are wounded in doing that.
Thank you for addressing this issue.
[The prepared statement of Messrs. West and Marsh follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Thank you both very much for those opening
statements.
We are going to proceed to the question period under the 5-
minute rule. I am going to begin. I suggest that whoever feels
best qualified to answer the questions so select down there on
that, or I will leave it to the spokesperson if you want on
that.
I noted under both your comments on that and in page 6 of
your testimonies that you recommend one combined physical
disability review process. That is the crux of much of what we
are talking about for both the Department of Defense and the
Veterans Administration.
To whom should we look to be held responsible to make sure
that gets done?
Mr. West. My recommendation, Mr. Chairman, are the
Secretaries of Defense and the Secretaries of Veterans Affairs.
They have the rulemaking authority for their two Departments
and can probably solve that. To the extent that it requires any
legislative adjustments, then, of course, that is your
bailiwick.
Just one example. In the Department of Defense, if you are
a member of the Army and you are eventually going to end up
leaving the service because of medical difficulties you have
encountered, the wounds, whatever, you can face four boards to
consider your physical evaluation, your disability, before you
even get to the VA. That is because there is one that
determines whether you will remain in your MOS. Well, that is
four including the VA. One determines your MOS. Then there is
the medical evaluation, the physical evaluation, and then, of
course, there is the DAV's Board. When you look at the larger
picture, they are all deciding two issues: one, will you have
to leave your current duty, and, if so, under what
circumstances.
Now, I understand that there are many analyses that can
show the other different aspects, but that is what it boils
down to, and for service members that is very difficult.
Mr. Tierney. Thank you. I would assume, and you probably
don't have to answer, that is going to work fine if the
Department of Defense and Veterans Administration Secretaries
understand that somebody at the White House wants an answer and
wants to ride herd on this thing, so I accept your answer, I
think it is excellent. They can suggest legislation to us. They
can make the rule changes on that.
But I would just add the caveat that I assume that this
only works if somebody at the White House is making sure that
both those Secretaries know that somebody has to answer the
bell and get that work done. It is not going to be enough to
swallow, it is not going to be enough to do it in silos; it has
to be a cooperation.
Mr. West. Yes, sir.
Mr. Tierney. What is the estimated time that we should be
looking for them to complete this implementation? I think it is
going to be a large task on that, but not one that we can let
linger, so this committee likes to set time lines for continued
hearings to sort of keep the process going here. What would be
a reasonable time for us to expect those Secretaries to have
that done?
General Roadman. Mr. Chairman, I am Chip Roadman. I am a
former Surgeon General of the Air Force.
I think re-engineering the system, putting it at a year is
probably a reasonable issue. Common sense would say but there
are going to be people who are going through this system for
the next year. Actually, one of our recommendations was that
every one of the disability determinations, from 0, 10, 20,
less than 30, from 2001 to the present should be re-evaluated
to be sure that there is consistency and that there is fairness
in the decisions, in addition to all those that were discharged
under the existing prior to service.
Mr. Tierney. That is what you would do in the interim?
General Roadman. That is what I would do in the interim.
Mr. Tierney. And you would have one group do all that
evaluation?
General Roadman. Yes, sir.
Mr. Tierney. Who would that be?
General Roadman. I think that a group of people who really
understand the clinical issues, as well as the rehabilitative
issues that our servicemen have to undergo should be appointed
to do that.
Mr. Tierney. And that would be for both the VA and for the
DOD?
General Roadman. It probably would be, sir, but it would be
a significant group of clinical records to review and is a
mammoth task but should be done.
Mr. Tierney. Thank you.
General Jumper. Mr. Chairman, if I could just add, for one
moment.
General Jumper. At some point during this continuum of
care, which is what we call it in the Corps, unbeknownst or
unannounced to the wounded soldier or Marine the system turns
from one of tremendous advocacy, and you have heard the
testimony about getting people off the battlefield and into
primary care in record time, performing virtual miracles
keeping people alive, but at some point this continuum of care
turns from one of advocacy, profound advocacy, into an
adversarial process.
The point of view of this single process needs to be from
the point of view of the wounded warrior and not from the point
of view of the bureaucracies that look down on the wounded
warrior and make the processes more comfortable for themselves.
It has to be that of the warrior, and be able to streamline,
from the point of view of the soldier, Marine, airman, sailor,
the expeditious way through this process. That is the point of
view that has to be taken.
Mr. Tierney. Thank you.
I notice that the yellow light is on. I am going to move
on. We may come back for a second round on this, so I don't
want to keep any of our other Members from that.
Dan.
Mr. Burton. Thank you, Mr. Chairman.
You mentioned the wounded warrior. I had a young man from
my District who was severely wounded, and he went to Walter
Reed and received very good treatment. He went back home and he
has to come back for additional treatment on a regular basis,
but one of the things, he is still on active duty, and so he
was being required, even though he was almost completely blind,
to come back and stand with his company on a regular basis.
Now, I called out there and talked to the company commander
and he said, well, we will try to arrange for him to stand with
a company in Indianapolis so he and his wife don't have to get
on a plane and come out here and stand for just a few hours and
then go back. I just wonder if any other personnel are
experiencing that, because it doesn't seem logical to me, if
somebody is severely injured, they have been treated at Walter
Reed, to go home and, unless they are coming back for
treatment, come back and forth and back and forth just to stand
with their company when they are called out for regular order.
It doesn't make any sense.
I just wondered if that was addressed at all by this. I
mean, it is something that is not necessarily directly
connected, but it seems to me something that is very important.
You talk about treating the wounded warrior very well. This
is one of the things that should be done. They ought to take
into consideration not only his condition and what they have to
do to make him whole, or whole as much as possible, but also
try to make it as convenient for him as possible to get to and
from and do the duties that he has to do while he is still on
active duty.
Major Holland. Sir, it is very much appreciated for you to
bring that up, because, as the NCO on this group, non-
commissioned officer, it is my job to look out for those folks.
I have to tell you some of the things you will hear as we try
to get our wounded warriors back to their units and back in
formations at times. Secretary West brought up the idea of
using common sense. Somehow we have lost some common sense.
That is not the way we should be treating these wounded
warriors that are on very strong medication.
Now, yes, we do need to keep accountability of them, we
need to keep track of them. No doubt about that. For PTSD, TBI,
we need to do even a better job, sir, of keeping track of them.
Mr. Burton. Well, in this age of computers and the way we
keep track of almost everybody any more, it doesn't seem to me
very difficult to say to a wounded veteran, you can go to a
unit in Indianapolis to make sure that your attendance is
shown. But this guy is almost 90 percent blind, and for him to
come back to Washington requires his wife to come with him,
they have to get a place to stay, then they have to go to his
unit, then they have to go back to Indianapolis or back to the
district. He is outside of Indianapolis. That didn't make
sense.
Major Holland. Sir, one thing to add to that if you will,
that individual may look at community-based health care,
because we have CBHCOs in a lot of the areas that they can go
under.
Mr. Burton. Well, in his case he still requires treatment
at Walter Reed, and he has been getting good treatment. The
problem I am talking about is this unnecessary travel.
Major Holland. Yes, sir.
Mr. Burton. And I hope you will look into that for others,
because this is probably not an isolated case.
One of the things that I noticed in your report, it says
``Create a recruiting and compensation plan including a review
of the military service obligation should be pursued to address
health care professional staffing shortages.'' I had a
conference yesterday and had about 400 veterans there in
Indianapolis, and we talked about Walter Reed, and Bethesda. We
talked particularly about the treatment at Roudebush Hospital
in Indianapolis and the hospitals at Fort Wayne and in Marion,
IN, and one of the problems they talked about was getting
treatment in a relatively quick fashion when they needed it,
among other things.
I noticed here you were talking about having a problem in
attracting health care professional and staffers, people on
staff. Do you need more money for that? Is it a logistical
problem? What kind of a problem are we talking about here?
General Roadman. Sir, I'm Chip Roadman. The money is an
indirect issue, and that is you have to have the ability to
hire. In other words, if you have the money but it is not
competitive in the marketplace and you can't hire, then that is
essentially not having the money.
Mr. Burton. If I might interrupt, I apologize for this. It
seems to me in time of war, when we have young men and women
coming back who are suffering severe injury, that whatever it
takes to make sure we hire the best personnel possible, even
for a short time, ought to be done. And if additional
appropriations are needed for that, I hope somebody will tell
us what is needed so that we can make sure that, if there is a
shortage of nurses or doctors in a given field, we can cough up
the additional funds to make sure they are there to take care
of those guys.
General Roadman. Of course, as you know from our report, we
identify high expense marketplaces where, in fact, the pay
grade needs to be higher in order to be able to hire people.
But your basic point is almost as if you had been on our review
panel, and that is: if you are at war, and our view in many
ways is that our bureaucracies have remained at peace while the
war fighters have remained at war, and so we see the processes
and the ability to have other than business as usual as the way
to get things solved is one of the inherent issues that we
have.
Now, if I might, you took the easy patient with the active
duty patient without sight. You have to think in terms of, as
we look out in the system, the Reservist, the Guardsman who is
separated not with retirement and goes out into their local
area, and it may be a very rural community where that health
care is not available. In fact, our system disconnects from
them and they are on their own.
I think that there is a fundamental flaw in how we design
our systems to take care of individuals wounded in war in that
we have a lifetime obligation. It is the cost of war that I
believe is there. There is a moral and a human cost, and it can
be costed fiscally, as well, as a tail that has to be
calculated in cost. When we put force on force, we need to be
willing as a Nation to stand up and accept that.
Mr. Tierney. The gentleman's time has expired. Thank you.
Mr. Marsh. Mr. Burton, there are 94 nurse's vacancies at
Walter Reed Hospital, and you can't fill them because they are
not competitive because they are only permitted to pay in the
pay scale directed by the Office of Personnel Management, which
was set up in 1972. They have tried to give them some leeway,
but it is so far below the going rates for nurses in the
Washington area you can't fill the vacancies.
Mr. Burton. Mr. Chairman, let me just say I know my time
has expired.
Mr. Tierney. It has.
Mr. Burton. This is critical.
Mr. Tierney. It is critical, and I would just ask the
Secretaries, would we not expect the Secretaries to make a
recommendation to Congress for adjustment of funding for just
that purpose so we wouldn't be waiting here so many years later
to catch up?
Mr. Welch.
Mr. Welch. Thank you, Mr. Chairman.
I want to thank the members of the panel for your great
work.
There is a lot of discussion about the disability review
process, that it is incredibly complicated, and you have
addressed that. Professor Linda Bilmies from Harvard has made a
recommendation to try to simplify that by doing something such
that there would be a rating based on a scale, and you get a
one, two, three, four, or five. You would make that
determination. It would be a simple thing to do. Then the
Department would audit these going back to see whether those
determinations, in fact, were consistent with standards. That
is the accountability.
It makes a lot of sense to me. My question is whether it
makes sense to you.
I would maybe start with you, General, because I thought
that the point that you made is really true. You go from
advocacy to an adversary situation. To some extent that is
endemic in the entire medical system, whether it is in the VA
system or it is in the private health care system, because, no
matter what, it is extraordinarily confusing, so finding some
practical way to simplify and take the complexity out of it to
me sounds like an excellent recommendation that you made, so I
would be very interested in making improvements.
General Jumper. Let me start, and then I will call on my
colleague, Chip Roadman, who really dove into this.
My observation is that this process could be extremely
simplified, and I don't think it would take a lot of work. But
when you get down into the regulations and the rules and you
look at, for instance, the coding process that is required by
these outdated regulations to be used for traumatic brain
injuries, then you quickly get these people classified in a way
that is completely out of step with what their true injury is.
And it is all caused because the coding system, the
deliberative coding system, has not been caught up to date,
brought up to date. We are actually subject to printing cycles
to update these regulations.
One of the things that didn't get into the report that is,
I think, badly needed is a way to update the medical community
on some of the cutting edge things that are happening out
there. At Bethesda there is a very forward-leaning diagnosis
and treatment protocols that have been advanced for TBI, but it
is not promulgated system-wide. We need something like, in my
business, the FAA bulletins that are put out for aircraft
discrepancies that are immediately put out to the community,
adjudicated by a scholarly board that has authority over this
and gets this out to the communities right away, something like
that, along with a simplified rating process that you
mentioned, sir.
Mr. Welch. Thank you.
General Jumper. Chip.
General Roadman. Yes, sir. I think what you are describing
is an occupational medicine approach to if you lose a hand you
are compensated X amount of money, and that is a civilian type
of a model.
That clearly is easy to implement. The real problem comes
down to we took Johnny out of his community and we returned him
not in the same condition that we got him, and he is no longer
able to do the occupation that he was trained for.
Mr. Welch. Yes.
General Roadman. And so if you are actually discharged or
don't get a retirement, you are not eligible for the health
care. You get a severance pay, and that generally is not a
livable allowance. So there is an issue with how well
compensated the warrior is as he comes back into his community.
We said the real measure of success was that if his mother
thought he was treated fairly, that probably we hit the mark.
That is hard to put into bureaucratic measurable programmatic
terms.
The issue that we have been talking about on coding is one
where PTSD and mild traumatic brain injury seem to be signature
injuries of this war. There is not an obvious civilian analog
to this, in that brain damage that is seen in our emergency
rooms every day is due to acceleration and deceleration
injuries, coup contrecoup within the calvarium.
The problem is that what we are seeing with TBI, mild and
not penetrating head wound but mild, is due to over-pressuring
from a blast injury and is an invisible injury and, in fact, is
hard to diagnose because it overlaps with PTSD. They are in the
area called attributable diseases, which you take symptoms
rather than findings, and we are out beyond what we now
clinically know, and we need a tremendous amount of research.
Now, all of us are very quick to say we need quick
research, at least getting to the 80 percent answer and not
necessarily this grinding peer-reviewed type of scientific
study that we have the answer 20 years from now and then have a
cohort of wounded soldiers.
So I think the issue is that we clearly need a way to track
and identify. What General Jumper was taking about, in the
civilian coding of medical records there are about 19 codes
that could be mild TBI. If you put that through the ICD-9 codes
and then you come back through the DSM-IV to try to actually
finally--this is more technology than even I understand, so I
hope you don't pin me down on this, but what happens is those
come out as psychiatric disease rather than a neurologic
injury. That is not what our scientists can do either
retroactively or prospectively to define the cohort that we
need to study to get the answers.
So what we have found as we pulled the thread, it attaches
to everything else.
Mr. Tierney. Thank you. The gentleman's time has expired.
Mr. Welch. Thank you.
Mr. Tierney. Mr. Shays.
Mr. Shays. Thank you, Mr. Chairman.
I would like to ask you gentlemen your opinion about the
need. First off, do you agree the challenge is primarily
outpatient as opposed to inpatient? Second, I would like your
opinion about what you think about an ombudsman, someone to
just be assigned to the soldier for years, if necessary, at
least in wherever location they are.
Mr. West. Well, the answer to the first one is clearly yes.
The problems are in the outpatient as that applies to Walter
Reed and other areas. That is where we focused, that is where
it arose. That is not to say that in our course of reviewing
things we didn't come across some ways in which there could be
other improvements, but the problem is in the treatment of the
outpatient, the group that are going through rehabilitation and
the process for the physical and medical evaluations, as well.
Mr. Tierney. Is that agreed by all of you?
Mr. Marsh. Yes.
Mr. Fisher. Yes.
Major Holland. Yes.
General Roadman. Yes.
Mr. Shays. Do you have an opinion as to why the system
broke down? Or did the system never work properly when it
involves outpatients?
Mr. West. I think everybody on the panel--who wants to
start?
General Roadman. I will start on that. Health care
generally is taught and oriented in an acute care inpatient
setting. What we are talking about is rehabilitative care,
which is fundamentally different from acute care. The only
reason I think this came up is that the system was stressed by
the volume of patients. The system will work today by bailing
faster, but as you get more and more patients the system
actually has to be fixed.
There are three ways we need to look at health care:
prevention, acute care, and rehabilitation. Our job we are
talking about now is taking Johnny back to his community able
to re-engage in life, and that is different from the acute care
that we normally deliver.
Mr. West. You raised a question of an ombudsman, Mr. Shays.
I wonder if the Sergeant Major might say something on that.
Major Holland. Sir, the service member certainly needs an
advocate, but they need an advocate that is schooled enough to
be able to help them walk through the mine field that they have
to walk through.
Now, we talk about the ombudsman, but we also talked about
the rating system. Let's make sure that no one gets service
concern. The services still should have the ability to say
whether or not I am fit for duty or not fit for duty. Once it
is said that I am not fit for duty and I go in that other
category, then I ought to go to the disability system, and that
is where I really need an ombudsman.
We talked about case workers. We talked about case
managers. But with a load of 30 and 40 to 1 they are not given
a good, positive situation.
Earlier you brought up legal staff. Three legal folks at
Walter Reed is unacceptable. I talked to the head of the JAG.
They tell me that there are five Reservists, legal staff,
coming in that will be there for the next year or two. We need
certainly more advocates for the individuals to understand what
their rights are and to make sure that they get treated fairly
every day, sir.
Mr. Shays. Thank you.
If you would all describe to me the differences of what you
saw at Walter Reed versus Bethesda.
General Roadman. Sir, I am Chip Roadman. There was a
significant difference between the two. Bethesda had
reorganized their patient care as a team so that very holistic
health care was delivered per individual. In other words, if
someone had an orthopedic injury and a soft tissue injury, they
didn't have to go to two physicians at Bethesda. They had a
team approach to that. At Walter Reed what we found was that
the disease were treated by organ systems, primarily,
sequentially rather than in parallel. We made that point in the
report, saying that was one of the really best practices that
we had seen.
Mr. West. There are some other differences that come out.
First of all, of course, the numbers at Walter Reed exceed
those at Bethesda. What that means then is that when you are
talking about folks who can function as an ombudsman for, say,
service members and families, Bethesda had theirs covered. The
Marines who are there are well helped in making their way
through the process and also through the regulatory procedures.
That wasn't happening at Walter Reed. That is the impact of the
ratio to case worker, the ratio of patient to those who can
help them through the process.
The Marines take their folks the minute they get off the
plane, in fact perhaps even before the plane that comes in, and
has someone assigned to be responsible for that serviceman
through the whole process, all the way back to their wounded
warrior barracks on either coast. The Army folks at Walter Reed
just don't have enough people to see that that happens.
Now, in some cases it does. Special Forces are there from
the beginning to sort of follow their people. But the fact is
numbers can make a difference and did make a difference there.
There are some other things. The Navy does its facilities
maintenance at Bethesda much better than the Army does it at
Walter Reed. Now, is that a service tradition that the Army
fighting in worse conditions somehow lives in worse conditions?
Even if it is, it is no way to treat the wounded. But the point
is you can notice those distinctions, and they make a
difference in what service members and their families
experience at those two facilities.
Mr. Shays. Thank you very much.
Mr. Tierney. Thank you very much. The gentleman's time has
expired.
Mr. Yarmuth.
Mr. Yarmuth. Thank you, Mr. Chairman.
I would also like to thank the panel for their work and
their testimony, and I would particularly like to commend
General Jumper on your comments about the nature of the
relationship toward the soldier throughout the system. I think
we can all agree that the focus ought to be on the soldier's
welfare from beginning to end.
I have a question about resources. During the initial
hearing we had, I and others on the committee continued to ask
those in charge at Walter Reed whether resources, namely
financial resources, were part of the problem, and they kept
saying no, no, no, which I don't think that made sense to many
of us because there was so much implied argument to the
contrary.
I know you have mentioned in your report that resources
were contributing, a lack of resources contributed to the
problem, so I would like you to comment on, first of all, the
notion of the efficiency wedge, what that is, because I know
that was mentioned in your report, and how this might have
adversely affected care, and also why you think there was
denial of the fact that resources were part of the problem.
Mr. Marsh. Mr. Congressman, the resource methodology is
very difficult to understand for the medical community in the
Department of Defense. It has undergone a very significant
change some time in the last 15 or so years, where the funding
is taken out of the service, either Army or Navy or Air Force,
and is moved up to Defense Health Affairs, and then the funding
will be allocated at the Defense level without review or input
at the Secretariat level of the three services.
I think some of this is done because it is thought to be
more effective, but I am not sure it is working out here in the
time of war.
Out of this comes what are called wedges, and either
Admiral Martin behind me or General Roadman can tell you
better, but the wedges come down to the service. They may tell
the Army medical community your wedge is $42 million, which
means that you have to find that $42 million in your whole
total community and the answer is you will find it in
efficiencies. You often can't find it. And the last wedge I
think that came down I think was $142 million, and I believe
the Surgeon General indicated there was no way he could execute
that. In the previous wedge, to protect Walter Reed, they kept
them out of the wedge. The wedge means a wedge into your
medical budget that comes back up to Health Affairs.
Chip, do you want to speak to that?
General Roadman. Yes, sir. Chip Roadman.
The wedge is a formula applied to workload that is
retrospective. As your workload goes down, it is assumed that
your costs go down in a formula relationship. I call that the
death spiral of health care, because as we mobilize critical
skills and send them into the theater of combat, those skills
are no longer available within the treatment facilities at
home, and the workload of course will go down. The problem with
that logic as you extend that out is you ultimately end up with
only a deployable medical force with everything else being
bought in the civilian sector. I don't think that is where we
need to be going as a military health care system.
You know, I hate to give you a flip answer, but the
efficiency wedge is a death spiral.
Mr. West. Sir, it can also be very misleading, Congressman.
Having overseen two Departments, I can tell you that the wedge
goes in and you are given inducements to meet it. You meet it
or you don't, but if you meet it, having accepted essentially
that percentage cut in your budget, you are rewarded by having
the budget the next fiscal year set at that level with a new
wedge.
General Jumper. Sir, may I add there is also a stealthy
dimension to this as far as resources go. A lot of the
resources that are put against the immediate problem, for
instance, at Walter Reed, come from other areas of the budget,
the line of the Army that come in there to do and pick up some
of the slack that was identified in the Washington Post and
other places. Eventually, those functional areas from which
those resources came--that is money and people--will be asked
to go back to those functional areas. Unless they are
institutionalized, they stand a good chance of evaporating when
the immediate crisis evaporates. That gets to the
recommendations in our report that talk to institutionalizing
and some strong oversight to implementing the measures that are
written in the report.
Mr. Tierney. Thank you. The gentleman's time has expired.
Mr. Hodes.
Mr. Hodes. Thank you, Mr. Chairman.
I want to also thank the panel for your good work on this.
I have two areas of questions. The first concerns the
office of the ombudsman. I asked my office to send me some
information just to check. I want to make sure that the panel
is aware that Congress recently passed the Wounded Warrior
Assistance Act of 2007, and I have not matched up what we
passed with your recommendations, but I would urge you to take
a look at that. I don't know how the timing worked with your
study and that act, but I think we really probably need to take
a look at that in light of your recommendations, and any help
or guidance you could provide Congress on that I think would be
helpful.
One of the things that the act did was it set up an office
of an ombudsman in the Department of Defense. Section 102 of
the act sets up an overall office to coordinate, as I read it,
other offices of ombudsmen in the various military divisions.
I am hearing that, while the Navy and the Marines have done
a pretty good job with somebody, some office, some way to
coordinate all the benefits, care, and services that may be
available to the wounded warriors on that side, the Army has
not. So one of the things it sounds like we need to look at is
making sure that there is specifically an office of the
ombudsman, and perhaps at each medical facility, whose duty is
to the soldier and their family, not to the armed services so
much but to the soldier and their family, their duty runs to
them to help them coordinate what they are going to have to go
through. Is that, as a concept, something that you agree with?
Mr. West. Mr. Hodes, the answer is yes. I think that
Command Sergeant Major Holland has already indicated, and his
indications are certainly those of the panel.
In fairness to the Army and to Walter Reed, much has
changed since we did our review, and they have, in fact,
addressed the case worker issue, the imbalance, reworked the
numbers, and so you will hear, I think that they have made an
effort to address it.
Whether the case worker does what the act requires is
another matter to be looked at. Certainly from our perspective
the need for some advocate who can help guide individual
service members and their families through that time when the
service member cannot be expected to be thinking clearly, when
the family is tormented by anguish and concern, is one that we
think the Army is trying to meet, but certainly what you have
mentioned in the act also seems a way to be helpful.
Mr. Hodes. My concern is amplified by a meeting I had with
a constituent at home recently. I met with the soldier and his
wife who was at Walter Reed. He described a similar story to
that which we heard when we were there for testimony, you know,
having to navigate 14 different signatures to have somebody say
what he already had been told, which is he is blind in one eye,
half blind in the other, his arm is busted in 13 places; having
to show up for formation when he could hardly stand, with
nobody to go to to help him, a case manager who seemed more
interested in telling him what he didn't need than what he did.
So my concern is very personal to me with that constituent.
The second question is perhaps briefer. General Jumper, I
listened with interest when you talked about essentially an
attitude issue. The same constituent that I met with described
a suck it up soldier attitude to what he was dealing with. I
don't think you can legislate attitude. How are we going to
change the mind set from suck it up soldier to these are
wounded patient soldiers who need our care? How are we going to
change that attitude, because I don't think we can pass an act
that would do it.
General Jumper. Sir, I think that is a very good question.
Indeed, it is the tradition of all of our military services to,
as you say, suck it up. That is the way we look at things. I
don't think the American people would want it any other way.
However, when you transition yourself into this sort of an
environment where you now involve families and loved ones, and,
indeed, in a process where the families and loved ones are
necessary to be able to coordinate all of the activities of our
more severely wounded warriors, then that is when compassion
has to take over for a little of the suck it up attitude.
I think everybody agrees with that. I think everybody
agrees that it was probably a bit overboard in that direction.
I know that the commanders that we have talked to have
instituted steps to correct that, to pay more attention to the
families and to the loved ones.
Mr. Tierney. I thank the gentleman. His time has expired.
Mr. Braley.
Mr. Braley. Thank you, Mr. Chairman.
Quite frankly, General, telling a patient suffering from
post traumatic stress disorder or traumatic brain injury to
suck it up is counterproductive. Isn't that correct?
General Jumper. Yes, sir.
Mr. Braley. And one of the problems that we have sitting up
here is that when we had our first hearing at Walter Reed on
March 5th I asked General Schoomaker, General Cody, and the
Acting Secretary Garon if any of them could tell me how many
patient advocates were serving the patient population at Walter
Reed, because the Post article indicated not only were case
managers being added to the population, but also patient
advocates. You know what they told me? None of them could
answer the question.
I made a request at the end of that questioning for a
clarification on what the number of patient advocates were,
because it is contained in the Wounded Warrior Assistance Act.
It is contained in your independent review. And nobody has
answered my question. So when you want to talk about the
frustration of inaction, it is on both sides of the table here.
One of the things that we have to do is get back to the
point of view you talked about. One of the recommendations you
made in your report has to do with employment assurances. My
brother works at the VA Hospital in Knoxville, IA, which has
been on a yo-yo for 10 years on whether they are going to close
the largest VA hospital in Iowa, spend $260 million of new
facilities management and move them to Des Moines, and they are
losing their best employees who are going to other VA
facilities around the country because no one is giving them
that assurance. This is an endemic institutional problem that
has to change, and you have to be the voice to make it change,
because, quite frankly, we are not getting a lot of answers on
this end.
One of the things that I think that is very important is
you raised the point, General Roadman, about what is the cost
of war. You have talked in your report about the advancements
in medical care that are changing many former fatalities into
wounded warriors with injuries that are, frankly, going to cost
us staggering sums if we invest the money we should to take
care of them.
If you look at a life care plan for somebody with a
traumatic brain injury or PTSD, the average life expectancy of
a 19 year old male, according to the U.S. life tables, is 57
years. You cost that out. It is a lot more than your $100,000
DOD death benefit. Yet, we are not getting any information from
the administration on what the long-term consequences of health
care are for the casualties of this war. You have to use your
platform to be an advocate for that, because that is a hidden
cost that nobody is talking about.
One of the things that was also frustrating to me is one of
your recommendations deals with promoting education and
research in prosthetic care, production, and amputee therapy,
and we heard very compelling testimony about people with
multiple amputations going back to active duty performing
valuable functions as active duty personnel, and yet we know
when we are dealing with the rampaging cost of long-term health
care that if we want them to be active throughout that 57 year
life expectancy and not be a burden on our health care system,
we have to invest in the type of prosthetic care that keep them
active and functioning. Yet, if you look at those DOD
reimbursement schedules, they provide initial prosthetic care
and then they are left to fend for themselves.
So what I want to emphasize is your value to this country
in keeping this topic front and center, because we can have
hearings until hell freezes over, we can pass the assistance
act, but unless the military and Department of Defense do
something to act on their recommendations nothing is going to
change.
Female Speaker. What if you stop funding war?
Mr. Tierney. Excuse me 1 second. The witness will suspend,
please. We have been more than, I think, lenient with what is
going on here. Now I am going to ask that you sit down and not
disrupt the room. As long as you are quiet and you don't
disrupt other people and you don't get in the way with their
hearing of this witness, this hearing, we are perfectly fine.
There are people sitting behind you who want to watch the
proceedings, people who want to listen to it, so I ask you to
keep your comments to yourself, keep in your seat, and you will
be just fine.
Otherwise, we want to be respectful of what is going on
here, about the people who are returning from Afghanistan and
Iraq that we all have great concern for, including you. We
appreciate that concern. So please work with us. We have been
as lenient as we could. Now we expect that you are going to
stay seated and stay quiet. Thank you.
The witness may proceed.
Mr. Marsh. That was a very timely and powerful statement
you just made.
Let me mention something to you that I am afraid the
Congress is going to overlook, because we had a tendency to
overlook it. There are statutory differences between the
National Guard and the Reserves and the active force. Those
statutory differences, unless they are identified, in the
process of treating the wounded can have some very significant
consequences.
For example, if the National Guard or Reservist soldier
goes off of active duty when he returns home with his unit, if
he goes back to his unit and is mustered out, his chances of
being able to get back into the system are extraordinarily
difficult and very hard for him to achieve. I don't think that
Congress is looking enough at these two very important
distinctions in the service. And there is a difference between
Reservist and Guard, too. But the point you make I'm sure was
not lost on all these military people sitting here behind me,
but you are quite correct.
General Roadman. Mr. Braley, I absolutely agree with you on
the hidden cost issue. After leaving active duty, I represented
nursing homes and assisted living in the District here with the
American Health Care Association, and I understand fully what
the lifetime costs of rehabilitation care and care for people
with chronic diseases are.
We have had some interviews, and the question was, well,
who do you think is going to pay for these recommendations? The
panel generally has taken the position of actually that is not
our problem to fix. Our problem is actually to point out the
remaining gap for the people who serve our country, and we
recognize the cost is immense and it is our moral obligation to
address those issues. As we engage in force on force, recognize
that it is not just bullets, it is not just weapons systems, it
is also the tail programmatically of people who are wounded in
defense of our country.
I would like to add one thing quickly. We have talked about
wounded warriors. One of the things that we have seen going
from facility to facility is people saying, wait a minute. I
have been injured and I am not a warrior. It wasn't in
Afghanistan and it wasn't in Iraq. The fact of the matter is
what we are talking about is service members, regardless of
where they were wounded, they need the same standard of care,
the same standard of access, and the same standard of respect
and priority.
I don't want us to fall into the trap of saying this is for
``wounded warriors'' and therefore limited to particular
operations. This is an all volunteer force. We have obligations
to take care of them.
Mr. Tierney. Thank you, General.
The gentleman's time has expired.
Ms. McCollum.
Ms. McCollum. Thank you, Mr. Chair, and thank you,
gentlemen.
Mr. Marsh, you are right. We are not doing our Reservists
and our Guards and our active duty members any favors by having
compensation and everything being so jumbled and such a mess
when they come home, because they all talk to one another, they
all live in the same communities, they all served in
Afghanistan, Bosnia, Iraq, with great honor. To come home and
find out that they are treated differently when they worked and
served and stood in harm's way is a huge, huge disservice to
the sacrifice and the commitment that they and their families
made, so thank you for pointing that out. I look forward to
correcting those inequities, especially as our Guards in
Minnesota have been now extended. The second wave just got
extended an additional 4 months.
My concern that I am coming with is the seamlessness
between the DOD and the VA, and, where appropriate, maybe DOD
people who would still be covered by DOD might be more
appropriately receiving care in a VA facility. It should be
seamless. It should function in a way that really takes care,
puts the patient first.
So I am concerned when I see that the focus on Walter Reed
and Bethesda, which I think needs to be because of the current
problems we had, but I think your panel needs to be looking at
the VA system, the outreach that we have in community rural
health services, how we take care of our soldiers when they
come home and their homes need to be refitted in order to
accommodate a wheelchair, accommodate a walker, accommodate
kitchens so that they can be active not only in their
communities but in their homes, which helps toward healing.
So my question to you is going to be, what do we need to
do--and I met with my county Veterans Service officers who are
great, wonderful people, but they are all close to retirement.
What are we going to do to make our Government live up to its
obligations, to be advocates for families, to have case workers
and ombudspeople, as well as county Veterans Service officers?
They all have very separate roles.
What I am concerned about, just as we have people mixing up
what the Guards and the Reservists and what the regular service
members are entitled to and people not understanding the
differences in that and correcting it, I am also concerned
about making sure that case workers are given their jobs to do,
which are very different than what an ombudsperson does, very
different than what a county Veterans Service officer would do.
Who is going to track and provide that seamless integration
between DOD and VA, and who is going to make sure that we have
all the different layers of paraprofessionals available and
that the ombudsperson truly is independent?
Let me give you an example of where I think we are failing
already. DOD has someone assigned to the VA hospital in
Minnesota. VA system loves having that person there. DOD tries
to keep someone there. That person rotates on an average of
every 4 months. How do we, you know, have someone who
understands the difference between the systems and really
working with someone? Can you address the human need of making
sure that we have DOD/VA be seamless in all the different
levels of people who works with patients that aren't providing
health care but access to health care?
Mr. Marsh. He's the former Secretary of VA.
Mr. West. Congresswoman McCollum, you are absolutely right.
When you outlined the problem, you outlined a whole host of
problems that need to be addressed, and that we in the panel
got to some of them in terms of the seamlessness. We got to the
question of the transfer of records back and forth, which is so
extraordinarily important to our service members. We got to
that question of what had to be looked at in terms of the
physical disability review system.
Some of the other issues, in fact, in 45 days we just
didn't get to. There is a panel that comes after us. It is
already started. I think you know of it, the one chaired by
Senator Dole and Secretary Shalala, whose mandate is to look at
precisely that interface and in its broadest context as well as
in narrow ways.
In terms of the DOD representation at the military
locations, you know, even that small presence, that one person
is something that is vitally important and that, frankly, a lot
of advocates had to work hard to get. As with any agency, but
especially with DOD, if there is one person there is a whole
history of re-deployments and reassignments in their career. If
it is a civilian person, then certainly they could stay longer.
My point is you probably need more than one person, and you
probably need it to work. You are certainly right that 3
months, or whatever that period was, is not nearly as helpful
as a year. Frankly, from DOD point of view and every other
assignment I have ever heard of, you can't even get to know the
territory in a year, at least 2 years.
So you make a good point. We didn't address that. We did
address the broader issue of seamlessness. And, of course,
there is a panel to whom we just reported our findings on
Saturday, the Presidential panel, that is going to look at that
broader issue.
Mr. Tierney. Thank you, Mr. Secretary.
Mr. Van Hollen.
Mr. Van Hollen. Thank you, Mr. Chairman.
Secretary West, Secretary Marsh, thank you for your
leadership on this in co-chairing. Thank you to all the others
who served on this panel, and for your prior service to our
country, as well.
I just have a few comments, and then a question.
First, with respect to the role that the A-76 process
played in your findings here, and you state in the report,
``The A-76 process had a huge de-stabilizing impact on the
civilian work force at Walter Reed Army Medical Center,'' and
indicate that if the military had taken advantage of the waiver
opportunities or didn't have to go through the A-76 process we
would have avoided at least part of the problem where a lot of
attention was focused on A-76, No. 1. No. 2, as a result of A-
76 there were lots of people who decided to leave Walter Reed.
I only suggest that I think that problem is endemic not
only to Walter Reed but to other Government agencies. AS
someone who represents a congressional District right outside
our Nation's Capital, I hear regularly from the heads of those
agencies--and I include political appointees in that group--who
say that this A-76 process has significantly compounded their
management problems, the way it has been implemented, not that
contracting out doesn't have an important role, I think it
does, but the way it has been implemented in a fairly
ideological fashion. So I think that recommendation can be
generalized to other Government agencies, as well.
With respect to BRAC, as you know, in terms of the BRAC
process, you have entered into sort of a discussion that is
going on in Congress. Some people have responded to the
terrible situation with regard to the treatment of our soldiers
at Walter Reed by saying we should not move forward at all with
the BRAC process and the transfer. Others have suggested we
should push the accelerator pedal and really accelerate it. In
your recommendations, you say that you might even want to
accelerate or waive the environmental impact statement.
Now, Senator Warner, who is the ranking member on the Armed
Services Committee, has said he doesn't want to short-circuit
the process. I must say, given that part of the lessons at
Walter Reed was the failure to plan in advance for the influx
of wounded soldiers we would have, I would think that we would
not want to short-circuit that planning process. I think in the
long run it will cause more problems for the soldiers who are
being treated, as well as the people who have to provide the
care, if you rush into a situation without adequate planning,
including the environmental impact statements.
Third, I know someone raised the issue of H.R. 1538, the
Wounded Warriors. It has passed the House and is pending in the
Senate. I am interested in your comments on that, whether you
have had an opportunity to review it.
Finally, I was at Bethesda Naval Hospital recently. It is
in my District. Talking to Admiral Robinson there, he said one
of the issues in discussion--and there is not really a meeting
of the minds right now as part of this transfer--is this whole
question of medical hold. It gets a little bit to Congresswoman
McCollum's comments.
At the Bethesda Naval Hospital they were pretty clear that
they tried to push earlier for people to be returned to their
communities and provide care through the veterans hospital
system. This was an ongoing and quite pointed discussion even
as we gather here today with respect to the merger between the
two and the different philosophies. Given the fact that
outpatient care and the medical hold system is clearly
implicated as one of the real problems here, I am curious as to
your view of how to resolve that debate.
Mr. Fisher. I am Arnold Fisher. I would like to address the
point about the BRAC Commission that 2 years ago decided to
close Walter Reed. It is like moving out of your house before
you buy a new one. There is no reason why the addition to
Bethesda on the third floor, which would create 50 new ICU
rooms, can't be done yesterday. I don't understand. We don't
need an EIS. You don't need any approvals. You have to have
plans made and you need to build it. I still to this point do
not understand why that has not been started now.
My problem with all of this is that the one word that has
been mentioned a few times today but is not addressed when it
comes to fixing Bethesda is that we are at war. This is not
peacetime. This is not a time where we can go through 13 months
of EIS approval or to go through 16 months of an architectural
and engineering plan. We are at war. We have to address this
now. In Vietnam we had three wounded to every dead. We now have
16 to every death coming back. We need to take care of them. We
need to have the facility for them. We can't sit around and
wait like we would in peacetime and do it in 2 or 3 years.
As far as the EIS is concerned, it is Government land.
Waive it. Waive it. I know that the environmentalists will kick
and scream, but they are not going to scream and kick as much
as these kids that are coming back without arms and legs. They
can bring them in. We can satisfy them. This is a golf course
we are talking about. You don't have to knock anything down.
You can start it. You should start it now, not wait for 13
months for this approval. We should start Bethesda now.
These kids have not stopped coming back. The first day I
was on this Commission, Secretary West and I went to Andrews
Air Force Base and we watched a C-17 come in with eight
stretchers on it. They come in every day except Thursday. These
kids are coming back. They are being put in buses, taken to
Walter Reed and Bethesda. Now, from battlefield to bed they get
the greatest treatment in the world, but the rooms that they go
into a 30 year old hospital are as big as closets. Their
families cannot get in there to see them. This is wrong. We
need to fix it and we don't need to fix it in 3 years, we need
to fix it now. We don't have to wait 3 years.
When I first got on this Commission and somebody came from
BRAC and told us about the EIS and everything. I hit the
ceiling. This is not right, and I want it changed.
Mr. Van Hollen. Mr. Chairman, may I make a comment?
Mr. Tierney. Certainly. Go ahead.
Mr. Van Hollen. I am interested, as well, in an answer to
the other question with respect to the medical hold, but if
somebody told you that the reason--the BRAC Commission
recommendation came recently. If someone told you that the
reason it is being held up is as a result of the EIS, I can
tell you they were giving you a story. That is not what has
been holding it up.
Now, what I want to know is if the Commission took a review
of the entire BRAC recommendation process. My colleague here,
and I am sure you will hear from her, Ms. Norton has pointed
out that maybe, if, instead of moving Walter Reed, we spent the
time investing in rehabilitating the facilities that you talked
about, that you would get the result you talked about. So the
issue is there are different ways. I am not going to weigh in
to that particular controversy right now, but I don't know if
your Commission reviewed in detail the BRAC recommendations and
reached a conclusion as to whether or not their original
recommendation was the most appropriate in terms of providing
medical care.
I happen to think they made a pretty good case, but I am
not sure, during your review, I certainly don't see that
analysis in this report, a thorough review of whether or not
their original decision was right, given the circumstances we
are facing right now.
I think every member of this committee feels exactly like
you do, that our priority has to be making sure that our people
get care, the soldiers returning get the care that they need. I
don't think any member of this committee is going to be second
to anybody in maintaining that objective.
So the question isn't whether, the question is what is the
best way to do it, and it is not clear to me that your
committee had the time or the resources to undertake a full
review of the BRAC recommendations.
Mr. West. Mr. Van Hollen, if I may?
Mr. Van Hollen. Mr. Secretary, the time is expired but I
would like you to respond to that.
Mr. West. Thank you, Mr. Chairman.
Mr. Van Hollen. Thank you.
Mr. West. I will be brief. You are correct. We are not
experts in BRAC. What we are experts in is urgency, the urgency
of those who spoke to us, the urgency, as mentioned by Mr.
Fisher, but we are not experts in BRAC and we realize that
others may make, based on a better understanding, a different
choice.
I remember my colleague General Roadman mentioned a minute
ago, he said something about cost. He said that is not our
problem. Actually, they are our problems, but our mechanism for
dealing with it is simply to make a recommendation based on
what we have heard and had a chance to see. But you are right,
we did not undertake a thorough study of the BRAC process.
Others have.
What we have to say is this: there has to be no
deterioration of what is happening at Walter Reed as we go
through whatever process goes through, because the key thing is
the care for these youngsters. There has to be appropriate
medical treatment and availability here, at Fort Belvoir, and
at Bethesda in such a way as can accommodate that sense of
urgency that we have.
But no, we are not the BRAC experts, but we do not claim to
be.
Mr. Tierney. I thank the gentleman.
Ms. Holmes Norton.
Ms. Norton. Thank you very much, Mr. Chairman. As a member
of the full committee I appreciate the opportunity to sit in
and question these witnesses. And I very much appreciate the
candor of your report and how rapidly it was concluded.
This committee is singularly interested, first, in
stabilizing Walter Reed and other facilities, and then
improving them. There is a tendency on this panel, particularly
the last lecture that was given by my colleague, Mr. Van
Hollen, the lecture to the tendency to conflate what, in fact,
has come out of these hearings and out of the Washington Post
stories, to conflate two issues: medical care and outpatient
care. We are not going to allow that to happen here. We are not
going to allow medical care to become a cover for the problem
that the soldiers tell us is the problem they have.
The House has not said that there should be no Walter Reed
built in Bethesda, no new hospital. The House has said that it
is inappropriate in the middle of a war to say that we are
going to close a hospital and build a new one. Let me tell you
why. We are aware that we are in the middle of a war. We are
aware of the deficit that has been built up in the last 5 or 6
years. Are you aware that nobody has appropriated the $2
billion it will take to build a new Walter Reed?
And if you are not, let me tell you this. If, after the
testimony we have had here, the House were to come forward with
a bill for $2 billion for bricks and mortar rather than putting
that money into where the grievance is, in the outpatient
system, there would be bipartisan fury, because we haven't had
one complaint about the hospital.
I have been into the hospital, sir. I have been into the
rooms, and I don't recall any closets. I have talked to
patients, as have many on our panel. What we have learned is
over and over again now, not only Walter Reed but veterans'
hospitals all across the country, we are inundated at not only
veterans' hospitals, sir, but veterans' hospitals [sic]. We now
have an outpouring of complaints because people now feel they
can speak up.
So we have a problem, we in the Congress. When we had our
first hearing I asked the generals--there were four of them--I
asked them a straight question, has the possibility of the
closure of the hospital had any affect on retaining or
attracting personnel. To the last general they said yes. If I
can quote one of them, Army Vice Chief of Staff General Richard
Cody--this is only one of the statements--``We are trying to
get the best people to come here to work, and they know in 3
years that this place will close down, and they are not sure
whether they will be afforded the opportunity to move to the
new Walter Reed National Military Center. That causes some
issues.''
Your answer apparently is to eliminate the environmental
impact statement. If you think that is a problem for the
environmentalists, I don't think you understand the Congress of
the United States, or dispense with the A-76 process and hurry
up the process.
Let me ask you this: if you were in our position, the
position of the U.S. Congress, faced with a war we have to fund
no matter what happens, faced with the rebuilding Iraq that we
have to do no matter what happens, faced with now chronic
neglect of domestic issues and pressure from all of our
constituents to get to it and to do something there, faced with
a deficit that we are committed now to halting and breaking
down, what would your priority be? I want the same kind of
candor from you that your report shows. If you had a choice
between spending the money on outpatient care and veterans'
facilities, a new hospital, what would you advise the Congress
to do?
Mr. West. Congresswoman Norton, I will give a specific
answer to the question you just asked. I would advise you to
look at the facts that we have gathered, look at the facts that
are available to you, look at the allegations of what is good
there at Walter Reed and what is not, how the maintenance is,
how the rooms are. Look at those facts. Look at the costing of
the estimates of what is necessary to be done at Walter Reed to
keep it going forward, remodeled, reinvigorated, the facilities
fixed and the like. Compare those with the cost of moving to a
new facility and doing that, and make a judgment on that basis.
Ms. Norton. But the $2 billion hasn't even included the
cost of equipment, just the cost of putting the bricks and
mortar up.
Mr. West. I have seen the costs. I have seen a cost workup
that was done for another committee. I have looked at that. I
tell you that is the way I would do it.
What we are after is one thing, and one thing only:
whatever resolution will get the best resolution of two things,
one, a need for facilities in which the medical care can be
delivered, but also the resolution of the rehabilitation, as
well.
Ms. Norton. Which is the problem before us. The problem
before us is the outpatient care, I remind the panel.
Mr. West. Right.
Ms. Norton. The problem before us is not the care at Walter
Reed Hospital. To the credit of the hospital, there has not
been a single complaint I know of about the hospital. In fact,
it remains the premiere military hospital on the planet.
Mr. Marsh. Delegate Norton, if I could add to that--and I
know that time is running short--from the standpoint of the
Commission, we were tasked with a single task: look at the army
medical services, particularly problems at Walter Reed, and, to
a lesser extent at Bethesda, which are much, much less. What we
were confronted with, I suspect maybe members of the
Commission, if we had been voting on BRAC might have had a
difference of view, and many might well have agreed with you.
But we were confronted with a BRAC decision, had been
accepted by the Congress of the United States, enacted into
law, and signed by the President of the United States, so we
had to deal with the situation. This is a matter of law and it
has been directed by the Congress of the United States that we
go forward with it, and so we made our recommendations that
were consistent with that.
Mr. Tierney. Thank you very much.
I want to thank the members of the panel, as well as the
Members here. I think it has been very helpful, and certainly
the report that you did was very extremely helpful. We thank
all of you, including Admiral Martin, who didn't get to sit at
the table on that, but we do acknowledge her work and George
Schwartz' work, as well. We have great admiration for the fact
that you were able to get it done in such a short period of
time and have it be so thorough with the significant respect
also for the fact that you dedicated your time and energies to
this. We know that you are all busy individuals in your own
right, and it is a patriotic and great act of citizenship that
you did this, and we thank you very, very much.
That will end the testimony from the first witnesses. The
second panel will please take the seats when you get a chance.
Thank you, again.
We will now hear testimony from the second panel of
witnesses before us today. Thank you for your patience and
thank you for taking the time to be here during the first
panel's testimony. I think it would be helpful as we converse
here.
I would like to begin by introducing our panel. On this
panel we have Mr. Michael Dominguez, the Principal Deputy Under
Secretary of Defense for Personnel and Readiness; Major General
Gale S. Pollack, the Acting Army Surgeon General and Commander
of the U.S. Army Medical Command; and Major General Eric
Schoomaker, Commander of the Walter Reed Army Medical Center.
Welcome to all of you. Thank you for your service to your
country and your willingness to be here today.
It is the policy of the committee to swear you in before
you testify, so I ask you to stand and raise your right hands.
Anyone else who is also going to be responding to questions, if
they would please rise, as well.
[Witnesses sworn.]
Mr. Tierney. May the record indicate that the witnesses
answered in the affirmative.
I am going to provide you the opportunity, if you would, to
give a summary of your testimony. As you know, we provide about
5 minutes for that. We would like you to try to stay within
that, if you could, and summarize. Your statements will be put
in full into the record, and then we would like some time to
have a colloquy and some questions back and forth.
Mr. Dominguez, perhaps you could start.
STATEMENTS OF DEPARTMENT OF DEFENSE AND ARMY OFFICIALS: MICHAEL
L. DOMINGUEZ, PRINCIPAL DEPUTY UNDER SECRETARY OF DEFENSE
(PERSONNEL AND READINESS), U.S. DEPARTMENT OF DEFENSE; MAJOR
GENERAL GALE S. POLLACK, ARMY SURGEON GENERAL (ACTING) AND
COMMANDER, U.S. ARMY MEDICAL COMMAND (MEDCOM); AND MAJOR
GENERAL ERIC SCHOOMAKER, COMMANDER, WALTER REED ARMY MEDICAL
CENTER
STATEMENT OF MICHAEL L. DOMINGUEZ
Mr. Dominguez. Thank you, Mr. Chairman, distinguished
members of this subcommittee, thank you for this opportunity to
discuss support and care for our wounded soldiers and their
families.
As you know, we have just received the draft report of the
Independent Review Group established by the Secretary of
Defense. We very much appreciate their work and their
recommendations. We will be working to coordinate the
Department's review of those recommendations for approval by
Secretary of Defense Gates.
We are currently staffing the recommendations of the
Interagency Task Force chaired by Secretary Nicholson of the
Veterans Affairs Department.
I can't articulate a clear action plan in response to the
Independent Review Group findings until our Departmental review
is complete and the Secretary has directed action. I would note
that the Department has not been waiting for the report to
address matters of identified concern.
For example, we have requested an adjustment to the fiscal
year 2007 emergency supplemental to provide $50 million so that
we can implement in this fiscal year improvements to support
and care for the wounded.
The Army has taken aggressive action to make improvements
at Walter Reed. I defer to my colleagues at the table to
address those actions.
The Office of Personnel Management provided direct hire
authority for over 100 patient care positions. As a result the
Army made 125 job offers at a recent fair.
Our first survey of wounded warriors and their families is
being fielded this month, with results expected in June. We
have been working through our Joint Executive Committee, with
the leadership of the Department of Veterans Affairs, on
improving the flow of electronic information and records
between VA and DOD.
I have described our efforts in my written statement.
We are thoroughly engaged in seeking the correct
configuration for our disability evaluation system. A joint
team of DOD and VA leaders begins that redesign this afternoon.
In addition, in partnership with the VA, we are preparing a
comprehensive plan to address TBI. The goal is to coordinate
our efforts into a comprehensive program of research,
education, treatment, and program evaluation.
We are supporting the President's Commission on Care for
America's Returning Wounded Warriors, which is taking a
comprehensive look at the full life cycle of treatment for
wounded veterans returning from the battlefield. We expect
their findings in June or July.
In October we expect the report of the Veterans Disability
Commission chaired by Lieutenant General Retired Terry Scott.
This group was chartered by the National Defense Authorization
Act of 2004.
Correcting the fundamental issues underlying our failure at
Walter Reed will require legislation. Legislation that
addresses root causes, however, will look substantially
different than legislation that treats symptoms. We have been
working this problem hard for several weeks now, but we don't
yet have a clear picture of the legislation needed to correct
the root causes. We hope that the IRG's report will help us
move down the learning curve there. When we have that picture,
we are committed to bringing it quickly to the Congress for
action.
Mr. Chairman, I look forward to your questions.
[The prepared statement of Mr. Dominguez follows:]
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Mr. Tierney. Thank you, Mr. Secretary. I do note, however,
that the last hearing we had on March 5th, where we asked the
witnesses there from a similar panel how much time we ought to
give for review on where they have been and where they have
gone, 45 days was the date given, so I know I have read General
Pollack's statement. I think she is going to be a little more
distinct in what she says has been done to date. But I am
hoping we have some things accomplished and not just waiting
for other people to file reports on that.
Mr. Dominguez. Yes, sir, we are moving out and we have
accomplished many things.
Mr. Tierney. Thank you.
General Pollack, please.
STATEMENT OF GENERAL GALE S. POLLACK
General Pollack. Mr. Chairman, distinguished members of the
subcommittee, I am delighted to have this opportunity to
discuss with you the actions the Army is taking to improve the
way that we care for and support our warriors in transition and
their families. I also want to thank the former Secretaries of
the Army, Secretary Marsh and Secretary West, for their
leadership on the Independent Review Group. The work of the IRG
and the other commissions viewing the Department of Defense
physical disability evaluation system is very important as we
continue to re-engineer the Army's medical and physical
evaluation system.
Our Army medical action plan is fast-paced and flexible so
we can quickly assimilate the recommendations from these groups
into our ongoing efforts.
On March 5th, Secretary Garon, General Schoomaker, and
General Cody testified before this subcommittee at Walter Reed
Medical Center and vowed that the Army would work aggressively
to identify and fix the problems at Walter Reed. They told the
subcommittee ``we would not wait for reports or
recommendations, but that we would fix things as we go.'' This
is exactly what we have been doing.
On April 3rd, the Army's medical holdover Tiger Team
included an exhaustive study of the Army's 11 key medical
treatment facilities. This team included experts in finance,
personnel management, medical care, and representatives from
the U.S. Army Installation Management Command. The Tiger Team
not only inspected facilities to identify problems, but also
sought best practices in the care and support of those warriors
in transition. These practices can be applied at Walter Reed
and implemented across the Army Medical Command.
The team found that outstanding and innovative work is
being done by many great Americans, military and civilian,
given available resources. There is ample evidence that
warriors are receiving high quality health care and are
generally satisfied with our efforts and their clinical and
administrative outcomes.
The team identified several best practices, including the
establishment of a deployment health section, dedicated medical
evaluation board physicians, and scheduling followup
appointments with the Department of Veterans Affairs prior to
their separation.
On March 19th the Army established a 1-800 hotline for
warriors and their families who want to raise their concerns to
the Army leadership. The hotline allows soldiers and their
families to gather information about medical care, as well as
to suggest ways to improve our medical support systems.
The hotline rings in the Army Operations Center and all
calls are logged, tasked for followup within 24 hours, and
briefed weekly to Army leadership.
As of April 9th, the Army had received 848 calls detailing
468 distinct issues. Of this total, only 245 were medical
issues, and 162 were tasked to the Army Medical Command for
research and resolution.
Last week, in answer to one of the Members' questions, we
trained 23 soldiers to work as warrior ombudsmen across the
Army Medical Command. The ombudsman is considered another
warrior resource and is not a means of circumventing the
soldiers' chain of command. The intent of this program is to
help cut through the red tape by linking soldiers and family
members with the correct sources of information in order to
answer questions or resolve issues emanating from a lack of
understanding or simply confusion.
This plan ensures that soldiers have additional advocates,
while we correct the administrative process that will require
policy or legislative change.
We have much work to accomplish. We are aggressively
improving the existing physical disability evaluation system to
minimize the difficulties soldiers have faced. The system was
developed half a century ago and has become overly bureaucratic
and too often adversarial. You have heard that often today.
The Army is developing initiatives to overhaul or replace
the current process. Rather than settle for yet another attempt
to re-engineer current processes, our goal is to eliminate the
bureaucratic morass altogether and develop a streamlined
process to best serve our soldiers.
As we move forward, there will be areas of policy, process,
and administration requiring full collaboration and
coordination between both DOD and VA. We have worked together
in the past, and it is imperative that we expand that
partnership to clarify the issues, fix the problems, and
improve the process for our servicemen and women.
We are under no allusions that the work ahead will be easy
or cheap or quick. We have a lot to do to get this right.
Fixing the myriad issues we have recently uncovered will take
energy, patience, determination, and, above all, political
will. Soldiers are the centerpiece of your Army and the focus
of our efforts. Soldiers should not return from the battlefield
to fight an antiquated bureaucracy. Wounded, injured, and ill
service members and their families expect and deserve quality
treatment and support as they return to their units or their
communities.
We know that the President, Secretary Gates, Secretary
Nicholson, Secretary Garon, the Congress, and the American
public are committed to this effort, as it is the cornerstone
of everything we are doing. With your help and the help of all
the agencies involved, we are confident that we can match the
superb medical care soldiers receive at the point of injury or
illness, whether on the battlefield or during training, with
simple, compassionate, and expeditious service that ensures
every soldier knows the Army and the Nation are, indeed,
grateful.
Thank you, again, for your invitation to testify. I look
forward to your questions.
[The prepared statement of General Pollack follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Tierney. Thank you, General.
General Schoomaker, do you have a statement?
STATEMENT OF MAJOR GENERAL ERIC SCHOOMAKER
General Schoomaker. Mr. Chairman, Congressman Shays,
distinguished members of the subcommittee, I am Major General
Eric Schoomaker. I command the U.S. Army North Atlantic
Regional Medical Command and the Walter Reed Army Medical
Center.
I join Major General Pollack and the Department today in
thanking the subcommittee for the opportunity to discuss the
many improvements in living conditions for our patients at
Walter Reed campus, our efforts to improve command and control
and accountability for soldier welfare, and what we have done
to build a warrior-centered and a family centered program at
Walter Reed and throughout my regional medical command and
beyond, to the medical command of the whole Army.
First, I want to reassure the committee and the Congress
the Army, the U.S. military, the American people, that the
quality of medical and surgical nursing, psychiatric,
rehabilitative, and other care that is delivered at Walter Reed
Army Medical Center, our sister medical treatment facilities
within my region that include Fort Bragg, NC; and Fort Knox,
KY; and Fort Drum, NY, and others. The U.S. Army Medical
Command under General Pollack has never been in question and
remains the highest quality. Frankly, it was heartening to hear
Congressman Shays say that we provide an unparalleled level of
care within our hospitals, and that survival on the battlefield
has reached unprecedented levels in the history of American
warfare.
Shortly after national attention was drawn to Walter Reed
and our care of wounded warriors, an unannounced inspection of
the hospital was conducted by the Joint Commission. This is the
Nation's leader in accrediting hospitals and health care
systems. We were reassured by their finding of high quality
health care overall, while directing us to areas of
improvement, especially in the transition from inpatient to
outpatient care. We fully addressed these areas with a
comprehensive program for outpatient warrior care management,
some steps of which I will outline in a few minutes.
The Army and the DOD leadership pledged that we would fix
the problems as they were identified. I think that has been a
question from the subcommittee all morning. Armed with insights
derived from media accounts, your subcommittee's earlier
hearings that were held at Walter Reed on March 5th, town hall
meetings I conducted personally immediately after taking
command over a month ago, and the excellent recommendations
provided by the Independent Review Group under former
Secretaries of the Army, Marsh and West, and many others, we
have done exactly that. We are eagerly applying best practices
from our colleagues in the Army Medical Command and Navy and
Air Force medicine, and we are actively seeking new ideas for
improving care, for administrative oversight, and services for
patients and families during this important transitional period
in their lives. We call these soldiers warriors in transition.
They are returning to duty after an injury or an illness. They
are returning to full and productive civilian life after a
recovery. Or they are retiring with a medical disability for
continued care and rehabilitation, and hopefully employment
within their communities.
We are clear to separate those issues which are unique to
the Walter Reed campus for which I am accountable, those that
are Army- and DOD-wide problems, and those for which solutions
lie in the interagency area.
All patients, I can reassure you, were moved out of
Building 18 almost immediately. They have been moved into newer
barracks on the installation. Many of you have come and seen
those new barracks. The building, Building 18, will never again
be used to house patients or families. The new barracks have
been further upgraded with state-of-the-art computers and
communications. The Army has been extremely forthcoming with
that and very aggressive in their support.
A comprehensive survey of all critical housing and life
support infrastructure on Walter Reed installation is being
conducted, and repairs are being performed on a priority basis
as they are identified by this team.
The Acting Secretary of the Army and the new Chief of Staff
of the Army have made it very clear that we should restore
Walter Reed to a standard which makes all of us proud to work
and live on that installation until we build and occupy the new
Walter Reed National Military Medical Center with our Navy
colleagues in Bethesda, MD, under the provisions of the BRAC
plan.
Among the most important improvements is the infusion of
new leadership officers and non-commissioned officers,
beginning with my new Deputy Commander, Brigadier General Mike
Tucker, a combat veteran and a line commander--he is our
bureaucracy buster, as he has been called--and our new Warrior
in Transition Brigade Commander, Colonel Terry McKendrick, also
a combat veteran, and his Command Sergeant Major, Jeff
Heartless, who, as a combat veteran, has also been a patient in
our hospital and is very savvy about the problems that soldiers
and warriors confront.
With my new Command Sergeant Major Althea Dixon, we have
given every warrior in transition a new chain of command with a
smaller span of control for added accountability for their
welfare. Additionally, we have added better trained nurse case
managers to ensure fluid administrative processes, and primary
care physicians for assurance that medical care is coordinated
and is of the highest quality.
I am here today to answer any additional questions you may
have for me or my command about the improvements in care, our
living conditions, and the administration of this critical
transitional period in the lives of our soldiers and their
families. Thank you again for the opportunity to serve in this
fashion.
Mr. Tierney. Thank you all for your statements.
Mr. Braley, you have 5 minutes.
Mr. Braley. Thank you, Mr. Chairman. Thank you to the
panel.
Mr. Dominguez, let me start with you. You talked about the
supplemental request for $50 million for the medical support
fund. Were you aware that in the supplemental passed by the
House there was $1.7 billion above the President's budget
request for DOD medical assistance, and also $1.7 billion of
additional funding for the VA?
Mr. Dominguez. No, sir.
Mr. Braley. I would suggest that you talk to people within
the Department to see what can be done within the parameters of
those additional appropriations to find room for the $50
million, which I think would be a completely appropriate use of
that funding that was added to the supplemental.
Mr. Dominguez. Congressman, Secretary Gates is committed to
fixing the problem and doing what is right. That is his
standard he has set. As we were talking about before the
hearing with the chairman, the resources are available. It is
about making tough choices. I appreciate that the Congress has
made those choices in enacting the supplementals that you have
done. We will make the tough choices, too, to get the job done.
Mr. Braley. One of the issues that seems to come up over
and over again is the whole inconsistency in the disability
evaluation process between the DOD and VA disability system,
and one of the concerns that is identified in the written
statements has to do with that process becoming adversarial,
which is something you identified and General Pollack, you also
mentioned.
The reason why those systems become adversarial is because
patients feel like they aren't being taken care of and their
concerns aren't being heard. I did town hall meetings with
veterans groups throughout my District the last 2 weeks when we
were back in recess, and this is the No. 1 concern I heard from
veterans advocacy groups is the backlog of disability claims,
and that is why at the March 5th hearing I specifically asked
the final panel how many patient advocates were there to assist
people in the disability process at Walter Reed.
It was very disturbing to me that there was a
misunderstanding of the role that case managers and patient
advocates play, and one of the concerns I have about an
ombudsman program is typically an ombudsman is a clearinghouse
for complaints that has the authority to hold hearings and take
action on behalf of a group of dissatisfied individuals, but
when you are dealing with the complex bureaucracy that exists
in the VA and DOD disability systems, you need someone there by
your side helping you on your behalf. Whether that is an
adversarial process or not is going to depend, in large part,
on how the environment is created for the processing of those
claims.
I would like to hear what institutional changes are being
made within the DOD to make sure that adversarial environment
is reduced.
Mr. Dominguez. Congressman, what I will tell you is that
these are works in progress now. We have all heard the same
thing that you have heard, that the process is cumbersome,
bureaucratic, unfriendly, and it loses that focus on the
soldier and the family around the wounded warrior. We all
recognize we have to turn that around and we have to re-
engineer the processes.
Now, several efforts are going on right now to look at
that. Each of the services, as they have great discretion in
how their process works, is working on that. There is training
involved for the people that we put in to guide the warriors
and their families through that process.
That is ongoing. We don't have all the solutions yet. We
are working them aggressively.
As I said in my opening comments, when I leave here today I
am going to join the leadership of the Veterans Administration
with some of my colleagues from DOD, and we are beginning the
redesign of the disability process for both our agencies and,
again, hope to have that implemented expeditiously.
Mr. Braley. General Schoomaker, at the March 5th hearing I
commended your brother for having the courage to say that PTSD
is real. Part of the concern I have is when we label all of
these measures with the words wounded warrior it brings about a
history that has evolved over centuries of what it means to be
a warrior and doesn't leave much room for people who suffer
from post traumatic distress order or closed-hit injuries that
are diagnosed as mild traumatic brain injuries, and give people
the sense that there isn't a significant impairment that comes
about to those individuals.
I admonished him at that time to make sure that message was
communicated down the chain of command and into the DOD and VA
health care treatment facilities to change that culture. Can
you shed any insights on what is going on under your command to
make sure that those injuries are treated and are perceived
just as real as a penetrating injury?
General Schoomaker. I appreciate the question and I think
you are right on target. I think the Army, especially, has
taken a very active and aggressive role in recognizing that we
are in an era right now of emerging science and medicine in
understanding the nature of injuries in their totality of 21st
century war. Some of these injuries have undoubtedly been with
us since warfare began and hostile conflict began. Others might
be elements of the newer forms of urban warfare and the weapons
that are being used against us and our soldiers, sailors,
airmen, and Marines.
But the fact is the DOD has leaned forward as far as we can
and needs to go further in understanding what it means to have
mild traumatic brain injury. I think you heard that from the
first panel here. We need some fast but good science to best
understand that, and many of us have suggested that the new
Walter Reed National Military Medical campus be a warrior care
center of excellence to include work on that.
Fortunately, Congress, in the NDAO-6 legislation gave us
language to coordinate, synchronize all research and treatment
within the DOD under a blast injury program which is now being
put together through the Army's Medical Research and Material
Command, my last command.
I would have to also say that changing the culture is
difficult, and we again are leaning forward as much as possible
by getting leaders, leaders, themselves, leaders of war-
fighting units coming back in the Marines and the Army,
wherever they might be, to bring their soldiers with them as we
do the mandatory screening for stress disorder-like symptoms,
because those symptoms, if recognized and treated early, do not
result in a lifelong, we believe, disability from PTSD and mild
traumatic brain injury.
Mr. Tierney. Thank you.
The gentlewoman from Minnesota, Ms. McCollum.
Ms. McCollum. Thank you, Mr. Chairman.
To followup on the PTSD and the traumatic brain injury, how
often do you screen for that? If I have a loved one who comes
to Walter Reed, how often are they evaluated for PTSD or
traumatic brain injury?
General Schoomaker. Well, ma'am, we screen as often as it
is needed as often as symptoms dictate that we should be asking
about that, but it is mandatory that every soldier, sailor,
airman, Marine on deployment is screened prior to that
deployment.
Ms. McCollum. The reason why I ask the question is--and I
don't know if this is at all the VA centers, but the VA, every
time one of our soldiers comes in now, has a screening that
pops up that does a quick evaluation, not an in-depth, but a
quick evaluation to see if that soldier might be facing post
traumatic stress syndrome or traumatic brain injury that wasn't
diagnosed right away. Are you doing that at the DOD?
General Schoomaker. We don't have that tool, but we do
have----
Ms. McCollum. I have some other questions.
General Schoomaker. Yes, ma'am.
Ms. McCollum. And I don't mean to be rude by cutting you
off.
General Schoomaker. No, ma'am.
Ms. McCollum. I realize you are all talking to each other,
so I am sure Mr. Dominguez is going to work with the VA to find
out what they have, because if they have something we don't
need to reduplicate the wheel.
Who places the DOD service personnel in the VA hospitals?
General Schoomaker. That is on a case by case basis. In the
case of a soldier coming back to Walter Reed or any of our
facilities--and General Pollack may want to add to this--we
have relationships with VA hospitals across the country in our
local communities. We also have four large VA poly trauma
centers.
Ms. McCollum. I wanted to know the DOD personnel--excuse
me, I might have been too brief in asking my question--who is
there to help a soldier who has been transferred to the VA
system who still might be in the Department of Defense payroll,
and to make sure that person has someone there who can answer
questions. My understanding, and I will tell you this, is that
there was one individual who was assigned to cover all the
different branches of service, which all have different rules
and regulations, at our VA system in Minneapolis, and the VA
greatly appreciated having that individual there, but through
no fault of the VA or the individual who had been assigned by
DOD they rotated out every so many months. So I want to know do
you know who is responsible for having that individual assigned
to a hospital?
Mr. Dominguez. Congresswoman, we will have to look at that.
We don't have that clear in policy.
Ms. McCollum. And I bring it up because I think it needs to
be cleared up in policy.
There is a big difference between having a patient who has
a case worker assigned to them, an advocate assigned to them,
and an ombudsperson assigned to them. Those are three different
roles. So you said that you have trained, Ms. Pollack, 23
people in the Army to be ombudspersons. Now, an ombudsperson is
probably not the first person you should start with, going
through a system, because that person is going to be a pit bull
against the Army for the patient, and I want to know what level
this individual is really advocating for, because if they have
to report back to the Army, if their promotion and everything
is dependent upon the Army, it makes it very difficult to put
somebody in a position to be at times aggressively in the face
of the Army. So what have we trained here? More case workers?
More general advocates to help with red tape? Or people who are
going to be in the face of the Army on behalf of the patient?
General Pollack. I think that in this position, ma'am, they
will be in the face of the Army Medical Department, because it
is the Army that wants it done, and therefore the Army will
support them and they will be haranguing us inside the Medical
Department if we are failing the soldiers. So I think that for
the time being it is a good option. Many have raised the fact
that now there are so many people engaged in the care of the
patient, and that was one of the complaints that we had from
the soldiers, that there were too many people engaged and they
didn't know who their advocate was. They didn't know who to
turn to. That is why I am very hopeful that, as we place the
nurse case manager into position so that when the service
member arrives at the facility they are assigned to a nurse
that will be with them through their inpatient procedures as
far as oversight, not the moment-to-moment care, but the
planning and interaction with the family, and then continue
with that service member through their entire transition
process.
Ms. McCollum. Mr. Chair, can I ask for a qualification?
Mr. Tierney. Briefly, sure.
Ms. McCollum. OK. So what is the job title of these 23
people? Are they an advanced case manager? I mean, you just
described case managers. Is that the 23 individuals that the
Army has brought on?
General Pollack. No. No, I was saying that there are people
that are going to be very closely aligned with the service
members as soon as they arrive and will stay with them, and I
think that we are going to see over time that----
Ms. McCollum. Thank you. The Chair asked us to be brief.
If you could please provide to this committee what you are
doing on these three different levels.
General Pollack. Certainly.
Ms. McCollum. And who do they have to report for and how
much autonomy that they have. Thank you.
Mr. Tierney. I thank the gentlewoman.
Mr. Shays.
Mr. Shays. Thank you, Mr. Chairman. Again, thank you for
holding this hearing.
General Pollack, there is a view that I hold and I think a
number of other people hold that doctors do not really consider
medical administration issues as part of their charge. I think
you see that even in private hospitals, as well. In other
words, doctors are for medicine and administration is for case
managers.
What I would like to ask you is: what current policies or
directives does the Medical Command have for medical
administration staff that work with patients? First, do you
agree with that assessment? Second, if so, how do you want to
deal with it?
General Pollack. I would disagree with that assessment for
the Medical Command, because the men and women that serve as
our physicians are also volunteers, and they would not be there
if they were not interested in caring for the men and women in
uniform. So I have always seen them as advocates for our
patients.
The nurse case manager that I raised a moment ago I think
is part of that. What we are developing now is a triad with a
physician, a nurse, and a line soldier, a non-commissioned
officer, to be the group of three that is able to manage all
the different pieces to ensure that patient can smoothly go
through their transition and have everything coordinated. By
bringing in the different perspectives, I think that we are
going to have a much more satisfied population.
Mr. Shays. Then what accounts for the problems we have had?
General Pollack. I'm sorry?
General Schoomaker. What accounts for the problems that we
have had? I mean, we know the problem exists. I was trying to
identify why it might exist. So you tell me why it exists.
General Pollack. Why does the problem in the
dissatisfaction of the patient in the process?
Mr. Shays. Yes. And, well, first off, you can say it that
way or we can say the fact that they deservedly can be
dissatisfied because of what, and then tell me why.
General Pollack. Well, I think that dissatisfaction is
related to the length of the process. The challenge is in
explaining to people sometimes why rehabilitation and the
length of rehabilitation needs to be in a certain timeframe.
Mr. Shays. That is really not the problem. I mean,
otherwise, you are saying that it is just a perception of the
patient because they just don't understand how difficult this
issue is.
General Pollack. No.
Mr. Shays. And we have literally at one time close to 100
cases that this committee was trying to help with individuals
who are getting lost in this administrative Byzantine process.
We are well beyond that. I was trying to throw out the fact
that I think doctors want to be doctors and they don't want to
be administrators. It wasn't meant to be unkind, it was just
meant to explain something. So if that is not the answer, is it
because everybody is not communicating with each other because
of paperwork and technology? What is it?
General Schoomaker. Could I just make a comment, ma'am?
General Pollack. Sure.
General Schoomaker. With respect, sir, I think what I hear
General Pollack saying is--and I think I need to say this, as
well. One of the real heartbreaking aspects of everything we
have gone through is that, whether you are a physician in
uniform or a nurse or an administrator or whether you are an
NCO, whether you are a civilian employee, we all like to feel
very strongly that we are advocates for the patient. I think it
speaks to how badly broken the system is right now that the
patient at the end of the day and his or her family feels that
we are all part of an adversarial system.
I think we all play a role in every case in trying to do
best by these soldiers, ill and injured, irrespective of what
the route of their injury or their illness is.
What we understand, and I think the point about the
ombudsman I think points this out, is that we need as part of
that plan to have, standing aside from the rest of us, because
at the end of the day the patient and his or her family may
feel that we are part of their problem, is to put someone in an
ombudsman or a patient representative's role. At Walter Reed
right now we have four patient representatives who are
ombudsmen for patients who can bust through bureaucracy for
them. They were there before. We didn't put enough emphasis on
that role. We have three new ombudsman that General Pollack has
brought in for us to serve in that capacity.
But I think the causes of what you have seen here, as the
IRG has laid out, are myriad. We start at Walter Reed with the
fact that we didn't have a primary care base system, and we are
working on that.
Mr. Shays. My red light is on, and obviously we could
probably go on since there is just three of us, but I would
suggest to you that, you know, an ombudsman is helpful, but an
ombudsman is someone who steps in when the system has broken
down.
Could I make my motions now?
Mr. Tierney. Yes.
Mr. Shays. I mean, one of the things that it seems to me we
need to be doing is we need to create, obviously, a Defense-
wide ombudsman office that people can turn to. This is one of
the suggestions that has come out of the work of our committee
that you served on, as well, last time. I would like to submit
this for the record. It is H.R. 1580.
Another one, this was actually advocated by Mr. Bilirakis
this year. Another one is by myself and Mr. Davis, and this
establishes a monitoring and medical hold over for performance
standards. That is H.R. 1578.
Another is 1577, submitted by myself and others, and this
is to create a Department of Defense wide program of patient
navigators for wounded members of the armed forces, people who
actually take on each individual patient and walk them through
the process.
Finally, one to create a standard per-soldier patient
tracking system that goes from one branch to the other.
I would just like to say I would love a hearing, Mr.
Chairman, and I think that you would be inclined to want to
look at it, and I think the committee is already, but just the
hand off from the active armed forces to our veterans, because
we are having just an abysmal time getting records of
individuals once they go into the VA system. It is like somehow
there aren't any records for our military personnel. You are
not going to be holding on to these folks indefinitely. They
are ultimately going to be veterans.
I know we are all wrestling with this issue but it actually
took pictures to get the military to want to do something in
the way that they are doing it now. It took pictures. Yet, I
think as you know, Mr. Schoomaker, Building 18 does not define
Walter Reed in one way or the other.
Thank you, Mr. Chairman.
Mr. Tierney. Without objection, copies of those bills will
be added in the record.
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Mr. Tierney. Thank you, Mr. Shays.
General Pollack, I don't want to ask you a question on this
but I just want to make a quick point on that. I think attitude
is important, and I think that the report that was filed by the
IRG had some comments to make on what has been happening in the
past and also the leadership issues there. You were on record
on March 13th indicating that the media, you sort of attacked
the media, down-played the problems at Walter Reed, and I think
your quote from your e-mail read that the media makes money on
negative stories, not by articulating the positive in life.
Then you added that you then went on to articulate your
displeasure with the misinformation about the quality of care.
I hope that is an indication that you were trying to
distinguish between those parts of the service that had been
working will, but an acknowledgment, at least, that much has
gone wrong, because if you are going to be the leader of this
situation and now you are going to sit here and tell us that
nothing is wrong in the face of the IRG report, our March 5th
hearing, and the numerous other reports on that, I think I
would be a little hard-pressed to think that you would be the
person that should be responsible for fixing it.
General Pollack. May I make a comment?
Mr. Tierney. If you would like, sure.
General Pollack. The purpose of that e-mail was because the
staff across the MEDCOM were reeling from all of the
negativity, and we have men and women in and out of harm's way
that have been working very, very hard, and it was my attempt,
as one of the senior leaders, to remind them that they are
doing a number of very good things and not to stop doing those
things.
Sir, I joined the Army because my big brother had his leg
blown off in Vietnam. I am very, very committed to the care of
the men and women who serve. I am not going to pretend at any
time if something is broken that it is not. But at the same
time, I needed to reach out to the staff, and that was what the
purpose of that e-mail was.
Mr. Tierney. So it is not an attempt at all to fail to
acknowledge that there were things that need correction?
General Pollack. No, sir.
Mr. Tierney. OK.
General Pollack. No, sir.
Mr. Tierney. Thank you.
Mr. Dominguez, in your comments--and I think all three of
you talked about it, as did the first panel--we are talking
about senior leaders of the military departments, of the Office
of the Secretary of State beginning the process of designing a
system optimized for wounded and severely wounded service
members, speeding disability determinations, and providing
support for their transition to civilian life, which Mr. Shays
was just talking about on that. What is going to be done in the
interim for that while we are waiting for those final reports
to come out? Is there anything we can do to make that
transition better in the short run?
Mr. Dominguez. I think the steps that are being taken by
the individual services are actually quite noteworthy in this
regard, because a lot of the discussions that we have had here
are about the patient advocates and case managers and
ombudsmen. One of the things that we didn't discuss, which both
the Army and the Marine Corps have done, is put in for the
wounded warriors a chain of command, assign them to a unit,
give them a squad leader, give them a first sergeant, give them
a commander. If you want a bulldog advocate for taking care of
troops, it is called a first sergeant or squad leader.
Those are now going into place. Those people will have as
their mission, the command's mission is helping that wounded
warrior and family transition either back into service or back
out to civil society. That is the kind of thing that closes the
seams that Congressman Shays was talking about when he was
identifying those different fixes.
The tragedy that these two officers were just talking about
is the total commitment we have of people working inside their
seams, believing that what they are doing is solving the
wounded warriors problem, but not realizing that to the
warrior, who is looking at this as a seamless process, that it
is fragmented and broken and confusing.
Well, a CO, a first sergeant, and a squad leader can fix
that. I think that is the most significant thing that has been
done by both the Army and Marine Corps since your hearing on
March 5th.
Mr. Tierney. Let me take it up a notch then on that. On
page 6 of your testimony you say that we have invited
representatives from the Veterans Administration to sit on the
council to assist the process as we strive for a seamless
transition for our service members from the Department of
Defense disability system to the Veterans Administration
system. We anticipate a revised Department of Defense
instruction will be completed in May 2007.
Mr. Dominguez. Yes.
Mr. Tierney. So you are talking about the Department of
Defense's instructions.
Mr. Dominguez. Yes.
Mr. Tierney. My question to you: has the President clearly
indicated at his insistence that this be a seamless process,
and has he communicated that to the Veterans Administration as
well as to the Department of Defense, and has he designated
somebody from the White House to so ride herd on this thing?
Because you can get your Department of Defense instructions and
the Veterans Administration can get its instructions. The
question is: are they going to be joint instructions and is
somebody from higher up going to give you license to cut across
that and, in fact, insist on it?
Mr. Dominguez. Yes, sir. The President set up two
commissions to advise him. First he put Secretary Nicholson in
charge of an interagency task force and they have spoken on
this issue. We are presently reviewing their recommendations.
And then the President's Commission. So the President----
Mr. Tierney. You said a commission, but is there any
indication that the White House has somebody who is going to be
riding herd on this thing, an individual who is responsible,
who this committee can hold accountable for making sure that is
done, because I don't want to be sitting here criticizing the
Department of Defense when it has done its work and it has
given its instructions and the Veterans Administration has done
its work and done its instructions.
Mr. Dominguez. Right.
Mr. Tierney. It will all come down to the White House as to
whether or not they have them working together and giving them
the support to do that.
Mr. Dominguez. Well, first of all, I conveyed to you
Secretary Gates' and Secretary Nicholson's commitment to fixing
this problem without regard to where the seams are. The
President did put Secretary Nicholson in charge of the
interagency task force, but, again, you know, the President
can't specify what the answer is right now.
Mr. Tierney. He can sure make sure there is an answer.
Mr. Dominguez. But he took these two actions to bring to
him the recommendations for how to fix this, and so from that I
anticipate, you know, a powerful and strong action by the White
House.
In the interim, our two agencies are working very closely
together. I am going to join Under Secretary Cooper this
afternoon, and we are working this problem. And Gates and
Nicholson are passionate about getting this right.
Mr. Tierney. Do you, sir, agree that the physical
evaluation, physical disability evaluation system should be
completely overhauled to implement, one, Department of Defense
level Physical Evaluation Board/Appeals Review Commission with
equitable service representation in an expansion of what is
currently the Disability Advisory Council, as the IRG
recommended?
Mr. Dominguez. Sir, I would like to withhold my personal
judgments on that pending the work that we are going to be
doing evaluating the IRG's recommendations and the work we have
already been doing for the last month or so.
Mr. Tierney. How long do you think it will take you to make
that evaluation?
Mr. Dominguez. Secretary Gates will be back here on April
27th. I think he is scheduled to see the IRG, like, May 3rd or
4th. I expect he will want the DOD staff's recommendations to
him about May 5th.
Mr. Tierney. Directly after May 5th I am going to ask that
you communicate to the Secretary that one of you get back to
the committee with whether or not they agree with that
assessment of the IRG.
Mr. Dominguez. Yes, sir.
Mr. Tierney. And, if they agree that can be done, the
process can be completed within 1 year, as was testified here
this morning, and, if not within 1 year, what would be a
reasonable time for us to expect it to be completed so that we
can continue our responsibilities there.
Mr. Dominguez. Mr. Chair, if I might, one of the things
that we are thinking about and just beginning the dialog inside
the Department is for authority for the Congress to pilot on a
subset of the population just that kind of thing. This is a
complex system. We feel like if we could take something, put it
in place, operate it for several months, that by this time next
year we would have concrete, hard evidence from a process that
worked that we could learn from and that we could come back to
the Congress with very clear and detailed findings leading to
legislation.
Mr. Tierney. I hope that, pilot or no pilot, that within a
year or so we have some firm answers on that, but I hear what
you are saying.
We have received reports, we have seen articles about some
injured soldiers being given lowered disability ratings they
say because the Army doesn't want to pay the 30 percent, the
current maximum compensation, for a large number of permanently
wounded soldiers. Have any of you investigated allegations of
that nature? How are we going to have somebody accountable to
make sure that is not happening?
General Pollack. There is a review of that process going on
now, sir. I don't have those specifics in front of me.
Mr. Tierney. Will you share them with the committee when
you have a chance to get them?
General Pollack. Yes, sir.
Mr. Dominguez. I do, sir, want to say this came up in
testimony that Secretary Garon and Secretary England had before
another committee of the Congress last week, and they were
unequivocal in that our policy instructions are directives to
these boards. That is not part of the calculus that they are
supposed to be thinking about. This is to be what is the
disability and how does it rate in the schedule and make a
determination.
Mr. Tierney. I will look forward to General Pollack's
response on that. I appreciate it.
Mr. Shays, if you will just bear with me 1 second, I have
some unfinished business.
General Schoomaker, do you know if Staff Sergeant Dan
Shannon had his reconstructive surgery scheduled yet, one of
the witnesses in our first panel?
General Schoomaker. Yes. I am trying to recall the status
of him. I know one of the two soldiers has returned to Fort
Campbell on active duty, Sergeant Duncan. I don't know the
status of Shannon, but I can get back to you on that.
Mr. Tierney. Would you do that for us?
And can you tell us whether or not the Army has taken any
steps to review the denial of benefits to Corporal McCleod? I
recall that it was determined at one review that his brain
function problems they said were the result of a pre-existing
learning disability rather than a traumatic brain injury.
General Schoomaker. I can check on that, sir.
Mr. Tierney. Could you see if that has been re-evaluated?
And Specialist Duncan has been returned to service, has he?
General Schoomaker. As far as I know. I saw him last week
or the week before, and he was on his way back to Fort
Campbell. Yes, sir.
Mr. Tierney. Thank you.
Last question I have is about the problem that was
testified to earlier, which I have heard in my District from
some people involved with the psychological and psychiatric
units, a declining number of mental health, behavioral staff in
the medical system and some problems about out-sourcing some of
that, contracting out, which these people that were talking to
me did not feel was as good as having people within the
service.
I know that the preliminary findings of the American
Psychological Association that 40 percent of the Army and Navy
active duty licensed clinical psychologist billets are
presently vacant, and the IRG, of course, found that has
affected the care and treatment of TBI and post traumatic
stress disorder. What are we doing about that and what are we
going to continue to do about that, if you would?
General Pollack. Sir, we recently had approved at the
Department of Defense level a critical skills retention bonus
that we are implementing in 2007 to retain those officers. We
have also established, because the behavioral health profession
is so broad, we have instituted a master's of social work to
assist with the, as well, and that program will begin in 2007,
as well.
Mr. Tierney. Thank you. And one of the Secretaries made a
point that if they are recruiting doctors over 50 they might
have some success if they didn't impose the 8 year commitment
rule. Is that being reviewed at all?
General Pollack. Yes, sir. The G-1, the personnel
community, is working that as a policy and as a legislative
proposal, because I think we need relief. If I remember
correctly, we need relief from a title 10 requirement.
General Schoomaker. We approve of doctors over 50, sir.
Mr. Tierney. I approve of all people over 50. Thank you.
Mr. Shays.
Mr. Shays. Thank you. I just have a few questions.
Secretary Dominguez, Ellen Embry, the then Deputy Assistant
Secretary of Defense for Force Health Protection and Readiness,
testified before this Committee on Government Reform in 2005
that DOD would direct all possible resources to address
outpatient process. Why did this not happen, No. 1? Who dropped
the ball? What will the Under Secretary do to see that he
maintains oversight and input into policies that affect our war
wounded?
Mr. Dominguez. Sir, unfortunately I am not able to tell you
who dropped the ball. In terms of what we are doing----
Mr. Shays. Well, let's not answer the question who dropped
the ball, but answer this: why did this not happen?
Mr. Dominguez. Why did this not happen? Well, I think there
is some uncertainty, but many of us believe that a shortage of
resources was not the issue, that there were adequate resources
in the system to be able to deal adequately with outpatient
care.
There were some real problems at Walter Reed, in
particular, as you heard from the IRG, associated with BRAC and
A-76 that, in the implementation of those program stuff,
created a real capability gap that was noticed by patients and
families and resulted in problems that we saw.
So I don't know that it was a resource problem, and I don't
believe it was a policy direction and policy architecture
problem. It manifested itself in execution at this one facility
because of the perfect storm of events.
Mr. Shays. This is not a problem at one facility.
Outpatient is a problem throughout.
Mr. Dominguez. Yes, sir, and as a result of the light
shining on Walter Reed, all of the services sent people out to
all of the facilities where they have----
Mr. Shays. I guess the problem that is discouraging is, you
know, this was not a new problem. We documented it was a
problem. We had people testify under oath that they would take
care of the problem and the problem was not taken care of. You
know, it makes you wonder.
Let me ask another question. The IRG recommends that the
physical disability evaluation system must be completely
overhauled to include changes in the U.S. Code, Department of
Defense policies and service regulations resulting in one
integrated solution. First, I want to know if you agree in one
integrated solution. Then I would like to know your honest
assessment of how this will be done and how long it will take
and what resources will be needed.
That is the end of my questions, but I would like an
answer.
Mr. Dominguez. Again, I think one integrated solution is
one we absolutely, positively, clearly have to look at. I thank
the IRG for putting it on the----
Mr. Shays. Look at does not mean have.
Mr. Dominguez. Yes, sir, because we are now evaluating the
IRG's recommendations.
Mr. Shays. So you think you need to look at it, but you are
not sure you need to do it?
Mr. Dominguez. At the current time I know we have to do
something to change this process. It is not working. It is not
working for service members and families. It is not doing what
we----
Mr. Shays. How long is it going to take for you to decide
you need an integrated system?
Mr. Dominguez. Sir, I think we are going to evaluate, in
collaboration with the VA, we are going to look at designing
that system, we are going to look at the statutory bases for
the systems of disability that now work, which are different
for the DOD, for the VA, and for the Social Security
Administration.
We will see how you can reconcile those competing or those
different policy objectives--they are coded in the statutes
enabling these things--into one system, see how we can make
that work, if we can figure out how to do that, honoring the
statutory bases of the different calls that have to be made--
are you fit to serve, or do we have to terminate your career,
have you lost income, and are you unemployable.
So these different things have to be welded together into
the system. We will see if we can make that work, and then we
will come back with a proposal.
Mr. Tierney. If the gentleman would yield?
Mr. Shays. Yes.
Mr. Tierney. I understand from your earlier answer that by
May 5th or immediately thereafter you are expecting to get back
to us as to whether or not it can be combined into one, and
then how much time you think it will take you to do that.
Mr. Dominguez. Yes, sir, we are going to try to move that
expeditiously. I am hoping we do that by May 5th, because that
is when we will have our conversation with Secretary Gates, and
he will expect us----
Mr. Shays. What I would have thought the answer would have
been would have been, one, we know we need to do it, we just
don't know how long it is going to take, and this is what we
are going to do to figure out how long it is going to take.
Mr. Dominguez. Yes, sir.
Mr. Shays. But, you know----
Mr. Dominguez. I have to be able to assure you that in one
system I can be true to the purpose that is enshrined in each
of the statutes that provide a piece of the disability
continuum that----
Mr. Shays. I asked one basic, simple question. How long
will it take for the various hospitals, VA hospitals, to know
that they can get records that are accurate about the
servicemen and women that they are not treating?
Mr. Dominguez. Sir, if we have shared patients, I believe
that is happening now with the bi-directional health
information exchange that has been in place. We are sharing
records. There are problems. There are, you know, many
different pieces of a medical record. These two can be more
specific about it, but that is a major effort, and we are
sharing data on millions of patients right now with the VA back
and forth.
General Pollack. Sir, if I might?
Mr. Shays. Sure.
General Pollack. There is significant progress that is
promised at this time that by the end of the summer the VA and
DOD should be linked. It will not be as clean as a simple click
on your computer to move from one screen to another, because
you will need to go into the other system and query, but
General Schoomaker and I yesterday afternoon were briefed by
Mr. Foster and his team from TMA, because this is a concern for
us, as well, and there seems to be progress on this. But we
will need to see it.
Mr. Shays. One is being able to share information within
DOD and another to be able to share information between DOD and
the VA.
General Pollack. Yes, sir.
Mr. Shays. And in these United States, with such bright
people and the resources that we should be able to put, it just
seems to me it is more an issue of will rather than of anything
else, just the will.
General Schoomaker. Sir, we are assured that by the end of
the summer that we will have bi-directional exchange of a large
amount of the clinical record available to both the DOD and the
VA system.
Mr. Dominguez. And there is a significant technological
challenge here, Congressman. There is the will. There is
actually commitment by the leadership of VA and DOD to make
this happen. It is a challenging problem and we are working on
it very hard.
We are not, by any means, where we need to be as a Nation.
Mr. Tierney. Before we wrap up, we asked for a number of
records in a previous request back on March 5th, or whatever,
and unfortunately this is all we have received so far, which is
obviously quite inadequate for that, and a considerable amount
of time has passed. Do we have your assurance? And who is going
to take responsibility to make sure that those requests are
completed in full and promptly?
Mr. Dominguez. Yes, sir.
Mr. Tierney. General Schoomaker.
General Schoomaker. I will have the first delivery of those
documents to you this week, sir.
Mr. Tierney. Well, when is the last delivery going to come?
I mean, this is the first delivery, I guess. When can we expect
that we will have it? Within a reasonable period of time here?
General Schoomaker. Yes, sir. I think I will have----
Mr. Tierney. We are already beyond a reasonable period of
time, so now we are going to give you a second reasonable time,
if we can.
General Schoomaker. I understand, sir.
Mr. Tierney. Thank you.
Thank you all for your testimony. Thank you for your
service to your country, as well. We don't mean to be
individually tough on you, specifically, but I think you share
our need to be tough on this issue, and we appreciate your
willingness to cooperate. Thank you.
[Whereupon, at 12:55 p.m., the subcommittee was adjourned.]
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