WEBVTT 00:00.130 --> 00:02.660 - And before I give my remarks 00:02.660 --> 00:06.030 I would want to recognize and welcome 00:06.030 --> 00:09.600 one of our colleagues from the great state of Ohio, 00:09.600 --> 00:11.780 Congressman Brad Wenstrup. 00:11.780 --> 00:14.030 It is my understanding that you will also 00:14.030 --> 00:15.710 be testifying before the committee 00:15.710 --> 00:18.980 on our member day given your interest 00:18.980 --> 00:20.560 in some of the issues we're gonna have 00:20.560 --> 00:21.700 before the committee today. 00:21.700 --> 00:23.853 You would certainly be welcome to. 00:26.480 --> 00:28.340 This afternoon the subcommittee will receive 00:28.340 --> 00:30.320 testimony on the defense health program 00:30.320 --> 00:31.630 and military health system. 00:31.630 --> 00:34.580 We welcome the six witnesses. 00:34.580 --> 00:36.720 If I could, in the order of introduction 00:36.720 --> 00:39.340 that would also then in the interest of time, 00:39.340 --> 00:41.070 since we have six on the panel, 00:41.070 --> 00:44.460 be the order of speaking if we could, 00:44.460 --> 00:46.410 as far as your testimony. 00:46.410 --> 00:49.290 First of all Mr. Thomas McCaffrey, 00:49.290 --> 00:51.240 Principle Deputy Assistant Secretary 00:51.240 --> 00:54.170 of Defense for Health Affairs. 00:54.170 --> 00:56.860 Vice Admiral Raquel Bono, our Director 00:56.860 --> 00:59.860 of Defense Health Agency. 00:59.860 --> 01:02.370 Lieutenant General Nadja, 01:02.370 --> 01:05.530 Nadja Y. West, I'm sorry General, 01:05.530 --> 01:07.103 Surgeon General of the Army. 01:08.040 --> 01:13.040 Vice Admiral Forrest C. Faison, Surgeon General of the Navy. 01:13.250 --> 01:15.950 Lieutenant General Dorothy A. Hogg, 01:15.950 --> 01:18.330 Surgeon General of the Air Force. 01:18.330 --> 01:21.630 And Miss Stacy Cummings, a Program Executive 01:21.630 --> 01:25.750 Officer of the Defense Health Management Systems. 01:25.750 --> 01:30.210 And Miss Cummings this will be the last 01:30.210 --> 01:33.830 time you're before the subcommittee as I understand it. 01:33.830 --> 01:36.030 We wish you well in your new position 01:36.030 --> 01:39.160 in the Office of the Assistant Secretary of Defense 01:39.160 --> 01:42.073 for Acquisition, good luck on that one. 01:43.580 --> 01:47.560 Having a panel of six witnesses is unusual for our hearings. 01:47.560 --> 01:49.721 However each of you has a unique vantage point 01:49.721 --> 01:51.760 and responsibility in implementing 01:51.760 --> 01:54.680 the significant reorganization that is underway 01:54.680 --> 01:57.763 within the Department of Defense's health enterprise. 01:58.740 --> 02:00.870 We intend to have a look at how these changes 02:00.870 --> 02:03.850 are impacting the spectrum of Military Health System 02:03.850 --> 02:06.370 for medical readiness to beneficiary care, 02:06.370 --> 02:08.250 and how those changes are reflected 02:08.250 --> 02:10.890 in the fiscal year 2020 budget submission. 02:10.890 --> 02:12.660 I'm particularly interested in the update 02:12.660 --> 02:14.440 on the Defense Health Budget as it relates 02:14.440 --> 02:17.340 to the reductions in the service's medical corp., 02:17.340 --> 02:19.930 what the future of care looks like 02:19.930 --> 02:21.647 for our service members and their families, 02:21.647 --> 02:23.680 and an update on electronic health 02:23.680 --> 02:26.900 medical records system, Genesis. 02:26.900 --> 02:28.390 We'll look forward to hearing about 02:28.390 --> 02:29.750 each of these topics are more. 02:29.750 --> 02:32.800 With that I again thank you for appearing 02:32.800 --> 02:34.350 before the committee today. 02:34.350 --> 02:36.700 But we'll first recognize my friend 02:36.700 --> 02:39.400 Mr. Calvert for any opening comments he has. 02:39.400 --> 02:40.603 - Thank you Chairman. 02:40.603 --> 02:43.107 I would like to welcome all our witnesses today. 02:43.107 --> 02:44.630 And I will keep my statement brief 02:44.630 --> 02:46.500 so we have a chance to hear from all of you. 02:46.500 --> 02:49.140 I'm looking forward to learning from you 02:49.140 --> 02:51.363 about the provision of health care 02:51.363 --> 02:54.190 that will change in order to address 02:54.190 --> 02:56.610 the threats from near peer adversaries. 02:56.610 --> 02:59.040 How will a fight with China or Russia 02:59.040 --> 03:02.490 stress our military health system, and are we prepared? 03:02.490 --> 03:04.700 These are large country with large territory, 03:04.700 --> 03:07.640 much different from our current 03:07.640 --> 03:09.450 engagements in the Middle East. 03:09.450 --> 03:11.050 Are we taking advantage of technology 03:11.050 --> 03:13.420 to extend the time when critical care 03:13.420 --> 03:16.160 must be provided in the moments following injury. 03:16.160 --> 03:17.500 I think this is an important hearing. 03:17.500 --> 03:19.960 If we are facing threats that have the potential 03:19.960 --> 03:22.230 to inflict harm on our service members 03:22.230 --> 03:24.340 at levels not seen in many years. 03:24.340 --> 03:27.150 We need to be fully cognizant of what you are doing 03:27.150 --> 03:29.150 and how you're positioning the military health 03:29.150 --> 03:31.850 system to address these threats. 03:31.850 --> 03:34.100 Do we have the capacity to respond 03:34.100 --> 03:35.790 with the appropriate levels of evacuation 03:35.790 --> 03:38.860 and medical care if one of our carriers is hit? 03:38.860 --> 03:41.040 An issue that has been critical importance 03:41.040 --> 03:42.410 to this subcommittee many years, 03:42.410 --> 03:45.260 the development and fielding of electronic medical files 03:45.260 --> 03:46.620 that will allow you to share medical 03:46.620 --> 03:49.120 data with the Veteran's Administration. 03:49.120 --> 03:50.640 We all look forward to hearing about 03:50.640 --> 03:53.400 your progress to date on this effort. 03:53.400 --> 03:54.950 We need to be able to field a system 03:54.950 --> 03:56.440 that is flexible and able to keep up 03:56.440 --> 03:59.020 with the demands of younger workforce and customer base 03:59.020 --> 04:02.560 with a used, continued technological enhancements. 04:02.560 --> 04:04.630 Again many important topics to get to today. 04:04.630 --> 04:07.280 Thank you again for each of our witnesses. 04:07.280 --> 04:08.533 We appreciate your service to this country. 04:08.533 --> 04:10.440 I'll look forward to your testimony. 04:10.440 --> 04:11.770 And with that, thank you Mr. Chairman. 04:11.770 --> 04:12.750 I yield back. 04:12.750 --> 04:15.300 - Thank you I would now like to recognize Miss Granger, 04:15.300 --> 04:17.090 our former chair and ranking member 04:17.090 --> 04:19.369 on the full committee for her statement. 04:19.369 --> 04:20.937 - Thank you, and thank you Chairman Visclosky, 04:20.937 --> 04:22.120 and ranking member Calvert. 04:22.120 --> 04:24.470 And thank each of you for what you're doing 04:24.470 --> 04:26.430 on this very important issue. 04:26.430 --> 04:28.740 You each have important roles in ensuring 04:28.740 --> 04:30.450 that our service members and their families 04:30.450 --> 04:32.890 have the very best medical care. 04:32.890 --> 04:34.350 And this committee is monitoring 04:34.350 --> 04:36.400 changes in the delivery of healthcare 04:36.400 --> 04:39.240 both on the battlefield and back home. 04:39.240 --> 04:41.249 I know that our troops are operating 04:41.249 --> 04:43.630 in changing environments, I'd like to hear 04:43.630 --> 04:45.796 you address that, what's changing 04:45.796 --> 04:48.770 in the way we're delivering healthcare. 04:48.770 --> 04:49.803 But also, 04:52.230 --> 04:57.230 I was briefed this week on two issues that I wanna make sure 04:58.160 --> 05:00.860 that where our dollars are being spent. 05:00.860 --> 05:05.810 Some very specific concerns related 05:05.810 --> 05:07.673 to defense medical research. 05:08.730 --> 05:11.853 Two Alzheimer's and pancreatic cancer, 05:12.870 --> 05:15.780 pancreatic cancer if you compare that 05:15.780 --> 05:17.530 for instance to breast cancer, 05:17.530 --> 05:20.860 the dollars are going to research on that cancer 05:20.860 --> 05:25.460 are not nearly as much, and the alarm is very high. 05:25.460 --> 05:29.620 Because more and more are being 05:29.620 --> 05:31.290 diagnosed with pancreatic cancer, 05:31.290 --> 05:34.300 and because it's almost no symptoms 05:34.300 --> 05:35.860 usually the first time they hear about it, 05:35.860 --> 05:38.360 they also hear how many months they have to live. 05:38.360 --> 05:40.050 And so I'd like you to look at that. 05:40.050 --> 05:42.920 And understand also the high incidence 05:42.920 --> 05:45.410 in the African American community. 05:45.410 --> 05:46.960 The other is Alzheimer's disease. 05:46.960 --> 05:50.140 And there was good news in one way, 05:50.140 --> 05:52.880 I was briefed on that this week. 05:52.880 --> 05:55.910 And with Alzheimer's the research is showing 05:55.910 --> 05:58.201 there's some really things that we can do in our life, 05:58.201 --> 06:00.570 how we live our life, what we eat, 06:00.570 --> 06:02.730 whether we exercise that sort of thing. 06:02.730 --> 06:04.670 But the money to get that message out 06:04.670 --> 06:06.968 is really important 'cause it could make a difference. 06:06.968 --> 06:08.413 I say that's the good news 'cause we know 06:08.413 --> 06:10.480 what we're dealing with, but we're also dealing 06:10.480 --> 06:12.610 with it at much younger ages. 06:12.610 --> 06:17.180 I had a woman that was diagnosed at age 37 in her family. 06:17.180 --> 06:20.340 And so I'd like to hear what we're doing at that, 06:20.340 --> 06:22.860 and what the statistics, and how we can improve that. 06:22.860 --> 06:26.380 I wanna again thank you so much for what you're doing. 06:26.380 --> 06:28.834 And it's very important to us. 06:28.834 --> 06:30.751 Thank you Mr. Chairman. 06:32.690 --> 06:34.280 - For each witness your full testimony 06:34.280 --> 06:35.570 will be placed in the record, 06:35.570 --> 06:37.230 and members have a copy at their seats. 06:37.230 --> 06:39.530 In the interest of time it is my understanding 06:39.530 --> 06:41.477 that people will limit their remarks 06:41.477 --> 06:44.180 as far as opening statements to about three minutes 06:44.180 --> 06:46.703 and Mr. McCaffery we'll start with you please. 06:48.220 --> 06:49.470 - Thank you Chairman Visclosky, 06:49.470 --> 06:53.040 and ranking member Calvert, and members of the subcommittee. 06:53.040 --> 06:54.930 Thank you for inviting me to present 06:54.930 --> 06:58.950 our medical program funding request for fiscal year 2020. 06:58.950 --> 07:01.420 We are honored to represent the dedicated military, 07:01.420 --> 07:03.410 and civilian medical professionals 07:03.410 --> 07:05.100 in the military health system providing 07:05.100 --> 07:07.328 direct support to our combatant commands 07:07.328 --> 07:10.980 in delivering or arranging care for over 9,000,000 07:10.980 --> 07:14.130 beneficiaries who rely on us for medical care. 07:14.130 --> 07:16.240 This budget supports numerous reforms 07:16.240 --> 07:17.930 to the military health system 07:17.930 --> 07:21.430 that were enacted under the fiscal year 2017 07:21.430 --> 07:24.060 National Defense Authorization Act. 07:24.060 --> 07:26.640 These reforms taken together represent 07:26.640 --> 07:28.803 the most sweeping changes to military 07:28.803 --> 07:32.090 medicine in over three decades. 07:32.090 --> 07:33.870 The overarching direction from Congress 07:33.870 --> 07:36.090 was to consolidate and standardize 07:36.090 --> 07:37.767 many military healthcare functions 07:37.767 --> 07:41.070 in a way that better integrates medical readiness 07:41.070 --> 07:43.860 and health delivery throughout the department. 07:43.860 --> 07:46.350 Include among these reforms the transition 07:46.350 --> 07:48.180 of responsibility for the administration 07:48.180 --> 07:51.680 and management of our medical military treatment facilities 07:51.680 --> 07:54.840 from the services to the Defense Health Agency. 07:54.840 --> 07:57.073 It includes implementation and standardization 07:57.073 --> 07:59.560 of enterprise wide activities. 07:59.560 --> 08:01.181 And the assessment and restructuring 08:01.181 --> 08:03.840 of medical end strengths and infrastructure 08:03.840 --> 08:05.070 in the military health system 08:05.070 --> 08:09.500 to maintain core competencies of our healthcare providers. 08:09.500 --> 08:12.830 This last item called for the military departments, 08:12.830 --> 08:14.550 the joint staff, and organizations 08:14.550 --> 08:16.480 within the office of the Secretary 08:16.480 --> 08:18.810 to assess the operational medical requirements 08:18.810 --> 08:22.050 needed to support the National Defense Strategy. 08:22.050 --> 08:24.080 The military department's identified the personnel 08:24.080 --> 08:26.020 and skill sets they need to support 08:26.020 --> 08:29.300 our Combatant Commander's operational needs. 08:29.300 --> 08:30.860 As a result of this assessment 08:30.860 --> 08:33.190 the department intends to reduce overall uniformed 08:33.190 --> 08:36.780 medical positions over a phased period of time. 08:36.780 --> 08:39.470 This proposed reshaping will focus on ensuring 08:39.470 --> 08:41.750 the military department medical forces 08:41.750 --> 08:45.270 are best structured to meet operational requirements. 08:45.270 --> 08:46.770 In those cases where end strength 08:46.770 --> 08:49.060 is in excess of operational requirements 08:49.060 --> 08:50.910 the budget will be repurposed to other 08:50.910 --> 08:53.290 military department priorities. 08:53.290 --> 08:54.740 We remain committed to sustaining 08:54.740 --> 08:56.960 the superb battlefield medical care 08:56.960 --> 08:58.880 we have provided to our war fighters, 08:58.880 --> 09:01.530 and the world class treatment and rehabilitation 09:01.530 --> 09:05.370 for those who bear the wounds of past military conflicts. 09:05.370 --> 09:08.093 Our proposed FY2020 budget sustains 09:08.093 --> 09:11.310 the medical research and development portfolio 09:11.310 --> 09:13.580 and includes our continued commitment 09:13.580 --> 09:16.690 to maintain our management infrastructure 09:16.690 --> 09:19.120 that has managed the Congressionally directed 09:19.120 --> 09:22.060 research program for these past many years. 09:22.060 --> 09:23.430 Our budget for military medicine 09:23.430 --> 09:26.410 represents a balanced, comprehensive strategy 09:26.410 --> 09:27.790 that aligns with the Secretary's 09:27.790 --> 09:30.580 priorities and congressional direction. 09:30.580 --> 09:31.960 I look forward to your questions. 09:31.960 --> 09:33.813 And I want to thank you for inviting us here today 09:33.813 --> 09:35.830 to speak with you about the essential 09:35.830 --> 09:38.170 linkage between readiness, and health, 09:38.170 --> 09:40.810 and our plans to further improve our health system 09:40.810 --> 09:43.320 in support of the National Defense Strategy. 09:43.320 --> 09:44.153 Thank you. 09:49.810 --> 09:52.000 - Chairman Visclosky, ranking member Calvert, 09:52.000 --> 09:53.650 and members of the subcommittee, 09:53.650 --> 09:55.150 thank you for this opportunity to share 09:55.150 --> 09:56.850 the work of the Defense Health Agency 09:56.850 --> 09:58.650 in support of our combatant commands 09:58.650 --> 10:00.460 and the military departments. 10:00.460 --> 10:02.760 I will briefly build on Mr. McCaffrey's statement 10:02.760 --> 10:05.190 and provide insight into the work of the DHA 10:05.190 --> 10:08.950 to execute our responsibilities under this proposed budget. 10:08.950 --> 10:11.130 As Mr. McCaffrey noted both Congress 10:11.130 --> 10:13.820 and the Secretary of Defense's guidance was clear. 10:13.820 --> 10:15.730 To pursue efficiencies and create value 10:15.730 --> 10:17.440 for the department by consolidating 10:17.440 --> 10:20.550 and standardizing military healthcare functions 10:20.550 --> 10:24.260 to support an integrated system of readiness and health. 10:24.260 --> 10:26.470 The DHA is honored and privileged 10:26.470 --> 10:28.880 to facilitate that integration. 10:28.880 --> 10:31.260 We are a strategic enabler to the department 10:31.260 --> 10:32.700 in supporting the readiness needs 10:32.700 --> 10:36.300 of our Combatant Commanders and the military departments. 10:36.300 --> 10:38.670 Through a management of enterprise activities 10:38.670 --> 10:42.180 the DHA is positioned to reduce unwarranted variation 10:42.180 --> 10:45.943 and costs in both clinical and administrative functions. 10:46.860 --> 10:50.090 On October 1st, 2019 all military facilities 10:50.090 --> 10:52.270 in the eastern region of the United States 10:52.270 --> 10:54.310 will transition to the Defense Health Agency 10:54.310 --> 10:56.410 for administration and management. 10:56.410 --> 10:58.530 Placing over 50% of facilities, 10:58.530 --> 11:00.823 admissions and enrollees under the DHA. 11:01.830 --> 11:04.390 Support for medical logistics, health facilities, 11:04.390 --> 11:06.780 and acquisition will be fully managed for MTFs 11:06.780 --> 11:08.830 in the military health system by the DHA. 11:09.740 --> 11:11.600 We will also be preparing for the transition 11:11.600 --> 11:13.460 of the remaining facilities in the continental 11:13.460 --> 11:18.000 United States and Alaska on October 1st, 2020. 11:18.000 --> 11:20.020 With regards to the proposed military 11:20.020 --> 11:23.150 medical manpower reductions, the military departments 11:23.150 --> 11:25.580 and DHA are working closely together 11:25.580 --> 11:27.960 to ensure that access to care and availability 11:27.960 --> 11:30.000 of health services will be consistently 11:30.000 --> 11:33.110 maintained for all of our beneficiaries. 11:33.110 --> 11:35.640 As needed alternative staffing models, 11:35.640 --> 11:38.270 contracts, military civilian partnerships, 11:38.270 --> 11:41.030 and existing Tricare networks will be utilized 11:41.030 --> 11:44.010 to best meet the needs of our patients. 11:44.010 --> 11:45.840 We will continue to meet all standards 11:45.840 --> 11:48.540 for timely access for our beneficiaries. 11:48.540 --> 11:50.840 And while care delivery locations may change, 11:50.840 --> 11:52.460 our commitment to provide our patients 11:52.460 --> 11:53.960 with high quality healthcare 11:53.960 --> 11:57.130 that they deserve will remain steadfast. 11:57.130 --> 11:59.760 I am particularly proud of how we have standardized 11:59.760 --> 12:01.410 the performance management system, 12:01.410 --> 12:03.022 providing all levels of the military 12:03.022 --> 12:06.150 with our performance measures in readiness, 12:06.150 --> 12:11.150 health, access, quality, safety, and cost. 12:11.360 --> 12:12.520 Our dashboards can be viewed 12:12.520 --> 12:14.770 at an enterprise level by service, 12:14.770 --> 12:18.250 by market, and by individual hospitals, and clinics. 12:18.250 --> 12:20.710 These dashboards help us assess performance 12:20.710 --> 12:23.340 and identify where we need to invest resources, 12:23.340 --> 12:25.520 training, or management in order 12:25.520 --> 12:27.600 to achieve further improvement. 12:27.600 --> 12:29.350 Along with Mr. McCaffery I look forward 12:29.350 --> 12:31.480 to working with you over the coming months. 12:31.480 --> 12:33.080 And I welcome any questions you may have 12:33.080 --> 12:36.500 about out plans, performance, and vision for the future. 12:36.500 --> 12:38.700 Thank you for inviting me to join you today. 12:43.960 --> 12:44.870 - Good afternoon. 12:44.870 --> 12:47.430 Chairman Visclosky, ranking member Calvert, 12:47.430 --> 12:48.930 distinguished members of the subcommittee. 12:48.930 --> 12:50.610 It's my pleasure to address this committee 12:50.610 --> 12:53.590 a final time as the 44th Army Surgeon General 12:53.590 --> 12:55.990 and Commanding General of the US Army Medical Command. 12:55.990 --> 12:58.040 It's been my honor to serve with and lead 12:58.040 --> 12:59.930 our talented and dedicated soldiers 12:59.930 --> 13:02.600 and Army civilians for more than 30 years. 13:02.600 --> 13:04.410 On behalf of my soldiers, their families, 13:04.410 --> 13:06.260 and Army civilians I would like to sincerely 13:06.260 --> 13:08.630 thank you for your unwavering support. 13:08.630 --> 13:10.260 But also I'd like to thank my colleagues 13:10.260 --> 13:13.357 in our sister services, my fellow Surgeons General, 13:13.357 --> 13:15.590 the Defense Health Agency and team here. 13:15.590 --> 13:17.730 And it's been an honor to serve with each of you 13:17.730 --> 13:19.790 with the military medicine team. 13:19.790 --> 13:21.800 Today I'm proud to tell you with the utmost confidence 13:21.800 --> 13:24.410 that Army's commitment to its medical mission 13:24.410 --> 13:26.930 and to our people remain steadfast. 13:26.930 --> 13:29.180 We are poised to deliver timely health services 13:29.180 --> 13:30.860 in the operational environment 13:30.860 --> 13:33.240 and comprehensive care at home stations, 13:33.240 --> 13:35.030 and to remain on the cutting edge of medical 13:35.030 --> 13:37.390 research, development, and fielding. 13:37.390 --> 13:39.410 Which are the key components of a continuum of care 13:39.410 --> 13:42.600 that provides for forces that are medically ready, 13:42.600 --> 13:45.633 and enhances the readiness of our Army's medical force 13:45.633 --> 13:49.277 into any environment that we might be asked to operate in 13:49.277 --> 13:51.513 and the multi domain joint environment 13:51.513 --> 13:53.483 that we are anticipating in the future. 13:54.890 --> 13:56.380 America's Army stands ready today 13:56.380 --> 13:59.400 to deploy, fight, and win our nation's wars. 13:59.400 --> 14:01.230 As our Chief continually emphasizes 14:01.230 --> 14:05.110 readiness is number one, and there is no other number one. 14:05.110 --> 14:06.880 As a key component of the joint health services 14:06.880 --> 14:08.710 enterprise and a deployable Army, 14:08.710 --> 14:10.410 Army medicine is ready to provide 14:10.410 --> 14:13.370 capability across unified land operations. 14:13.370 --> 14:15.840 We support Combatant Commanders across the globe, 14:15.840 --> 14:18.840 and in 10 named contingency operations. 14:18.840 --> 14:22.680 Various exercises, and the security cooperation activities. 14:22.680 --> 14:26.490 Army readiness begins with fit, and healthy fighting force. 14:26.490 --> 14:28.280 And medical issues currently account 14:28.280 --> 14:31.750 for approximately 3.7% of soldier non deployability 14:31.750 --> 14:34.810 which is a marked improvement in the last 24 months. 14:34.810 --> 14:36.580 I'm confident that we will continue to trend 14:36.580 --> 14:39.160 in the right direction as evidenced by the increased 14:39.160 --> 14:41.980 readiness in our brigade combat teams. 14:41.980 --> 14:43.120 The Army has made strides 14:43.120 --> 14:45.100 in improving mental resilience. 14:45.100 --> 14:47.270 61 embedded behavioral health teams 14:47.270 --> 14:50.260 support our operational units throughout the Army. 14:50.260 --> 14:55.140 In FY19 we dedicated approximately 455 million dollars 14:55.140 --> 14:58.830 to support various behavioral health initiatives. 14:58.830 --> 15:00.740 Army's implementation of the holistic health 15:00.740 --> 15:02.720 and fitness program in our combat 15:02.720 --> 15:05.230 formations has increased readiness. 15:05.230 --> 15:06.970 The addition of physical therapists, 15:06.970 --> 15:10.143 strength trainers, and dieticians to units 15:10.143 --> 15:13.840 is improving the Army's culture of fitness. 15:13.840 --> 15:15.170 Army medicine is extremely proud 15:15.170 --> 15:19.350 of our high quality medical education and training as well. 15:19.350 --> 15:22.830 Annually we train over 1500 physicians in our facilities. 15:22.830 --> 15:25.560 Our first time medical board certification rate 15:25.560 --> 15:28.310 of approximately 92% well exceeds 15:28.310 --> 15:30.510 the national average of 86%. 15:30.510 --> 15:32.200 Meaning that we have well trained 15:32.200 --> 15:33.550 medical professionals to support 15:33.550 --> 15:35.540 our Army in any environment. 15:35.540 --> 15:37.150 The Army Medical Department Center and School 15:37.150 --> 15:40.190 in San Antonio trains more than 31,000 15:40.190 --> 15:44.070 US student and 330 international students annually 15:44.070 --> 15:48.130 in diverse programs dedicated to again, readiness. 15:48.130 --> 15:49.830 Army medicine has continually evolved 15:49.830 --> 15:51.497 to meet global threats to improve 15:51.497 --> 15:56.290 that battlefield survivability rate over the years. 15:56.290 --> 15:58.660 Our researchers have focused on traumatic brain injury, 15:58.660 --> 16:01.510 behavioral health, combat causality care, 16:01.510 --> 16:03.380 military operational medicine, 16:03.380 --> 16:06.100 military infectious diseases and counter measures, 16:06.100 --> 16:07.740 radiation health effects, 16:07.740 --> 16:09.760 clinical and rehabilitative medicine, 16:09.760 --> 16:12.040 health services, global health engagements, 16:12.040 --> 16:14.820 and medical training systems, and health informatics. 16:14.820 --> 16:16.630 Again, all to support the war fighter 16:16.630 --> 16:19.210 in the various operational environments 16:19.210 --> 16:21.280 that we might find ourselves in. 16:21.280 --> 16:23.300 We have made great advances such as peripheral 16:23.300 --> 16:25.810 nerve growth following amputation, 16:25.810 --> 16:29.340 and a living anti infective human skin substitute. 16:29.340 --> 16:32.180 Most notably in 2018 the Food and Drug Administration 16:32.180 --> 16:33.910 approved the first ever blood test 16:33.910 --> 16:35.820 for traumatic brain injury. 16:35.820 --> 16:37.460 Continued generous funding from Congress 16:37.460 --> 16:39.230 has made the study and advancement 16:39.230 --> 16:41.640 of military medicine possible. 16:41.640 --> 16:43.510 And finally in keeping with congressional intent 16:43.510 --> 16:46.250 Army medicine supports and has committed resources 16:46.250 --> 16:49.460 toward reforming the Military Health System. 16:49.460 --> 16:51.290 We will divest responsibilities 16:51.290 --> 16:53.050 of the administration management 16:53.050 --> 16:55.520 of all military facility to the DHA, 16:55.520 --> 16:58.040 as you heard my colleague Admiral Bono mention, 16:58.040 --> 17:02.070 in a phased approach which began in one, October, 2018. 17:02.070 --> 17:03.710 For the Army with the transfer of Womack 17:03.710 --> 17:05.070 Army Medical Center at Fort Bragg 17:05.070 --> 17:06.930 to the Defense Health Agency. 17:06.930 --> 17:09.750 We are committed to ensuring that the transition 17:09.750 --> 17:11.690 is transparent to our soldiers, 17:11.690 --> 17:15.200 families, and retirees because again we are all one team 17:15.200 --> 17:16.060 and we need to make sure that 17:16.060 --> 17:19.280 that mission is a no fail mission. 17:19.280 --> 17:21.500 In closing our Army has relied on Army medicine 17:21.500 --> 17:25.030 to conserve the fighting strengths since 1775. 17:25.030 --> 17:26.890 The lethality of our Army is derived 17:26.890 --> 17:29.870 from our soldiers who are strengthened by their families, 17:29.870 --> 17:31.510 and we must take care of them. 17:31.510 --> 17:33.620 We will continue to respond to our nation's call 17:33.620 --> 17:35.240 with premier medical professionals 17:35.240 --> 17:37.330 providing high quality care. 17:37.330 --> 17:38.850 And I appreciate this subcommittee's work 17:38.850 --> 17:41.260 and your continued support to our soldiers, 17:41.260 --> 17:42.580 to Army medicine, and the Army. 17:42.580 --> 17:44.430 And it's been my honor to serve with you. 17:44.430 --> 17:46.060 And thank you again, and I look forward 17:46.060 --> 17:47.460 to answering your questions. 17:49.610 --> 17:52.190 - Chairman Visclosky, ranking member Calvert, 17:52.190 --> 17:54.330 distinguished members of the subcommittee, 17:54.330 --> 17:57.200 it's my honor and privilege to be with you here today. 17:57.200 --> 18:00.080 My message this morning is simple and straightforward. 18:00.080 --> 18:02.620 The operational tempo in global commitments 18:02.620 --> 18:05.640 of America's Navy and Marine Corp remains high. 18:05.640 --> 18:07.140 Sailors and Marines are deployed 18:07.140 --> 18:09.690 in operating around the world today. 18:09.690 --> 18:11.740 The Navy Medicine Team is with them 18:11.740 --> 18:13.800 working tirelessly to protect their health 18:13.800 --> 18:15.600 and preserve their readiness. 18:15.600 --> 18:18.080 On behalf of these dedicated men and women 18:18.080 --> 18:21.490 thank you for your continued support and confidence. 18:21.490 --> 18:23.450 My written statement provides you more details, 18:23.450 --> 18:26.890 but I want to highlight for you today three key areas, 18:26.890 --> 18:30.350 readiness, transformation, and our people. 18:30.350 --> 18:31.980 We have no greater responsibility 18:31.980 --> 18:34.360 than providing medical forces that are ready, 18:34.360 --> 18:36.830 prepared, and present to save lives 18:36.830 --> 18:40.150 of those who sacrifice and serve to defend our freedom. 18:40.150 --> 18:42.830 Every Sailor, Marine, and their families 18:42.830 --> 18:44.960 are depending on us to do all in our power 18:44.960 --> 18:47.570 to provide them the best care our nation can offer. 18:47.570 --> 18:51.230 And one day return them home safely and alive. 18:51.230 --> 18:54.080 To honor this trust we are continuing to develop 18:54.080 --> 18:56.650 new and improved capabilities to support 18:56.650 --> 18:59.330 the full range of operations today. 18:59.330 --> 19:01.040 These efforts are critical since we know 19:01.040 --> 19:02.710 that this aggregated operations 19:02.710 --> 19:05.830 pose unique challenges to timely access 19:05.830 --> 19:09.160 to life saving resuscitation and surgery. 19:09.160 --> 19:11.320 Integral to advancing our expeditionary 19:11.320 --> 19:13.550 combat casualty care capabilities 19:13.550 --> 19:15.480 is ensuring that our medical personnel 19:15.480 --> 19:18.110 sustain their clinical readiness skills. 19:18.110 --> 19:20.560 We are making solid progress implementing 19:20.560 --> 19:22.810 our Navy medicine trauma strategy. 19:22.810 --> 19:26.200 In July of 2018 our Naval Medical Center 19:26.200 --> 19:28.010 at Camp Lejeune was designated 19:28.010 --> 19:29.320 as a level three trauma center 19:29.320 --> 19:31.350 by the American College of Surgeons. 19:31.350 --> 19:32.950 And our staff there are now gaining 19:32.950 --> 19:35.800 valuable trauma experience while also providing 19:35.800 --> 19:39.130 an incredibly important service to the local community. 19:39.130 --> 19:40.850 We expanded our successful hospital 19:40.850 --> 19:42.860 corpsman trauma training course 19:42.860 --> 19:44.756 in partnerships to Stroger Hospital 19:44.756 --> 19:47.040 in Cook County in Chicago, 19:47.040 --> 19:48.640 as well as the University of Florida 19:48.640 --> 19:50.320 Medical Center in Jacksonville. 19:50.320 --> 19:53.090 And we continue to send staff to LA County 19:53.090 --> 19:54.960 where they get invaluable trauma experience 19:54.960 --> 19:57.280 to prepare them for the next conflict. 19:57.280 --> 19:59.610 Bottom line, these efforts are preparing 19:59.610 --> 20:01.860 us well for the next fight. 20:01.860 --> 20:03.470 Reform efforts continue within 20:03.470 --> 20:04.980 the Military Health System. 20:04.980 --> 20:08.090 The Department of the Navy is in full support of these 20:08.090 --> 20:10.200 including the transfer of administration 20:10.200 --> 20:12.760 and management of our military treatment facilities 20:12.760 --> 20:14.730 to the Defense Health Agency. 20:14.730 --> 20:17.800 This legislation has reshaped military medicine 20:17.800 --> 20:19.660 to best support the war fighter 20:19.660 --> 20:22.090 while improving the healthcare delivery system 20:22.090 --> 20:25.360 with greater standardization and consistency. 20:25.360 --> 20:28.070 Our leadership recognizes that both the services 20:28.070 --> 20:30.750 and DHA must be successful 20:30.750 --> 20:33.130 in executing their responsibilities. 20:33.130 --> 20:35.970 For us this transition represents a unique 20:35.970 --> 20:39.370 opportunity to laser focus exclusively 20:39.370 --> 20:41.820 on the readiness of Sailors and Marines. 20:41.820 --> 20:44.270 This is especially critical as we return 20:44.270 --> 20:46.370 to competition between great powers, 20:46.370 --> 20:48.430 and the reality that future conflicts 20:48.430 --> 20:50.930 will present challenges to combat casualty care, 20:50.930 --> 20:55.410 and survival that we have not seen in the recent past. 20:55.410 --> 20:57.730 These reforms are allowing us to establish 20:57.730 --> 21:00.010 our organizational constructs to support 21:00.010 --> 21:02.540 readiness requirements while sustaining 21:02.540 --> 21:04.380 our critical responsibilities 21:04.380 --> 21:07.260 to man, train, and equip our forces. 21:07.260 --> 21:08.840 A key component moving forward 21:08.840 --> 21:11.000 will be to ensure that Navy medicine 21:11.000 --> 21:13.180 is resourced to meet our services, 21:13.180 --> 21:15.510 Navy and Marine Corps authorities, 21:15.510 --> 21:19.360 responsibilities, and critically important missions. 21:19.360 --> 21:22.313 Nothing is more critical to our mission readiness 21:22.313 --> 21:24.370 than the Navy medicine team. 21:24.370 --> 21:26.450 Dedicated and talented men and women 21:26.450 --> 21:28.650 serving around the world today. 21:28.650 --> 21:32.010 A key priority for us is our human capital strategy, 21:32.010 --> 21:34.530 both our military and civilian shipmates 21:34.530 --> 21:36.050 to ensure that we have the proper 21:36.050 --> 21:38.580 mix of professionals that are trained, 21:38.580 --> 21:40.510 organized and equipped to execute 21:40.510 --> 21:44.130 their responsibilities whenever and wherever called. 21:44.130 --> 21:46.910 This focus requires an emphasis on talent management 21:46.910 --> 21:48.990 at all levels as well as recruiting 21:48.990 --> 21:51.240 and retaining the best and brightest. 21:51.240 --> 21:53.610 Navy medicine is grateful for your support 21:53.610 --> 21:56.220 and of our resource requirements to do this 21:56.220 --> 21:58.400 and to meet our accession and retention 21:58.400 --> 21:59.970 activities and goals. 21:59.970 --> 22:03.390 Particularly for many of our critical wartime specialties. 22:03.390 --> 22:05.640 In closing our commitment to you 22:05.640 --> 22:08.420 is that we will never waiver from our obligation 22:08.420 --> 22:10.010 and the trust placed in our hands 22:10.010 --> 22:14.240 to be ready to save the lives of those placed in our care. 22:14.240 --> 22:17.070 I am proud of the Navy medicine team beyond words. 22:17.070 --> 22:19.870 And remain appreciative of your strong support. 22:19.870 --> 22:21.520 I look forward to your questions. 22:24.700 --> 22:27.150 - Chairman Visclosky, ranking member Calvert, 22:27.150 --> 22:29.150 distinguished members of the committee, 22:29.150 --> 22:32.370 thank you for this opportunity to testify today. 22:32.370 --> 22:33.640 The Air Force Medical Service 22:33.640 --> 22:37.540 is in a period of great change driven by numerous factors. 22:37.540 --> 22:39.860 Throughout these transformations our commitment 22:39.860 --> 22:42.680 to our patients that we care for and our medical 22:42.680 --> 22:45.490 readiness mission has never been stronger. 22:45.490 --> 22:48.000 Today's Air Force operates the most effective 22:48.000 --> 22:50.270 patient movement system ever. 22:50.270 --> 22:53.760 We bring wounded service members home in record time, 22:53.760 --> 22:56.700 deliver critical care at 30,000 feet, 22:56.700 --> 23:01.320 and push lifesaving care farther forward than ever before. 23:01.320 --> 23:03.890 Multiple efforts are underway to further improve 23:03.890 --> 23:05.880 our patient movement capabilities 23:05.880 --> 23:07.610 to better position us to execute 23:07.610 --> 23:09.880 the National Defense Strategy. 23:09.880 --> 23:13.290 We will increase our critical air care transport teams 23:13.290 --> 23:16.770 based on the Air Medical Readiness Analysis Study. 23:16.770 --> 23:21.060 These team doctors, nurses, and technicians turn flying, 23:21.060 --> 23:23.960 turn aircraft into flying intensive care units 23:23.960 --> 23:26.270 that provide life sustaining care 23:26.270 --> 23:30.000 while moving patients hundreds and even thousands of miles. 23:30.000 --> 23:32.730 We continue developing our ground surgical teams, 23:32.730 --> 23:35.990 our primary battlefield surgical unit 23:35.990 --> 23:38.870 for deployment to austere locations. 23:38.870 --> 23:42.380 We're also looking at our other deployment platforms 23:42.380 --> 23:44.330 to prepare and modernize them 23:44.330 --> 23:47.150 for what may be our next conflict, 23:47.150 --> 23:49.680 as well as ways to make them lighter and leaner, 23:49.680 --> 23:51.920 and more tailerable to current and future 23:51.920 --> 23:54.360 Combatant Commander's requirements. 23:54.360 --> 23:57.260 We continue to collaborate with the Defense Health Agency 23:57.260 --> 23:59.519 in moving authority, direction, and control 23:59.519 --> 24:02.220 of the military treatment facilities. 24:02.220 --> 24:04.890 On October 1st, 2018 the Air Force 24:04.890 --> 24:06.980 transferred four military treatment facilities 24:06.980 --> 24:08.850 to the Defense Health Agency. 24:08.850 --> 24:11.410 And like any enterprise transformation 24:11.410 --> 24:14.420 we've identified gaps in our current planning process 24:14.420 --> 24:16.050 and we are working collaboratively 24:16.050 --> 24:17.990 to resolve these to improve the transition 24:17.990 --> 24:21.480 for subsequent military treatment facilities. 24:21.480 --> 24:24.540 In addition to the military health system transformation 24:24.540 --> 24:27.080 the Air Force medical service will also transform 24:27.080 --> 24:30.960 itself to refocus on operational medical readiness. 24:30.960 --> 24:34.510 We will stand down two field operating agencies 24:34.510 --> 24:36.860 and stand up a single agency called 24:36.860 --> 24:39.780 the Air Force Medical Readiness Agency. 24:39.780 --> 24:41.880 This will eliminate redundancies 24:41.880 --> 24:45.450 and right size my headquarters medical capabilities 24:45.450 --> 24:49.190 to focus on medically ready Airmen and ready Medics 24:49.190 --> 24:52.770 who are current and competent to do their missions. 24:52.770 --> 24:55.920 We are also restructuring our medical squadrons. 24:55.920 --> 24:57.790 The Healthcare Operations Squadron 24:57.790 --> 25:00.740 will focus on providing beneficiary care 25:00.740 --> 25:03.700 without the distractions of military medical requirements 25:03.700 --> 25:07.750 such as periodic health assessments and waiver requirements. 25:07.750 --> 25:09.950 The Operational Medical Readiness Squadron 25:09.950 --> 25:13.730 will focus on active duty Airman's mission capabilities. 25:13.730 --> 25:16.770 This new structure optimizes both functions 25:16.770 --> 25:18.660 and allows us to return Airmen 25:18.660 --> 25:22.030 to full mission capability as quickly as possible 25:22.030 --> 25:24.693 without decrementing care to our beneficiaries. 25:25.750 --> 25:28.527 As Robin Sharma once said, "Change is hardest 25:28.527 --> 25:30.967 "in the beginning, messiest in the middle, 25:30.967 --> 25:32.870 "and easiest at the end." 25:32.870 --> 25:35.950 The Military Health System is in the middle of this change. 25:35.950 --> 25:37.830 These challenges create opportunities 25:37.830 --> 25:41.370 to shape the future, and to think without a box. 25:41.370 --> 25:44.970 Air Force medics are first and foremost warrior medics. 25:44.970 --> 25:46.680 As the Air Force Surgeon General, 25:46.680 --> 25:49.140 I am committed to achieving full spectrum 25:49.140 --> 25:52.940 medical readiness, developing joint medical leaders, 25:52.940 --> 25:54.910 and driving the Air Force Medical Service 25:54.910 --> 25:57.410 transformation to increase our agility 25:57.410 --> 25:59.440 and life saving capabilities required 25:59.440 --> 26:02.230 to execute the National Defense Strategy. 26:02.230 --> 26:04.590 Thank you for your support of Air Force medicine, 26:04.590 --> 26:06.530 and the opportunity to address you today. 26:06.530 --> 26:08.380 And I look forward to your questions. 26:09.930 --> 26:12.250 - Chairman Visclosky, ranking member Calvert, 26:12.250 --> 26:14.030 distinguished members of the committee, 26:14.030 --> 26:16.950 thank you for the opportunity to testify before you today. 26:16.950 --> 26:19.280 I am honored to represent the Department of Defense 26:19.280 --> 26:21.410 as the former Program Executive Officer, 26:21.410 --> 26:24.950 Defense Healthcare Management Systems, PEO DHMS. 26:24.950 --> 26:27.660 The mission of PEO DHMS is to transform 26:27.660 --> 26:30.440 the delivery of healthcare and advanced data sharing 26:30.440 --> 26:32.780 through a modernized electronic health record 26:32.780 --> 26:35.500 for service members, veterans, and their families. 26:35.500 --> 26:38.380 In 2015 the DOD awarded a contract 26:38.380 --> 26:40.460 to the Leidos Partnership for Defense Health 26:40.460 --> 26:44.800 to deliver a modern, interoperable, EHR, MHS GENESIS. 26:44.800 --> 26:46.940 MHS GENESIS provides an integrated, 26:46.940 --> 26:49.430 inpatient and outpatient, state of the market, 26:49.430 --> 26:52.670 commercial solution consisting of Cerner Millennium, 26:52.670 --> 26:54.410 an industry leading EHR, 26:54.410 --> 26:56.720 and Henry Schein's Dentrix Enterprise, 26:56.720 --> 26:59.360 a best of breed dental module. 26:59.360 --> 27:02.670 In 2017 the DOD deployed MHS GENESIS 27:02.670 --> 27:05.280 to four pilot sites in Washington state. 27:05.280 --> 27:07.160 The deployment to these pilot sites 27:07.160 --> 27:08.850 allowed DOD to better understand 27:08.850 --> 27:12.310 technical configuration and adoption challenges 27:12.310 --> 27:15.060 that are typical in an EHR deployment. 27:15.060 --> 27:17.940 Today those four pilot sites are using MHS GENESIS 27:17.940 --> 27:20.810 to safely deliver, manage, and document healthcare, 27:20.810 --> 27:24.163 completing over 100,000 patient encounters each month. 27:25.090 --> 27:27.610 In December of 2018 the Assistant Secretary 27:27.610 --> 27:29.860 of Defense for Acquisition, in coordination 27:29.860 --> 27:31.820 with the MHS leadership approved 27:31.820 --> 27:33.990 further deployment of MHS GENESIS 27:33.990 --> 27:37.130 to the next six waves beginning later this year. 27:37.130 --> 27:40.730 MHS GENESIS deployment will follow a regional wave model. 27:40.730 --> 27:43.520 A total of 23 waves across three regions 27:43.520 --> 27:45.940 in the United States and two overseas. 27:45.940 --> 27:48.660 This approach allows the DOD to take full advantage 27:48.660 --> 27:50.880 of lessons learned and experience gained 27:50.880 --> 27:53.883 to maximize efficiencies in our subsequent waves. 27:54.910 --> 27:58.870 As we work toward fully deploying MHS GENESIS across the DOD 27:58.870 --> 28:00.640 we recognize the benefit of expanding 28:00.640 --> 28:02.200 our federal partnerships. 28:02.200 --> 28:04.730 In 2018 the United States Coast Guard 28:04.730 --> 28:07.020 joined the DOD program and the Department 28:07.020 --> 28:09.270 of Veteran's Affairs awarded a contract 28:09.270 --> 28:12.990 to acquire, deploy, and adopt the same EHR as DOD. 28:12.990 --> 28:14.720 The result of these decisions will be 28:14.720 --> 28:18.050 a single integrated EHR for all service members, 28:18.050 --> 28:19.540 veterans, and their families. 28:19.540 --> 28:21.290 Fundamentally eliminating the need 28:21.290 --> 28:24.180 to exchange data between the departments. 28:24.180 --> 28:27.040 As the granddaughter, daughter, and spouse of veterans, 28:27.040 --> 28:29.830 and a beneficiary of the Military Health System myself, 28:29.830 --> 28:32.500 I can confidently say that PEO DHMS 28:32.500 --> 28:35.230 is equally committed to the successful deployment 28:35.230 --> 28:38.150 of a modern EHR, not just to the DOD, 28:38.150 --> 28:39.923 but to the Coast Guard, and the VA. 28:40.840 --> 28:42.880 In closing I would like to introduce 28:42.880 --> 28:45.340 and welcome the new PEO DHMS, 28:45.340 --> 28:47.910 Mr. Bill Tinston who's with me today. 28:47.910 --> 28:50.970 Mr. Tinston joins us from the Defense Logistics Agency 28:50.970 --> 28:53.610 where he served as the Program Executive Officer. 28:53.610 --> 28:55.350 He brings extensive executive level 28:55.350 --> 28:57.680 experience in information technology, 28:57.680 --> 29:00.170 program management, and cyber security. 29:00.170 --> 29:02.040 Thank you again for the opportunity to share 29:02.040 --> 29:03.400 our progress and I look forward 29:03.400 --> 29:04.800 to answering your questions. 29:06.100 --> 29:09.273 - Would the person introduced mind identifying themselves. 29:10.640 --> 29:11.640 Thank you very much. 29:12.960 --> 29:16.960 We'll turn to questions, and I would just suggest 29:16.960 --> 29:18.870 to the members because of the number 29:18.870 --> 29:21.190 of people on the panel to please direct 29:21.190 --> 29:24.540 a question at a specific witness, or two. 29:24.540 --> 29:26.410 Additionally we obviously would like 29:26.410 --> 29:28.490 a fulsome but concise answer. 29:28.490 --> 29:32.108 So I wouldn't feel the impulse to jump in 29:32.108 --> 29:34.630 unless there is some new information 29:34.630 --> 29:37.670 or a nuance we would miss in the original answer 29:37.670 --> 29:39.520 so we can continue to move on. 29:39.520 --> 29:41.517 With that I would recognize Miss Lowey 29:41.517 --> 29:43.320 for any opening statements she has, 29:43.320 --> 29:45.830 as well as any questions she has. 29:45.830 --> 29:48.020 - Well thank you very much. 29:48.020 --> 29:51.200 And I'm sorry there's so many hearings going on today, 29:51.200 --> 29:55.650 that I did not want to be late, but I couldn't help it. 29:55.650 --> 29:57.530 Thank you very much. 29:57.530 --> 30:00.620 I really do wanna thank Chairman Visclosky, 30:00.620 --> 30:03.520 ranking member Calvert for holding 30:03.520 --> 30:05.970 this very important hearing. 30:05.970 --> 30:09.450 And I welcome each of the service 30:09.450 --> 30:13.270 Surgeon's Generals, Mr. McCaffery, 30:13.270 --> 30:16.373 Vice Admiral Bono, and Miss Cummings. 30:17.210 --> 30:20.700 I do strongly believe that our military 30:20.700 --> 30:23.240 health system is world class. 30:23.240 --> 30:26.660 It contributes to ground breaking research 30:26.660 --> 30:30.170 benefiting both war fighters and the country they defend. 30:30.170 --> 30:33.040 It is critical to maintaining the highest 30:33.040 --> 30:36.700 levels of readiness and capability of the force. 30:36.700 --> 30:40.520 It also requires robust resources to ensure 30:40.520 --> 30:44.810 service members, retirees, and families 30:44.810 --> 30:47.000 receive the care they deserve. 30:47.000 --> 30:50.160 This is a commitment we must never fail. 30:50.160 --> 30:53.150 And I thank you all for your service. 30:53.150 --> 30:56.863 Now I think I saw Mr. Rogers, my friend down there. 30:58.160 --> 31:02.900 And Mr. Rogers and I, and several members 31:02.900 --> 31:06.850 of the committee, Miss Granger had been working 31:06.850 --> 31:10.490 on a coordinated health system, 31:10.490 --> 31:13.663 as we know with our records, for how many years Mr. Rogers? 31:16.830 --> 31:20.720 The billions of dollars we spend on this 31:23.590 --> 31:26.860 has caused a great deal of concern, 31:26.860 --> 31:28.540 which is the understatement 31:29.490 --> 31:31.760 for many members of this committee 31:31.760 --> 31:35.860 as we watch the money increase, increase. 31:35.860 --> 31:40.860 Now Miss Cummings you did touch on this system. 31:41.940 --> 31:45.610 Our expectation for electronic health record 31:45.610 --> 31:50.610 modernization is a system that is interoperable 31:50.920 --> 31:54.180 between DOD and the VA. 31:54.180 --> 31:59.080 And last September former Secretary of Defense Mattis, 31:59.080 --> 32:03.270 and VA Secretary Wilkie signed a joint statement 32:03.270 --> 32:05.690 to collaborate on implementation. 32:05.690 --> 32:08.990 In that statement a commitment was made 32:08.990 --> 32:12.330 for an accountability mechanism 32:12.330 --> 32:16.273 to coordinate decision making and oversight. 32:17.710 --> 32:21.660 I just ask because I couldn't believe my numbers was right. 32:21.660 --> 32:24.430 And I just asked someone to confirm. 32:24.430 --> 32:29.430 To date 4.9 billion dollars has been spent on this effort. 32:36.050 --> 32:37.880 You're aware of that I assume. 32:37.880 --> 32:42.820 4.9 billion dollars has been spent on this effort. 32:42.820 --> 32:45.860 Can you just describe more clearly 32:45.860 --> 32:50.860 what mechanisms are in place to collaborate with the VA. 32:51.020 --> 32:56.020 What implementation challenges do you foresee? 32:57.460 --> 33:00.050 What resources do you need? 33:00.050 --> 33:02.930 Will you finally get this done? 33:02.930 --> 33:07.080 Or are you gonna come up with another excuse next year? 33:07.080 --> 33:12.080 4.9 billion dollars has been spent to date. 33:14.310 --> 33:16.250 If I sound agitated, 33:16.250 --> 33:19.710 if some of my other colleagues sound agitated about this, 33:19.710 --> 33:23.430 we've been working on this for a very long time. 33:23.430 --> 33:27.420 And it seems to me we've run out of excuses. 33:27.420 --> 33:29.520 So tell me what's happening. 33:29.520 --> 33:31.564 When will it be completed? 33:31.564 --> 33:36.170 When will the VA and the military records 33:36.170 --> 33:38.790 truly be interoperable? 33:38.790 --> 33:40.440 - So thank you for that question. 33:41.470 --> 33:44.935 I've been the PEO for the last three years. 33:44.935 --> 33:47.680 But I have had a great opportunity 33:47.680 --> 33:50.000 to work very closely with the VA. 33:50.000 --> 33:52.050 And a lot of the teammates who are right now 33:52.050 --> 33:54.560 deploying the DODs electronic health record, 33:54.560 --> 33:56.870 we're part of the IEHR program. 33:56.870 --> 34:00.900 And I will say that, while I do agree 34:00.900 --> 34:03.020 that we spent money between the DOD and VA 34:03.020 --> 34:05.450 that got us to a place where we ended up 34:05.450 --> 34:07.830 going our separate ways, that that money, 34:07.830 --> 34:09.730 I do not consider it wasted because we got 34:09.730 --> 34:11.070 a lot of benefit out of that 34:11.070 --> 34:13.080 that got us to where we are today. 34:13.080 --> 34:14.890 And what I'll say about what's different 34:14.890 --> 34:16.839 about where we are today than where we were 34:16.839 --> 34:20.130 four and five years ago is that both the DOD and VA 34:20.130 --> 34:25.130 have a contract, we are resourced on the DOD side 34:25.140 --> 34:27.480 through our POM and through our POM submission. 34:27.480 --> 34:31.450 And the VA is resourced through their budget mechanisms. 34:31.450 --> 34:34.040 And the commitment has never been greater 34:34.040 --> 34:36.780 according to the history that I've talked 34:36.780 --> 34:38.680 to the people in my office. 34:38.680 --> 34:40.010 At the senior leadership level 34:40.010 --> 34:41.760 between DOD and VA the commitment 34:41.760 --> 34:44.310 has never been greater to work together. 34:44.310 --> 34:47.540 So I can say that I have great confidence 34:47.540 --> 34:51.050 that as we deploy MHS GENESIS in the DOD, 34:51.050 --> 34:54.770 the VA will be demonstrating their capability 34:54.770 --> 34:57.600 that is not, I won't use the word interoperable 34:57.600 --> 35:00.470 with the DOD, because it is integrated with the DOD. 35:00.470 --> 35:02.340 For the first time we're gonna have 35:02.340 --> 35:05.050 the service members data center. 35:05.050 --> 35:08.720 And the provider, whether they're a military provider, 35:08.720 --> 35:12.450 or a VA provider will be looking at exactly the same data. 35:12.450 --> 35:13.930 We won't have to pick it up and move 35:13.930 --> 35:15.670 it from one department to the other. 35:15.670 --> 35:18.360 So I am confident that we are going to accomplish that. 35:18.360 --> 35:20.150 The DOD timeline for full deployment 35:20.150 --> 35:22.620 is the end of calendar year 2023. 35:22.620 --> 35:26.380 The VA is on a 10 year deployment schedule 35:26.380 --> 35:30.820 to get across the entire VA Hospital 35:30.820 --> 35:32.290 capability in the United States. 35:32.290 --> 35:37.290 Which is in, I think in the 600 hospital clinic range. 35:37.780 --> 35:40.240 But we are working together. 35:40.240 --> 35:42.570 We are working together I think more closely 35:42.570 --> 35:44.240 than we ever have in the past. 35:44.240 --> 35:47.760 - Last time I checked this was 2019. 35:47.760 --> 35:48.593 - [Miss Cummings] It is. 35:48.593 --> 35:52.300 - So this system now is not interoperable? 35:52.300 --> 35:54.120 And it sounds to me that you still 35:54.120 --> 35:55.710 have one system, they have another, 35:55.710 --> 35:57.240 but you're gonna work together. 35:57.240 --> 35:58.560 I don't understand that. 35:58.560 --> 36:02.890 If a Mr. Jones is a veteran, 36:02.890 --> 36:06.380 and that's, he was in the military before, 36:06.380 --> 36:08.250 he still doesn't have one record 36:08.250 --> 36:10.340 according to where you are now? 36:10.340 --> 36:14.630 - So currently in our DOD Legacy, and VA Legacy systems, 36:14.630 --> 36:16.450 the way that we share data is through a tool 36:16.450 --> 36:18.330 called the Joint Legacy Viewer. 36:18.330 --> 36:22.400 That is interoperable in that the data can be viewed. 36:22.400 --> 36:24.260 What I'm talking about in the future, 36:24.260 --> 36:26.673 as an integrated system is that we don't 36:26.673 --> 36:28.790 have to move data or view data. 36:28.790 --> 36:31.440 It's actually there when you go to perform 36:31.440 --> 36:32.650 whatever medical-- 36:32.650 --> 36:34.178 - Why isn't it there now? 36:34.178 --> 36:37.550 It's gonna take four more years to get to that point? 36:37.550 --> 36:40.970 - We have the capability that is fielded 36:40.970 --> 36:44.470 centrally in a technical data center. 36:44.470 --> 36:46.910 But every single clinic and hospital 36:46.910 --> 36:48.920 needs to have a unique deployment. 36:48.920 --> 36:51.740 That is in following the commercial model. 36:51.740 --> 36:54.000 So as we go live in a region, 36:54.000 --> 36:56.180 we will have an integrated solution in that region. 36:56.180 --> 36:58.930 So we're live in the Pacific northwest. 36:58.930 --> 37:01.190 The VA will go live in the Pacific northwest, 37:01.190 --> 37:02.940 and we'll have an integrated system. 37:02.940 --> 37:05.140 And so we're gonna deploy in a way 37:05.140 --> 37:08.000 that we're deploying in the same locations at the same time. 37:08.000 --> 37:10.760 So we will have local, and then regional, 37:10.760 --> 37:12.830 and then national interoperability. 37:12.830 --> 37:14.830 So we're gonna start smaller and we're gonna work 37:14.830 --> 37:17.343 our way up to the higher enterprise. 37:19.950 --> 37:21.450 - I'm gonna turn this over. 37:21.450 --> 37:24.530 But just to clarify. 37:24.530 --> 37:29.440 Mr. Smith served his country with distinction. 37:29.440 --> 37:31.280 He becomes a veteran. 37:31.280 --> 37:36.280 And today there is not one record that's all coordinated. 37:36.350 --> 37:37.183 Is that correct? 37:37.183 --> 37:38.108 - [Miss Cummings] That is correct there is not one-- 37:38.108 --> 37:40.035 - Can you explain why? 37:40.035 --> 37:42.900 I know I have the indulgence of the chair, 37:42.900 --> 37:46.140 but many of us have been working on this for a long time. 37:46.140 --> 37:48.175 So I apologize. 37:48.175 --> 37:50.514 You can explain why? 37:50.514 --> 37:54.250 - Sure, so the DOD and the VA each built 37:54.250 --> 37:56.830 their own homegrown systems decades ago. 37:56.830 --> 38:01.190 So the DOD system of AHLTA was built in 2004. 38:01.190 --> 38:05.190 The VA built their system VistA years and years ago. 38:05.190 --> 38:07.960 In fact they were among the first electronic health records. 38:07.960 --> 38:11.220 And so because we each had our own homegrown system, 38:11.220 --> 38:14.900 the way that we found to share data 38:14.900 --> 38:18.210 was through an interface called the Joint Legacy Viewer, 38:18.210 --> 38:20.670 instead of putting all the data in one place. 38:20.670 --> 38:22.320 Now that we've shifted strategies 38:22.320 --> 38:25.760 and both the DOD and VA are gonna have this same system. 38:25.760 --> 38:27.760 We will have an integrated solution. 38:27.760 --> 38:31.100 But as you've pointed out we do have a deployment schedule 38:31.100 --> 38:34.360 that for the DOD is scheduled to be complete 38:34.360 --> 38:36.780 around the world by 2023. 38:36.780 --> 38:38.710 - I'll turn this back to the chair. 38:38.710 --> 38:41.350 But we'd like to remind you that you've 38:41.350 --> 38:45.000 already spent 4.9 billion dollars, 38:45.000 --> 38:48.150 and you're still working on an integrated system. 38:48.150 --> 38:50.000 Thank you Mr. Chair. 38:50.000 --> 38:52.790 - I appreciate the gentle woman for raising the issue. 38:52.790 --> 38:56.390 And given his deep concern and long years of work 38:56.390 --> 38:58.893 would now recognize Mr. Rogers. 39:01.907 --> 39:05.250 - Mr. Chairman thank you for the courtesy. 39:05.250 --> 39:08.740 And I appreciate Miss Lowey for bringing this topic up. 39:08.740 --> 39:12.170 Something we've been working on for years and years. 39:12.170 --> 39:16.683 It came to my attention 15 years ago, or whatever, 39:17.570 --> 39:22.560 the VFW brought a young soldier, retiree, 39:22.560 --> 39:24.723 from my district and to see me up here. 39:25.770 --> 39:29.320 He had been injured in Iraq, IED. 39:29.320 --> 39:30.743 It destroyed one eye. 39:31.940 --> 39:35.293 He was taken to the hospital in Germany, operated on. 39:36.580 --> 39:39.440 And they saved the one, the other eye. 39:39.440 --> 39:43.010 It was impacted but not blind. 39:43.010 --> 39:47.833 So when he came home and resumed his life in my district. 39:48.870 --> 39:52.373 Soon this injured eye began to deteriorate. 39:53.250 --> 39:56.220 So he goes to the VA hospital in Lexington 39:57.540 --> 39:58.483 because of that. 39:59.700 --> 40:03.393 They could not operate on this eye to save it. 40:04.600 --> 40:07.200 Why, because they could not get 40:07.200 --> 40:10.044 the DOD records from Germany 40:10.044 --> 40:12.670 into the VA Hospital in Lexington. 40:12.670 --> 40:14.490 So they were afraid to operate 40:14.490 --> 40:16.170 not knowing what they were getting into, 40:16.170 --> 40:18.193 what had been done for him in Germany. 40:19.310 --> 40:23.483 And so he goes blind, and comes to see me. 40:24.477 --> 40:27.350 It was my first introduction to this problem. 40:27.350 --> 40:29.270 And I was absolutely flabbergasted 40:31.440 --> 40:36.110 that the bureaucracies in DOD and VA 40:36.110 --> 40:39.910 were so intent on keeping their system in their hands, 40:39.910 --> 40:42.823 and not sharing with anyone else, both sides. 40:43.860 --> 40:45.740 This young man went blind. 40:45.740 --> 40:47.860 And I'm sure there's hundreds, 40:47.860 --> 40:50.423 thousands of instances like this. 40:51.610 --> 40:53.040 We've appropriated funds. 40:53.040 --> 40:54.660 We've preached, we've hammered, 40:54.660 --> 40:56.963 we have requested, we've met. 40:57.990 --> 41:00.940 Over the years I've met with the Secretaries 41:00.940 --> 41:04.670 in all these departments, including the Attorney General. 41:04.670 --> 41:06.963 Over the years, all the way back yonder. 41:08.420 --> 41:12.053 And we get this bureaucratic double talk. 41:13.820 --> 41:17.200 I've tried to follow what you're doing over the years. 41:17.200 --> 41:19.810 And I thought we were headed toward a solution. 41:19.810 --> 41:22.390 Then all of a sudden you switch lanes 41:22.390 --> 41:25.150 and try something else, and we're stuck 41:25.150 --> 41:27.400 with the same problem we've had all the time. 41:32.400 --> 41:35.110 I can't be very objective about this 41:35.110 --> 41:36.883 because I'm so involved with it. 41:38.687 --> 41:41.373 And you have stalled. 41:43.230 --> 41:47.083 And you've given us all sorts of double talk. 41:48.890 --> 41:53.040 And I want to know if that incident happened today. 41:53.040 --> 41:57.013 If this young man, Rufus Jugat is his name. 41:58.600 --> 42:01.693 If a person like him came to see me in his condition, 42:02.970 --> 42:05.930 would it be different today for that soldier? 42:05.930 --> 42:06.783 In what way? 42:07.930 --> 42:11.070 - It would be different in that the VA Hospital 42:11.070 --> 42:13.810 and the clinician would have access 42:13.810 --> 42:16.810 through the Joint Legacy Viewer to view the data 42:16.810 --> 42:20.480 that was collected in Germany, at the hospital, 42:20.480 --> 42:24.320 by the military medical provider. 42:24.320 --> 42:26.470 That is the capability that we have today. 42:26.470 --> 42:29.860 So that VA provider would need to go a system 42:29.860 --> 42:32.980 outside of his or her electronic health record. 42:32.980 --> 42:35.270 But they would have access to view it, 42:35.270 --> 42:36.570 to see who the doctor was, 42:36.570 --> 42:39.650 to be able to find out more information. 42:39.650 --> 42:43.270 But to your point, we're not satisfied with that. 42:43.270 --> 42:45.940 Which is why we're doing what we're doing now, 42:45.940 --> 42:48.510 which is MHS GENESIS for the DOD, 42:48.510 --> 42:52.460 and the Coast Guard and the VA have joined that solution. 42:52.460 --> 42:55.130 And we will have exactly the same technical solution 42:55.130 --> 42:57.180 where the data resides once. 42:57.180 --> 43:00.750 And so if this happens three, four years from now, 43:00.750 --> 43:02.590 then the data will reside once. 43:02.590 --> 43:05.490 And the VA provider will have access to the same exact 43:05.490 --> 43:07.757 information the DOD provider has access to. 43:07.757 --> 43:10.230 - It's gonna be another three or four years? 43:10.230 --> 43:15.050 - It is going to take, again the deployment is regional, 43:15.050 --> 43:17.840 across the country, and then overseas. 43:17.840 --> 43:20.370 So as we put more and more hospitals 43:20.370 --> 43:22.980 onto the new system, MHS GENESIS, 43:22.980 --> 43:27.470 and the VA does the same on the same timeline. 43:27.470 --> 43:29.540 It will be first deployed on the west coast, 43:29.540 --> 43:31.820 then the east, then the center of the country, 43:31.820 --> 43:33.970 then we'll move outside of the United States. 43:33.970 --> 43:35.263 - So a young soldier like Rufus Jugat 43:35.263 --> 43:39.693 that comes to me now, with the same situation. 43:41.138 --> 43:43.103 I've gotta say, I'm sorry it's gonna take 43:43.103 --> 43:45.660 another three or four years. 43:45.660 --> 43:47.930 - No, again the access to the data 43:47.930 --> 43:50.040 through the Joint Legacy Viewer exists today. 43:50.040 --> 43:53.520 Right now I can go in and see all of the data 43:53.520 --> 43:55.010 that was collected on me 43:55.010 --> 43:57.340 whether it was in the DOD, the VA, 43:57.340 --> 44:01.300 or in a commercial partner who has a partnership with us. 44:01.300 --> 44:03.280 So the data is accessible. 44:03.280 --> 44:05.680 The reason that we wanna have an integrated system 44:05.680 --> 44:08.560 is by having all of the data reside in one place, 44:08.560 --> 44:11.590 we can take advantage of clinical decision support. 44:11.590 --> 44:12.980 We can be more efficient. 44:12.980 --> 44:14.930 And know that when a test was done, 44:14.930 --> 44:17.350 that we have access to all of the test results, 44:17.350 --> 44:19.090 and we don't have to do that test again. 44:19.090 --> 44:21.190 And we can create additional efficiencies 44:21.190 --> 44:23.440 and effectiveness across the two departments. 44:24.330 --> 44:25.963 - Well his records in Germany, 44:27.410 --> 44:29.070 I assume there was a write up 44:29.070 --> 44:34.070 of his operations in great detail that DOD did, 44:36.380 --> 44:39.427 and which VA could not get their hands on. 44:39.427 --> 44:40.260 - [Miss Cummings] Correct. 44:40.260 --> 44:42.160 - Would that kind of info that the medical 44:42.160 --> 44:44.070 records of those operations, 44:44.070 --> 44:46.256 would that be available through this system? 44:46.256 --> 44:47.089 - [Miss Cummings] Yes. 44:47.089 --> 44:47.922 - Now? 44:47.922 --> 44:50.763 - Through the Joint Legacy Viewer, yes, today. 44:52.467 --> 44:53.980 - In the joint Legacy 44:53.980 --> 44:55.073 - [Miss Cummings] Viewer. 44:56.210 --> 44:57.310 - Tell me about that. 44:57.310 --> 44:58.143 - Sure. 44:58.143 --> 45:01.810 So what the Joint Legacy Viewer does is, it's a view. 45:01.810 --> 45:05.790 And it goes out and it looks at every source of data 45:05.790 --> 45:07.900 that there may be a record. 45:07.900 --> 45:10.870 And so it'll, again if we use me as an example, 45:10.870 --> 45:13.360 it would look for Stacy A. Cummings and my birth date, 45:13.360 --> 45:17.070 and my unique identifier, and it would go out 45:17.070 --> 45:22.070 to scores of databases and find any data on me. 45:22.110 --> 45:24.344 And then it would put it into a view 45:24.344 --> 45:27.770 that is shown in widgets. 45:27.770 --> 45:29.700 So there would be a widget that said 45:29.700 --> 45:33.403 procedures, problems, allergies, prescriptions, 45:34.260 --> 45:37.450 any radiology, any lab test results. 45:37.450 --> 45:40.320 And so the VA in your scenario, 45:40.320 --> 45:43.160 the VA provider could pull up the Joint Legacy Viewer 45:43.160 --> 45:46.010 and look up the gentleman, and he would be able to see 45:46.010 --> 45:47.570 the data that is currently stored 45:47.570 --> 45:50.940 in the DOD tool called Essentris. 45:50.940 --> 45:53.920 And they would be able to see that data and click on it, 45:53.920 --> 45:55.160 and be able to learn more about 45:55.160 --> 45:56.860 the procedure that happened in Germany. 45:56.860 --> 45:59.970 - Would that be available to the hospital in Lexington VA? 45:59.970 --> 46:01.833 - Correct, today. 46:03.734 --> 46:06.101 - Mr. Chairman I appreciate you letting me 46:06.101 --> 46:08.063 take out of order here. 46:10.680 --> 46:12.673 And I thank you ma'am. 46:13.670 --> 46:14.710 - Thank you Mr. Chairman. 46:14.710 --> 46:17.507 Miss Cummings I have worked on this issue for so long. 46:17.507 --> 46:20.030 And it is really, really frustrating. 46:20.030 --> 46:23.090 I'm a former hospital attorney. 46:23.090 --> 46:26.550 And you know what, hospitals often time as ours did, 46:26.550 --> 46:30.680 had different hospital locations within the corporation. 46:30.680 --> 46:33.200 And they shared medical records. 46:33.200 --> 46:34.650 So it was seamless. 46:34.650 --> 46:37.850 It just baffles me that this can't be done. 46:37.850 --> 46:40.720 And there's software, commercial software, 46:40.720 --> 46:43.300 medical record software that could simply 46:43.300 --> 46:46.720 be purchased by the VA and the Department of Defense. 46:46.720 --> 46:47.553 Is there not? 46:48.820 --> 46:50.730 - And that's exactly what our strategy is. 46:50.730 --> 46:54.010 So we've decided that both the DOD and the VA 46:54.010 --> 46:58.130 are going to buy the same electronic health record. 46:58.130 --> 46:59.970 It's based on Cerner's Millennium 46:59.970 --> 47:01.830 as well as Henry Schein Dentrix Enterprise 47:01.830 --> 47:03.330 which is a dental module. 47:03.330 --> 47:06.580 So we are exactly doing what you have asked us to do. 47:06.580 --> 47:09.040 Which is we're gonna have the same system. 47:09.040 --> 47:11.120 We are actually gonna store all of the data 47:11.120 --> 47:12.400 in the same data center. 47:12.400 --> 47:13.730 So we're gonna protect it. 47:13.730 --> 47:15.940 We're gonna make sure that there are protections. 47:15.940 --> 47:19.600 And we're gonna access that data, the same exact data, 47:19.600 --> 47:22.640 regardless of if you are a DOD provider, 47:22.640 --> 47:25.210 medical provider, or a VA medical provider. 47:25.210 --> 47:26.520 So that is our strategy. 47:26.520 --> 47:28.550 And we are implementing it. 47:28.550 --> 47:32.950 We have contracts in place, both the DOD and the VA. 47:32.950 --> 47:34.930 And we're working together from a technical 47:34.930 --> 47:38.310 and a programmatic perspective to align our strategies 47:38.310 --> 47:39.970 to make sure that the end result 47:39.970 --> 47:42.840 is that a patient, it is seamless for a patient. 47:42.840 --> 47:44.820 - Who from the Department of Defense 47:44.820 --> 47:47.170 is coordinating with the VA? 47:47.170 --> 47:48.554 Who are the people who are involved in making 47:48.554 --> 47:49.880 sure that that happens? 47:49.880 --> 47:51.300 - So that would be my position, 47:51.300 --> 47:55.110 which I've recently moved on to another position 47:55.110 --> 47:56.580 within the Department of Defense. 47:56.580 --> 47:59.680 But Mr. Bill Tinston, who is my successor. 47:59.680 --> 48:02.425 He is, that is his job. 48:02.425 --> 48:04.610 And I will say it's actually the job 48:04.610 --> 48:05.990 of everyone at this table. 48:05.990 --> 48:08.970 So we meet on a regular basis, Mr. McCaffery, 48:08.970 --> 48:11.250 Admiral Bono, the Surgeons General. 48:11.250 --> 48:14.570 We have people on our teams, or ourselves 48:14.570 --> 48:16.643 who meet with the VA on a regular basis. 48:17.691 --> 48:20.360 - But you said you're gonna start this on the west coast. 48:20.360 --> 48:22.530 It's gonna be a regional deployment, 48:22.530 --> 48:24.864 east coast and then the middle of the country. 48:24.864 --> 48:27.180 Why is it, why can't you just do 48:27.180 --> 48:29.010 this all at once, I guess? 48:29.010 --> 48:30.830 - Actually that's, I think that's the first question 48:30.830 --> 48:32.940 I asked when I took this job. 48:32.940 --> 48:35.535 We are applying commercial best practices. 48:35.535 --> 48:38.120 So we've talked to large hospital systems 48:38.120 --> 48:40.500 to ask them how they did their deployments. 48:40.500 --> 48:42.974 And what we learned from them is that 48:42.974 --> 48:47.974 doing a subset, refining, and then learning lessons, 48:48.260 --> 48:51.080 improving the system, and moving onto the next one 48:51.080 --> 48:53.290 is the best model. 48:53.290 --> 48:54.970 Now I will say that clearly, 48:54.970 --> 48:57.320 we've deployed only to our pilot sites. 48:57.320 --> 48:59.110 We're gonna gain more and more experience 48:59.110 --> 49:01.300 as we move to other sites. 49:01.300 --> 49:03.870 And we would always be looking for opportunities 49:03.870 --> 49:05.900 to be more efficient and more effective 49:05.900 --> 49:07.700 as well as partnering and being 49:07.700 --> 49:09.350 in coordination with the VA. 49:09.350 --> 49:12.400 - Well if this is a four year timeline, 49:12.400 --> 49:14.390 there will be updates, countless updates 49:14.390 --> 49:18.042 in that interim period before this is all in place. 49:18.042 --> 49:20.760 I just, I don't know how you're gonna do it. 49:20.760 --> 49:23.820 - Well the beauty of having a centrally hosted system 49:23.820 --> 49:25.590 is that we don't have to go out 49:25.590 --> 49:27.360 to each hospital and update it. 49:27.360 --> 49:29.890 So the Cerner Millennium software 49:29.890 --> 49:33.140 actually gets updated on a weekly, monthly, 49:33.140 --> 49:36.140 quarterly, sometimes even daily basis. 49:36.140 --> 49:40.050 And so we always have the most up to date software. 49:40.050 --> 49:43.270 And so we've already taken two major upgrades 49:43.270 --> 49:46.510 to the Millennium software in our MHS GENESIS deployment. 49:46.510 --> 49:48.040 And that's the beauty of a commercial 49:48.040 --> 49:50.055 off the shelf solution, as you pointed out 49:50.055 --> 49:51.507 that you experienced in your hospital. 49:51.507 --> 49:53.980 - So I have seven years on a district. 49:53.980 --> 49:55.070 I have the seven years on the VA. 49:55.070 --> 49:57.240 It was a wonderful hospital. 49:57.240 --> 50:00.790 But if a veteran goes in after just transitioning 50:00.790 --> 50:04.160 out of the military, this week, needs to refill 50:04.160 --> 50:07.760 a prescription, will they have the records 50:07.760 --> 50:10.290 from the military in order to do that? 50:10.290 --> 50:14.210 - So this week, today the VA medical provider 50:14.210 --> 50:15.950 could go into the Joint Legacy Viewer 50:15.950 --> 50:19.200 and see what prescriptions that that individual has, 50:19.200 --> 50:22.245 and then give them a refill of that prescription. 50:22.245 --> 50:25.110 What we can't do, if you're asking the question 50:25.110 --> 50:28.440 of can the VA simply fill a prescription 50:28.440 --> 50:33.140 that the DOD prescribed, no. 50:33.140 --> 50:35.360 And I don't, and I think that there may be 50:35.360 --> 50:37.260 medical reasons that I would defer 50:37.260 --> 50:41.520 to my medical colleagues that, about why that might be. 50:41.520 --> 50:44.320 - Well and that's the frustration that I've run into, 50:44.320 --> 50:48.330 is the veteran then has to see a physician, 50:48.330 --> 50:52.510 which takes time, we still have calendar issues at the VA. 50:52.510 --> 50:54.720 In the meantime without their prescription. 50:54.720 --> 50:57.990 A prescription lapse, which is a healthcare 50:57.990 --> 50:59.523 hazard for that veteran. 51:00.770 --> 51:02.820 And there's no other way to address that? 51:04.000 --> 51:05.200 - To the best of my knowledge, 51:05.200 --> 51:08.070 other than the Joint Legacy Viewer which we have today. 51:08.070 --> 51:11.370 Now in the future when we have an integrated system, 51:11.370 --> 51:13.190 that would simply be a policy issue, 51:13.190 --> 51:15.430 as opposed to a technology issue. 51:15.430 --> 51:17.462 But today the technology does not exist 51:17.462 --> 51:22.390 for the veteran to go into veteran's affair, 51:22.390 --> 51:26.110 or into a VA hospital and fill a DOD prescription. 51:26.110 --> 51:29.195 That technology does not currently exist 51:29.195 --> 51:31.568 as an enterprise solution. 51:31.568 --> 51:33.110 - I just don't get it, I don't see why not. 51:33.110 --> 51:36.060 I mean, but anyway. 51:36.060 --> 51:38.540 Thank you for your testimony here. 51:38.540 --> 51:40.780 We wanna work with both the Department 51:40.780 --> 51:42.810 of Defense and the VA to solve 51:42.810 --> 51:44.540 this problem as quickly as possible. 51:44.540 --> 51:47.090 Thank you Mr. Chairman, I yield back. 51:47.090 --> 51:47.923 - Thank you. 51:47.923 --> 51:50.382 And I hate to beat the same horse, but I'm going to. 51:52.360 --> 51:53.713 I have a question for ya. 51:54.700 --> 51:56.350 I came on this committee in 2004. 51:57.980 --> 51:59.973 This was an issue in 2004. 52:00.860 --> 52:04.133 In fact you actually used that date yourself. 52:06.470 --> 52:10.470 I know that MILCON put a billion dollars in it in 2004. 52:11.679 --> 52:13.260 I would be willing to bet the ranks, 52:13.260 --> 52:14.544 they put a billion dollars in it 52:14.544 --> 52:19.544 every year since 2004, at least a billion dollars. 52:20.589 --> 52:24.370 I would like to know how much you were 52:24.370 --> 52:29.100 in the appropriations bills that DOD received, 52:29.100 --> 52:33.260 what was the designated amount for this particular problem 52:33.260 --> 52:36.350 that was appropriated every year since 2004? 52:36.350 --> 52:38.090 I'd like that information. 52:38.090 --> 52:39.980 You should be able to get it for me. 52:39.980 --> 52:41.680 I'd appreciate it if you did. 52:41.680 --> 52:45.540 If you matched VA then that would be, 52:45.540 --> 52:47.640 four, this is 17, that would be 52:47.640 --> 52:51.360 13 billion dollars invested by VA. 52:51.360 --> 52:54.440 And assuming my, I am right on my hypothesis, 52:54.440 --> 52:57.090 13 billion dollars by DOD. 52:57.090 --> 52:59.763 And the result is a viewer. 53:01.460 --> 53:04.280 Or else that money went someplace else. 53:04.280 --> 53:05.113 Let me finish. 53:05.113 --> 53:06.070 - [Miss Cummings] Okay. 53:06.070 --> 53:06.903 - Okay. 53:06.903 --> 53:09.970 And the viewer doesn't solve the problem. 53:09.970 --> 53:11.800 And yet the problem is exactly 53:11.800 --> 53:15.563 as the lady described, right there in 2004. 53:17.690 --> 53:19.890 Now where did that money go? 53:19.890 --> 53:23.365 How was that money spent that was designated 53:23.365 --> 53:25.833 to come up with interoperability, 53:26.690 --> 53:31.690 and in 13 years we haven't gotten interoperability? 53:32.750 --> 53:35.690 It just blows your mind. 53:35.690 --> 53:38.487 I'd like that information from the Department of Defense. 53:38.487 --> 53:40.930 And I'm gonna get it from the VA, 53:40.930 --> 53:44.620 'cause I'm ranking member on that committee. 53:44.620 --> 53:45.453 And we're gonna think, 53:45.453 --> 53:47.940 we need to take a hard look at the amount of money 53:47.940 --> 53:51.870 we spent to get, at this time, a viewer 53:51.870 --> 53:55.580 that doesn't solve that poor prescription drug problem 53:55.580 --> 53:57.280 that was described right over there. 53:57.280 --> 54:00.170 'Cause I've had at least 50 people 54:00.170 --> 54:02.807 call me and say, "My prescription's expired 54:02.807 --> 54:04.287 "and I can't get it filled." 54:05.170 --> 54:07.480 And so it's, the veterans are constantly 54:07.480 --> 54:09.370 complaining about that. 54:09.370 --> 54:11.520 So this is beyond belief. 54:11.520 --> 54:13.150 Can you get that information for me? 54:13.150 --> 54:14.980 Someone, I don't care who it is. 54:14.980 --> 54:16.730 - I will take that for the record. 54:16.730 --> 54:18.770 - 'Cause I know we've designated, I assume, 54:18.770 --> 54:21.640 I haven't been on this committee that long, 54:21.640 --> 54:23.130 for that whole time. 54:23.130 --> 54:25.880 But I know the VA, we designated it for that purpose, 54:25.880 --> 54:28.680 interoperability, and it didn't get done. 54:28.680 --> 54:29.850 - [Chairman] Will the gentleman yield? 54:29.850 --> 54:30.683 - Yes. 54:31.760 --> 54:36.220 I heard this same conversation 15 years ago between, 54:36.220 --> 54:37.127 - Exactly. 54:37.127 --> 54:40.930 - And the departments, and yet here we are 54:40.930 --> 54:42.858 having spent zillions of dollars-- 54:42.858 --> 54:44.050 - Unbelievable. 54:44.050 --> 54:47.393 - No one knows how much, or where it was spent, presumably. 54:48.310 --> 54:50.073 And we still don't have an answer. 54:51.224 --> 54:52.413 - And that's why I wanna see the numbers. 54:52.413 --> 54:55.470 And I want, I think both committees 54:55.470 --> 54:57.700 oughta take a hard look at the numbers, 54:57.700 --> 54:59.143 and get some explanations. 55:00.110 --> 55:03.327 Because as many problems as we have, 55:03.327 --> 55:05.970 and as many issues we have with our war fighters, 55:05.970 --> 55:09.003 which we love, and we try to do the best we can for, 55:10.150 --> 55:13.070 this is a embarrassment in the amount 55:13.070 --> 55:16.440 of money we've poured into this to get to this point. 55:16.440 --> 55:19.250 When I've had merchants come into my office 55:19.250 --> 55:23.247 over the years and say, "I could do it in six weeks." 55:24.980 --> 55:28.233 And I will call the VA, and I'll call DOD, 55:29.150 --> 55:30.500 say I got these people you need 55:30.500 --> 55:32.480 to meet with, they'll go to ya. 55:32.480 --> 55:33.700 Oh they're already workin' on it. 55:33.700 --> 55:35.550 They don't wanna look at our program. 55:36.406 --> 55:39.340 So I want you to tell me about the money. 55:39.340 --> 55:41.050 Show me the money. 55:41.050 --> 55:41.883 Thank you Mr. Chairman. 55:41.883 --> 55:42.716 - [Miss McCollum] Mr. Chairman, 55:42.716 --> 55:43.670 I'd like a point of clarification. 55:43.670 --> 55:44.563 - Yes I'll yield. 55:46.120 --> 55:47.470 - So you've got the viewer. 55:48.540 --> 55:51.450 It's a part of a two step solution. 55:51.450 --> 55:52.970 You're running parallel and everything 55:52.970 --> 55:54.730 so nobody's medical records get lost. 55:54.730 --> 55:56.790 Not happy about the amount of money 55:56.790 --> 56:00.050 that's been spent to do this. 56:00.050 --> 56:03.513 But, if I have a DOD prescription, 56:05.550 --> 56:07.900 and I go to the VA, the viewer 56:07.900 --> 56:12.900 will allow my doc to see what prescription was written. 56:14.840 --> 56:16.920 And then the doc can make the assessment, 56:16.920 --> 56:21.080 I'm gonna write another one week, 30 days, 56:21.080 --> 56:25.020 or whatever until we, until I do my full assessments. 56:25.020 --> 56:26.897 So it isn't like that prescription's lost 56:26.897 --> 56:28.610 and it can't be filled, correct? 56:28.610 --> 56:29.443 - Correct. 56:29.443 --> 56:30.276 - Thank you. 56:32.750 --> 56:34.607 - I'd like for you to share with me 56:34.607 --> 56:37.010 and the Chairman if you don't mind please. 56:37.010 --> 56:37.843 Yield back. 56:40.200 --> 56:43.150 - Judge in answer to your question. 56:43.150 --> 56:46.903 Assuming anticipated requests for 2020, 56:46.903 --> 56:49.530 and that's a dangerous assumption, 56:49.530 --> 56:52.320 are approved in total, 56:52.320 --> 56:56.830 from 2008, and your question was from four. 56:56.830 --> 56:59.860 So there's still a response to the committee. 56:59.860 --> 57:03.997 Of 4,980,615,035 dollars. 57:07.540 --> 57:10.760 I would simply because our time is running. 57:10.760 --> 57:15.343 I appreciate the members participation. 57:16.580 --> 57:21.580 I share my Chairman's, I remember when Chairman Rogers 57:22.650 --> 57:25.350 and Miss Lowey had a meeting, among others, 57:25.350 --> 57:27.393 General Shinseki was in that room. 57:28.450 --> 57:33.450 So I would, people have used the term frustrated. 57:33.500 --> 57:35.123 I would say I'm appalled. 57:36.600 --> 57:38.730 And my good friend gave me my prompt. 57:38.730 --> 57:41.310 He has heard me say this many times before. 57:41.310 --> 57:43.470 And I'm deadly serious. 57:43.470 --> 57:48.470 This country fought and won World War II in four years. 57:52.743 --> 57:56.020 And we have had meetings on this for decades, 57:56.020 --> 57:58.303 and the rollout is gonna be another 10 years. 58:00.112 --> 58:02.470 Since we have probably about 60 minutes 58:02.470 --> 58:05.550 until votes start and we have 13 members here, 58:05.550 --> 58:07.120 we will have to move on. 58:07.120 --> 58:09.200 But my last comment parenthetically 58:09.200 --> 58:11.673 is why is the Midwest always last? 58:13.127 --> 58:14.482 - [Female Congresswoman] Here here. 58:14.482 --> 58:15.315 - I'm serious about that. 58:15.315 --> 58:16.148 - I am too. 58:16.148 --> 58:17.280 - I'm serious about this. 58:17.280 --> 58:18.932 Why is the Midwest 58:18.932 --> 58:21.349 (cross talk) 58:25.679 --> 58:27.570 (laughter) 58:27.570 --> 58:28.917 - Who was first in this fight? 58:28.917 --> 58:31.763 - Californians, it's first in the nation. 58:32.890 --> 58:35.160 People ask me why I'm cynical 58:35.160 --> 58:37.100 about national health insurance Mr. Chairman, 58:37.100 --> 58:38.263 this is it right here. 58:41.434 --> 58:42.267 Lemme think. 58:42.267 --> 58:45.360 I tell my friends that are supportive of Medicare for all, 58:45.360 --> 58:47.280 be careful what you wish for. 58:47.280 --> 58:49.120 But just... 58:51.400 --> 58:54.090 As I listen through this testimony, 58:54.090 --> 58:55.763 and read through some notes, 58:58.797 --> 59:00.930 I know that all of you wanna provide 59:00.930 --> 59:03.710 for the health and wellbeing of our service members. 59:03.710 --> 59:05.860 To that end I wanna get your thoughts 59:05.860 --> 59:10.003 on how to link and create interoperability. 59:11.330 --> 59:13.800 Obviously we have a problem with medical records 59:13.800 --> 59:18.260 between the VA and the Department of Defense. 59:18.260 --> 59:20.020 But also we have interoperability problems 59:20.020 --> 59:22.350 between the DHA and the services, 59:22.350 --> 59:25.190 and perhaps one of the reasons 59:25.190 --> 59:28.293 is because we don't have a command. 59:29.910 --> 59:31.773 Right now I suspect it, 59:33.490 --> 59:35.420 you don't have a Defense Health Command, 59:35.420 --> 59:38.453 and so you don't have clarity of command. 59:39.320 --> 59:41.510 And it seems to me that that would be important 59:41.510 --> 59:45.010 especially in a military setting. 59:45.010 --> 59:46.453 If something happens, 59:48.530 --> 59:50.493 that we don't want to have happen, 59:51.380 --> 59:53.900 and you need to move quickly, 59:53.900 --> 59:56.530 wouldn't it be better to have a command 59:56.530 --> 59:59.040 than it would be to have the type 59:59.040 --> 01:00:01.820 of situation that you're setting up at the present time? 01:00:01.820 --> 01:00:04.913 I don't know who's the right person to answer that question. 01:00:06.320 --> 01:00:09.723 But somebody please. 01:00:10.860 --> 01:00:14.870 - So Congressman Calvert I'll take the first stab. 01:00:14.870 --> 01:00:19.870 actually the NDAA of 19 has asked the department 01:00:20.070 --> 01:00:22.530 to ask that question exactly. 01:00:22.530 --> 01:00:25.270 So we are in the middle of looking at 01:00:25.270 --> 01:00:28.490 what is it feasible to consider 01:00:28.490 --> 01:00:30.640 some type of either a Defense Health Command, 01:00:30.640 --> 01:00:32.390 a Unified Medical Command. 01:00:32.390 --> 01:00:37.090 It's gonna, it's been debated for several years. 01:00:37.090 --> 01:00:39.940 We are putting together three or four options 01:00:39.940 --> 01:00:42.310 with the department to consider. 01:00:42.310 --> 01:00:45.920 And then we, later this year we report to Congress 01:00:45.920 --> 01:00:48.620 identifying those options, our assessment 01:00:48.620 --> 01:00:51.929 in terms of feasibility, and making those recommendations 01:00:51.929 --> 01:00:56.180 for not only the department, but for Congress to consider. 01:00:56.180 --> 01:00:58.680 But in the interim, and my colleagues 01:00:58.680 --> 01:01:00.530 can chime in and add to this, 01:01:00.530 --> 01:01:02.960 your issue of interoperability. 01:01:02.960 --> 01:01:05.760 One of the things we are trying to do in terms 01:01:05.760 --> 01:01:08.060 of where appropriate, standardizing things 01:01:08.060 --> 01:01:11.510 across the separate military run 01:01:11.510 --> 01:01:14.010 healthcare facility networks is indeed, 01:01:14.010 --> 01:01:16.910 on enterprise level, do it in a consolidated way. 01:01:16.910 --> 01:01:19.630 So for example, in medical logistics 01:01:19.630 --> 01:01:23.890 our goal would be that the same types of medical supplies, 01:01:23.890 --> 01:01:27.070 devices that are used in our NTFs 01:01:27.070 --> 01:01:30.000 are the same ones our providers are using down range, 01:01:30.000 --> 01:01:31.990 whether it's Army, Navy, or Air Force. 01:01:31.990 --> 01:01:33.780 And so that we have an effectiveness 01:01:33.780 --> 01:01:36.430 not only in our purchasing, but in terms of training. 01:01:36.430 --> 01:01:37.915 That we're training all of our providers 01:01:37.915 --> 01:01:40.760 on a common set of tools. 01:01:40.760 --> 01:01:42.584 So that's an example of one of the things 01:01:42.584 --> 01:01:44.750 that these reforms would try to get at 01:01:44.750 --> 01:01:47.623 is facilitate that kind of interoperability. 01:01:48.760 --> 01:01:50.950 - Well based upon what we've seen, 01:01:50.950 --> 01:01:53.320 in the beginning of this meeting. 01:01:53.320 --> 01:01:54.340 You know I have some real doubts 01:01:54.340 --> 01:01:56.790 about how this is going to work 01:01:56.790 --> 01:01:58.910 unless there is some kind of command structure, 01:01:58.910 --> 01:02:00.963 and somebody that's responsible. 01:02:02.424 --> 01:02:04.997 You know we've moved a lot since World War II, 01:02:06.350 --> 01:02:07.773 real quick Mr. Chairman, 01:02:09.150 --> 01:02:13.060 on December 6th, 1941 the Department of the Navy 01:02:13.060 --> 01:02:16.360 bought a large facility on the west coast. 01:02:16.360 --> 01:02:17.423 This, we're first. 01:02:18.280 --> 01:02:22.600 To build a hospital that had several thousand beds. 01:02:22.600 --> 01:02:27.010 It closed escrow on December 6th, 1941. 01:02:27.010 --> 01:02:30.053 And they were up and operating in a week. 01:02:31.510 --> 01:02:33.710 And a lots happened since then. 01:02:33.710 --> 01:02:34.970 And I don't know that we can do anything 01:02:34.970 --> 01:02:36.570 in a week anymore in this country. 01:02:36.570 --> 01:02:40.500 But we can't get our health records together. 01:02:40.500 --> 01:02:44.555 We certainly as hell can't fight a substantial war, 01:02:44.555 --> 01:02:48.020 potentially with one of these near adversaries 01:02:48.020 --> 01:02:52.370 we talk about, and put together the men, 01:02:52.370 --> 01:02:54.060 the equipment, and the facilities 01:02:54.060 --> 01:02:55.963 in a very rapid way it seems to me. 01:02:56.937 --> 01:02:58.083 So with that thank you. 01:02:59.360 --> 01:03:02.303 - Yes first Mr. Cummings, 01:03:02.303 --> 01:03:03.910 Miss Cummings, I'm sorry. 01:03:03.910 --> 01:03:05.310 Good luck in your new job. 01:03:05.310 --> 01:03:08.130 Mr. McCaffery, and Generals and Admirals 01:03:08.130 --> 01:03:09.563 so I can move quickly. 01:03:10.500 --> 01:03:13.610 Firstly I wanna mention the incredible work, 01:03:13.610 --> 01:03:14.973 and I'm going local now, 01:03:15.860 --> 01:03:20.140 in Maryland Shock Trauma, and the Kennedy-Krieger Institute, 01:03:20.140 --> 01:03:22.100 both located in Baltimore. 01:03:22.100 --> 01:03:23.670 And especially in terms of their 01:03:23.670 --> 01:03:25.820 behavioral health for military families, 01:03:25.820 --> 01:03:28.090 and spinal cord injury research. 01:03:28.090 --> 01:03:30.203 Now General West my question is to you. 01:03:31.980 --> 01:03:34.600 Primarily directed, the Major Extremity 01:03:34.600 --> 01:03:37.790 Trauma Research Consortium called METRC, 01:03:37.790 --> 01:03:39.995 you familiar with METRC? 01:03:39.995 --> 01:03:44.610 Was created in 2009 and was later expanded with funds 01:03:44.610 --> 01:03:47.547 from the Peer Review Orthopedic Research Program. 01:03:47.547 --> 01:03:50.400 The METRC consists of a network of clinical centers 01:03:50.400 --> 01:03:53.170 and a data coordinating center that works 01:03:53.170 --> 01:03:55.730 with the DOD to conduct clinical research 01:03:55.730 --> 01:03:57.790 studies with orthopedic trauma. 01:03:57.790 --> 01:03:59.640 METRC has made improvements in adapting 01:03:59.640 --> 01:04:03.080 several technologies to the orthopedic trauma setting. 01:04:03.080 --> 01:04:05.070 But more work can be done. 01:04:05.070 --> 01:04:06.670 Additional funding would allow 01:04:06.670 --> 01:04:08.420 for the integration of electronic 01:04:08.420 --> 01:04:11.660 medical records, and do clinical trials. 01:04:11.660 --> 01:04:14.450 The use of the mobile applications 01:04:14.450 --> 01:04:16.400 for long term patient followup, 01:04:16.400 --> 01:04:18.660 and additional statistical support 01:04:18.660 --> 01:04:22.150 for conducting secondary analysis on clinical trial data. 01:04:22.150 --> 01:04:25.080 My question, if this program were to receive 01:04:25.080 --> 01:04:26.934 additional funding with allocating 01:04:26.934 --> 01:04:30.100 towards meeting the technological goals 01:04:30.100 --> 01:04:32.520 I just mentioned be a wise investment? 01:04:32.520 --> 01:04:34.200 Does the DOD have plans to continue 01:04:34.200 --> 01:04:36.730 to provide sufficient funding for a consortium 01:04:36.730 --> 01:04:38.570 and coordinating center to support 01:04:38.570 --> 01:04:41.853 clinical research in the area of severe limb injury? 01:04:43.243 --> 01:04:44.424 And I have one other question for the record, 01:04:44.424 --> 01:04:46.410 so I think you can move pretty quick on this. 01:04:46.410 --> 01:04:47.460 Appreciate it. 01:04:47.460 --> 01:04:50.093 You know all that? - I got it all sir. 01:04:50.093 --> 01:04:52.030 And thank you so much for the question. 01:04:52.030 --> 01:04:54.300 And appreciate the support in that. 01:04:54.300 --> 01:04:57.550 As you know the orthopedic injuries, 01:04:57.550 --> 01:04:59.470 and musculoskeletal injuries in general 01:04:59.470 --> 01:05:03.297 are one of the mechanisms of injury that given the, 01:05:03.297 --> 01:05:04.361 - [Mr. Ruppersberger] Deal with all the time 01:05:04.361 --> 01:05:05.717 in any war right. - absolutely. 01:05:05.717 --> 01:05:08.490 - And so any additional resources 01:05:09.639 --> 01:05:12.250 to provide meaningful research that will 01:05:12.250 --> 01:05:17.250 lead to products or meaningful end state type 01:05:17.720 --> 01:05:20.003 of either lessons learned, 01:05:23.750 --> 01:05:25.740 apparatus or any type of structure 01:05:25.740 --> 01:05:28.950 to assist our service members would be greatly appreciated. 01:05:28.950 --> 01:05:31.580 So I'll take that for record Congressman 01:05:31.580 --> 01:05:33.210 so we can provide details of what 01:05:33.210 --> 01:05:34.470 additional funding would provide. 01:05:34.470 --> 01:05:35.303 - I know an example of that is, 01:05:35.303 --> 01:05:37.400 instead of having hooks they would 01:05:37.400 --> 01:05:40.473 actually create hands and arms. 01:05:40.473 --> 01:05:41.306 - [Lt. General West] Absolutely. 01:05:41.306 --> 01:05:42.162 - That's where that program's, 01:05:42.162 --> 01:05:43.710 and it really makes a difference for our military, 01:05:43.710 --> 01:05:44.770 and also the whole country. 01:05:44.770 --> 01:05:45.603 - It certainly does. 01:05:45.603 --> 01:05:47.930 And just recently the articulated ankle. 01:05:47.930 --> 01:05:52.180 Just to have that more proprioception 01:05:52.180 --> 01:05:56.050 for individuals to have more normal gaits 01:05:56.050 --> 01:05:58.927 is one of the research items that you were talking about. 01:05:58.927 --> 01:06:00.550 And those, things of that nature, 01:06:00.550 --> 01:06:04.065 we have more fine touch and articulation, 01:06:04.065 --> 01:06:07.653 or better articulated prosthetics would be, 01:06:08.801 --> 01:06:10.080 - This question is, 01:06:10.080 --> 01:06:11.880 - Gentleman if you could defer on the second 01:06:11.880 --> 01:06:13.313 just to make sure 'cause, 01:06:13.313 --> 01:06:14.667 - [Mr. Ruppersberger] That's okay. 01:06:14.667 --> 01:06:18.730 - Don't go any place, at this point to Miss Granger. 01:06:18.730 --> 01:06:19.563 - Thank you. 01:06:21.380 --> 01:06:22.850 - Thank you. 01:06:22.850 --> 01:06:25.780 Currently about 5.8 million Americans 01:06:25.780 --> 01:06:27.520 are living with Alzheimer's Disease. 01:06:27.520 --> 01:06:29.590 And it's now the sixth leading 01:06:29.590 --> 01:06:32.010 cause of death in the United States. 01:06:32.010 --> 01:06:34.480 We're seeing it in younger and younger people. 01:06:34.480 --> 01:06:36.250 Your fiscal year funding level 01:06:36.250 --> 01:06:39.150 for Alzheimer's research is $15,000,000. 01:06:39.150 --> 01:06:41.606 And while I know that the National Institutes of Health 01:06:41.606 --> 01:06:44.120 provide the bulk of the research dollars, 01:06:44.120 --> 01:06:46.510 15,000,000 just doesn't seem nearly enough 01:06:46.510 --> 01:06:48.136 given the number of families suffering. 01:06:48.136 --> 01:06:49.880 I don't have a question, I have a statement. 01:06:49.880 --> 01:06:52.210 I wanna see more from the Defense 01:06:52.210 --> 01:06:54.020 Health Program for Alzheimer's. 01:06:54.020 --> 01:06:56.300 But my question now is, 01:06:56.300 --> 01:06:58.640 each year in the hearing we discuss 01:06:58.640 --> 01:07:00.830 the importance of suicide prevention. 01:07:00.830 --> 01:07:04.960 Unfortunately rates continue to increase. 01:07:04.960 --> 01:07:07.240 Reports indicate the active duty military 01:07:07.240 --> 01:07:12.080 suicide rates reached highs in 2018. 01:07:12.080 --> 01:07:13.150 I think we have to do everything 01:07:13.150 --> 01:07:14.430 in our power to reverse this. 01:07:14.430 --> 01:07:16.440 I would like to ask, I don't know who to ask this, 01:07:16.440 --> 01:07:20.860 but I would like you to specifically say 01:07:20.860 --> 01:07:22.710 why do you think those suicide rates 01:07:22.710 --> 01:07:25.410 are remaining so high, and the important thing. 01:07:25.410 --> 01:07:27.503 If there was no limit on funding, 01:07:28.437 --> 01:07:30.537 what would you do to address the epidemic? 01:07:34.494 --> 01:07:35.327 Thank you. 01:07:35.327 --> 01:07:38.470 - Congresswoman Granger I'll start with that one. 01:07:38.470 --> 01:07:40.140 The why question is very difficult, 01:07:40.140 --> 01:07:42.490 of why the rates are remaining high. 01:07:42.490 --> 01:07:47.200 The causes of suicide are multi faceted. 01:07:47.200 --> 01:07:51.390 And so each case is, we do a deep dive, 01:07:51.390 --> 01:07:54.420 and you know kind of, an epi kind of what happened, 01:07:54.420 --> 01:07:58.090 and sometimes there's no common thread between all. 01:07:58.090 --> 01:08:01.306 There's some instances that we can predict, 01:08:01.306 --> 01:08:04.290 certain elements are the same, 01:08:04.290 --> 01:08:06.770 but most of them do not have a common thread. 01:08:06.770 --> 01:08:10.050 With each individual case, each case is individual. 01:08:10.050 --> 01:08:12.990 The, what we would do to decrease, 01:08:12.990 --> 01:08:14.710 I think more things that we could do 01:08:14.710 --> 01:08:16.610 is to decrease the stigma. 01:08:16.610 --> 01:08:18.451 To increase those efforts. 01:08:18.451 --> 01:08:20.110 We've come a long way in that, 01:08:20.110 --> 01:08:22.960 in identifying that individuals that need help 01:08:22.960 --> 01:08:25.240 should feel comfortable in getting help 01:08:25.240 --> 01:08:29.240 without feeling it's going to impact their careers. 01:08:29.240 --> 01:08:31.560 And we've made progress in doing that. 01:08:31.560 --> 01:08:33.490 But we still aren't where we need to go. 01:08:33.490 --> 01:08:36.470 We started embedding behavioral health far forward. 01:08:36.470 --> 01:08:39.680 We've in Army medicine have 61 embedded 01:08:39.680 --> 01:08:41.430 behavioral health units rather than having 01:08:41.430 --> 01:08:44.070 the individuals having to come to a facility for care 01:08:44.070 --> 01:08:46.370 we actually have those down in the unit areas. 01:08:46.370 --> 01:08:48.890 So they feel comfortable going to those individuals 01:08:48.890 --> 01:08:51.200 rather than waiting or suffering in silence. 01:08:51.200 --> 01:08:52.870 And we've seen it make a difference. 01:08:52.870 --> 01:08:56.160 From 2007 when there were about 900,000 visits 01:08:56.160 --> 01:09:00.674 Army wide rough to over 2,000,000. 01:09:00.674 --> 01:09:02.370 And it's not because there's more pathologies. 01:09:02.370 --> 01:09:04.550 Because people feel more comfortable getting care. 01:09:04.550 --> 01:09:05.900 Our senior leaders are stressing it. 01:09:05.900 --> 01:09:08.100 We have very high senior leaders who will say, 01:09:08.100 --> 01:09:09.600 I've had issues and have gotten help, 01:09:09.600 --> 01:09:11.220 so you need to do that as well. 01:09:11.220 --> 01:09:13.480 And so that's allowing individuals 01:09:13.480 --> 01:09:17.238 to have more faith in that they can come 01:09:17.238 --> 01:09:22.238 forward without having any adverse outcome to their careers. 01:09:25.010 --> 01:09:26.670 But the problem is, is they're individuals 01:09:26.670 --> 01:09:28.520 who still believe that if they do mention 01:09:28.520 --> 01:09:29.935 something it might impact their ability 01:09:29.935 --> 01:09:33.790 to remain in the service or do certain jobs in the service. 01:09:33.790 --> 01:09:36.330 So I think we do see a stigma. 01:09:36.330 --> 01:09:39.140 I'm ensuring that we have access in multiple venues. 01:09:39.140 --> 01:09:41.086 Which we do, not only within our direct care system, 01:09:41.086 --> 01:09:44.390 we have the ability for our service members 01:09:44.390 --> 01:09:47.990 to have anonymous visits so they don't feel 01:09:47.990 --> 01:09:52.120 necessarily tied to one facility, or tied to the facility 01:09:52.120 --> 01:09:53.229 but they feel comfortable that they can 01:09:53.229 --> 01:09:56.640 talk to someone without necessarily having repercussions. 01:09:56.640 --> 01:10:00.810 Again with hotlines, and services 01:10:00.810 --> 01:10:04.640 where they can actually get the care. 01:10:04.640 --> 01:10:07.540 - And if I could, just to build on General West 01:10:07.540 --> 01:10:11.070 comment about the challenge of kind of knowing 01:10:11.070 --> 01:10:14.243 what the solution would be to stem this, 01:10:15.460 --> 01:10:18.537 it's basically a public health crisis in the department. 01:10:18.537 --> 01:10:20.670 And that is like the fact that a clinic 01:10:20.670 --> 01:10:24.770 around 40% of those that commit suicide, 01:10:24.770 --> 01:10:27.130 did not even have a mental health diagnosis. 01:10:27.130 --> 01:10:29.800 And so it's the challenge of getting to them. 01:10:29.800 --> 01:10:31.409 So one of the things that we've been doing 01:10:31.409 --> 01:10:34.800 with the support of Congress the last several years, 01:10:34.800 --> 01:10:36.770 is how can we increase systematically 01:10:36.770 --> 01:10:41.110 the touchpoints where we can get service members 01:10:41.110 --> 01:10:42.298 to have a mental health assessment 01:10:42.298 --> 01:10:45.070 as an additional way, as an opportunity 01:10:45.070 --> 01:10:47.720 to see is something goin on that we can flag. 01:10:47.720 --> 01:10:50.104 And so with the last year we've added 01:10:50.104 --> 01:10:53.570 a requirement that every periodic health assessment 01:10:53.570 --> 01:10:55.957 of a service member includes a mental health assessment. 01:10:55.957 --> 01:10:58.670 And so asking questions that we hope 01:10:58.670 --> 01:11:00.727 can trigger identification. 01:11:00.727 --> 01:11:03.680 And the other thing, and Army's really been the lead on this 01:11:03.680 --> 01:11:08.350 is we've invested about 100 million dollars with the NIH. 01:11:08.350 --> 01:11:11.861 And one of the focus areas is what can we do, 01:11:11.861 --> 01:11:16.660 are there things that we can identify that are triggers. 01:11:16.660 --> 01:11:19.650 That if you identify you could then focus 01:11:19.650 --> 01:11:22.130 on that subpopulation and say hey, 01:11:22.130 --> 01:11:25.420 that population needs to have a further examination. 01:11:25.420 --> 01:11:26.708 And then be able to figure out 01:11:26.708 --> 01:11:29.903 how do you further assess and evaluate them. 01:11:31.680 --> 01:11:32.513 - Yes ma'am. 01:11:33.670 --> 01:11:38.540 Suicide prevention is really a community health issue. 01:11:38.540 --> 01:11:41.497 We need to get everybody involved in stepping in. 01:11:41.497 --> 01:11:44.344 And when they identify somebody who might 01:11:44.344 --> 01:11:47.650 be displaying symptoms to be at risk. 01:11:47.650 --> 01:11:49.440 So in the Air Force we have a program 01:11:49.440 --> 01:11:51.830 for all, some, or few. 01:11:51.830 --> 01:11:55.030 So we're teaching everybody how to identify 01:11:55.030 --> 01:11:58.520 what some of the factors are that you could identify 01:11:58.520 --> 01:12:03.050 somebody that might be at risk for attempting suicide. 01:12:03.050 --> 01:12:05.450 And then what can you do about it. 01:12:05.450 --> 01:12:07.090 How do you engage? 01:12:07.090 --> 01:12:08.690 How do you intervene? 01:12:08.690 --> 01:12:11.430 And where can you get this person to help? 01:12:11.430 --> 01:12:13.960 Some people need a little bit more help 01:12:13.960 --> 01:12:16.530 than just education and so we've got 01:12:16.530 --> 01:12:18.440 all kinds of counseling capabilities 01:12:18.440 --> 01:12:22.840 across the instillations, some within the clinic, 01:12:22.840 --> 01:12:25.010 some outside of the clinic. 01:12:25.010 --> 01:12:27.180 And then some people, the few, 01:12:27.180 --> 01:12:29.660 actually need mental health treatment. 01:12:29.660 --> 01:12:32.040 In the Air Force we have, much like the Army, 01:12:32.040 --> 01:12:34.490 and I'm sure the Navy, embedded mental health 01:12:34.490 --> 01:12:36.320 specialties into units. 01:12:36.320 --> 01:12:38.220 That is really helping to decrease 01:12:38.220 --> 01:12:41.050 some of the stigma where people feel more, 01:12:41.050 --> 01:12:44.230 members feel more comfortable at that unit level 01:12:44.230 --> 01:12:46.990 to go and talk to that mental health provider. 01:12:46.990 --> 01:12:51.180 And if they exceed, if it's more than just coaching 01:12:51.180 --> 01:12:53.610 at that point in time then that mental health provider 01:12:53.610 --> 01:12:56.150 then can get them into the clinic to be seen. 01:12:56.150 --> 01:12:58.070 We also have embedded mental health providers 01:12:58.070 --> 01:12:59.730 in the primary care clinics. 01:12:59.730 --> 01:13:01.882 So no longer does a member have to then 01:13:01.882 --> 01:13:04.280 make another appointment to get into mental health 01:13:04.280 --> 01:13:05.570 to get their issue addressed. 01:13:05.570 --> 01:13:06.590 They can walk across, 01:13:06.590 --> 01:13:08.652 a primary health care provider identifies 01:13:08.652 --> 01:13:10.930 a person at risk and they walk 01:13:10.930 --> 01:13:13.190 them straight over to the mental person 01:13:13.190 --> 01:13:14.481 in the primary care clinic. 01:13:14.481 --> 01:13:15.903 - [Congresswoman Granger] Thank you Mr. Chairman. 01:13:19.280 --> 01:13:20.113 - Thank you Mr. Chairman. 01:13:20.113 --> 01:13:21.843 I appreciate your time. 01:13:23.940 --> 01:13:25.343 I was just curious, 01:13:27.180 --> 01:13:29.483 I guess I direct this to Mr. McCaffery. 01:13:31.400 --> 01:13:34.070 I'd like to read a quote from Cayden Davis. 01:13:34.070 --> 01:13:35.730 He is serving in the Army National 01:13:35.730 --> 01:13:37.860 Guard in Palmetto Florida. 01:13:37.860 --> 01:13:39.810 As you're probably aware, the National Guard 01:13:39.810 --> 01:13:41.603 is particularly special to Florida, 01:13:42.520 --> 01:13:44.540 because of their role in disaster relief, 01:13:44.540 --> 01:13:45.623 among other things. 01:13:46.520 --> 01:13:47.483 This is his quote. 01:13:48.487 --> 01:13:50.587 "My service means a great deal to me. 01:13:50.587 --> 01:13:52.217 "I take pride from laying down 01:13:52.217 --> 01:13:53.947 "the widely accepted stereotype 01:13:53.947 --> 01:13:56.647 "that my generation has an inability 01:13:56.647 --> 01:13:59.157 "to exhibit selfless behavior. 01:13:59.157 --> 01:14:01.297 "One of the founding mantras of military 01:14:01.297 --> 01:14:05.057 "service is just that, selfless service. 01:14:05.057 --> 01:14:06.907 "My twin brother, who is currently stationed 01:14:06.907 --> 01:14:10.077 "at Patrick Air Force Base," also in Florida. 01:14:10.077 --> 01:14:11.427 "has equally committed himself 01:14:11.427 --> 01:14:13.667 "to the defense of our country. 01:14:13.667 --> 01:14:15.297 "It is difficult for me to accept 01:14:15.297 --> 01:14:16.997 "that one of us is free to serve 01:14:16.997 --> 01:14:20.023 "his country honorably while the other cannot. 01:14:21.327 --> 01:14:23.597 "When news reached me of President Trump's ban 01:14:23.597 --> 01:14:26.177 "on transgender service I was dejected, 01:14:26.177 --> 01:14:28.587 "and humiliated to say the least. 01:14:28.587 --> 01:14:30.947 "This assumption that transgender soldiers 01:14:30.947 --> 01:14:33.697 "are unfit to serve is not a personal attack against me, 01:14:33.697 --> 01:14:38.527 "but an assault on the marginalized LGBT populous. 01:14:38.527 --> 01:14:42.187 "The ramifications of this ruling, should it come to pass 01:14:42.187 --> 01:14:44.417 "would entail stripping capable soldiers 01:14:44.417 --> 01:14:47.387 "of their part in the defense of our country." 01:14:48.500 --> 01:14:50.650 Cayden Davis is transgender. 01:14:50.650 --> 01:14:52.590 He is just one story of thousands. 01:14:52.590 --> 01:14:55.270 Thousands of transgender service members 01:14:55.270 --> 01:14:58.210 who answered the call, put their lives on the line, 01:14:58.210 --> 01:15:00.960 and served our country honorably. 01:15:00.960 --> 01:15:04.290 As the branches continue to miss recruiting goals, 01:15:04.290 --> 01:15:07.650 what specifically about Cayden Davis' service 01:15:07.650 --> 01:15:09.703 does the administration find unfit? 01:15:11.170 --> 01:15:14.940 - So Mr. Crist, the policy, 01:15:14.940 --> 01:15:16.970 the new policy that will be going into effect 01:15:16.970 --> 01:15:21.970 on April 12th, it is a result of over a year 01:15:22.340 --> 01:15:25.640 of study and examination of the department. 01:15:25.640 --> 01:15:28.450 And it's not focused on transgender individuals, 01:15:28.450 --> 01:15:32.560 but it is focused on gender dysphoria. 01:15:32.560 --> 01:15:36.000 So much like other conditions that are either 01:15:36.000 --> 01:15:40.033 deployment limiting or are disqualifying for accessions, 01:15:41.030 --> 01:15:43.553 we are treating gender dysphoria the same way. 01:15:44.500 --> 01:15:49.380 Right now those individuals who have made 01:15:49.380 --> 01:15:52.820 a commitment to access into the military 01:15:52.820 --> 01:15:57.820 before this policy is in place on April 12th, 01:15:58.520 --> 01:16:01.280 and have met those requirements. 01:16:01.280 --> 01:16:03.800 If they have been diagnosed with gender dysphoria 01:16:03.800 --> 01:16:06.156 and they have been stable in their 01:16:06.156 --> 01:16:09.680 preferred gender for 18 months, 01:16:09.680 --> 01:16:12.390 they would be eligible to be accessed 01:16:12.390 --> 01:16:16.423 and provided services under their prior policy. 01:16:17.297 --> 01:16:21.003 The new policy goes in effect again on April 12th. 01:16:22.620 --> 01:16:25.750 That policy does have new accession standards. 01:16:25.750 --> 01:16:29.542 And so you would have to be stable 01:16:29.542 --> 01:16:34.130 in your gender for 36 months, 01:16:34.130 --> 01:16:36.070 and be willing to serve in your biological 01:16:36.070 --> 01:16:40.240 sex in order to be accessed. 01:16:40.240 --> 01:16:42.730 Folks that are current service members 01:16:42.730 --> 01:16:45.680 that have been diagnosed with gender dysphoria 01:16:45.680 --> 01:16:48.730 prior to April 12th would be eligible 01:16:48.730 --> 01:16:51.690 to receive all of the services associated 01:16:51.690 --> 01:16:54.773 with gender transition under the prior policy. 01:16:56.570 --> 01:16:59.950 - Can you define gender dysphoria please. 01:16:59.950 --> 01:17:04.108 - Yes, it is actually a medical diagnosis 01:17:04.108 --> 01:17:09.108 that indicates you have an issue 01:17:09.680 --> 01:17:12.640 with regard to not believing that your 01:17:12.640 --> 01:17:16.670 biological sex is your true identity. 01:17:16.670 --> 01:17:19.520 It carries with it, I'll let clinicians here 01:17:20.690 --> 01:17:22.290 provide better information, but, 01:17:23.420 --> 01:17:26.480 that it coexists with other issues 01:17:26.480 --> 01:17:30.090 in terms of distress and angst, anxiety, 01:17:30.090 --> 01:17:33.990 mental health issues that are caused by this inner conflict. 01:17:33.990 --> 01:17:38.000 And that is the diagnosis. 01:17:38.000 --> 01:17:40.933 - And that makes it disqualifying for them to serve? 01:17:42.150 --> 01:17:47.150 - So it is, it again, the focus is on a condition. 01:17:48.240 --> 01:17:51.230 And like there are other conditions 01:17:51.230 --> 01:17:55.690 that affect one's ability to carry on their, 01:17:55.690 --> 01:17:57.630 the military responsibilities. 01:17:57.630 --> 01:18:01.090 There are issues around gender dysphoria, 01:18:01.090 --> 01:18:04.760 as I mentioned, in terms of mental distress. 01:18:04.760 --> 01:18:08.560 Issues around if your medical treatment plan 01:18:08.560 --> 01:18:13.560 require total transition in genital reconstruction. 01:18:15.570 --> 01:18:16.930 The impact that has in terms 01:18:16.930 --> 01:18:19.300 of your ability to be deployed. 01:18:19.300 --> 01:18:22.140 And so those are the, that's the assessment 01:18:22.140 --> 01:18:25.720 in terms of why that condition like other conditions, 01:18:25.720 --> 01:18:29.550 the evaluation is, how does that affect 01:18:29.550 --> 01:18:32.300 your readiness and your ability to deploy. 01:18:32.300 --> 01:18:36.933 - So were these conditions being assessed before April 12th? 01:18:38.478 --> 01:18:41.193 - I'm not sure I understand that question. 01:18:42.600 --> 01:18:45.600 - Okay, you said that if this goes into effect 01:18:45.600 --> 01:18:48.380 it's April 12th, nine days from today it starts. 01:18:48.380 --> 01:18:49.340 - [Mr. McCaffery] Correct. 01:18:49.340 --> 01:18:53.240 - Have these people in this situation, 01:18:53.240 --> 01:18:54.930 have they been getting assessed 01:18:54.930 --> 01:18:57.340 prior to April 12th in the military? 01:18:57.340 --> 01:19:00.560 - Oh yes, yes, that has been ongoing. 01:19:00.560 --> 01:19:03.930 - So what's new about what's happening April 12th? 01:19:03.930 --> 01:19:08.200 - Well on, again on April 12th there's the policy, 01:19:08.200 --> 01:19:10.330 we have a change in terms of accessions. 01:19:10.330 --> 01:19:13.560 And so effective April 12th, 01:19:13.560 --> 01:19:18.110 if you are seeking to access into the military and you are, 01:19:18.110 --> 01:19:19.340 - [Mr. Crist] What's access mean, join? 01:19:19.340 --> 01:19:21.500 - Yeah, coming into the military, sorry. 01:19:21.500 --> 01:19:24.960 And you have gender dysphoria, 01:19:24.960 --> 01:19:27.580 you've been diagnosed with gender dysphoria, 01:19:27.580 --> 01:19:32.580 and you have been stable in your preferred gender 01:19:32.920 --> 01:19:36.500 for 36 months you can access as long as you 01:19:36.500 --> 01:19:38.923 are willing to serve in your biological sex. 01:19:40.720 --> 01:19:45.263 - And prior to April 12th you couldn't assess or join? 01:19:46.770 --> 01:19:48.408 You actually could, right? - yes. 01:19:48.408 --> 01:19:52.250 - With the changes you are, you become ineligible 01:19:55.160 --> 01:19:57.660 if you're trying to join the military? 01:19:57.660 --> 01:19:59.050 - If you're trying to join 01:19:59.050 --> 01:20:02.220 the military yes, after April 12th. 01:20:02.220 --> 01:20:04.220 - And who made this determination? 01:20:04.220 --> 01:20:07.610 - This is the policy of the department. 01:20:07.610 --> 01:20:10.200 - Who at the department issued the policy? 01:20:10.200 --> 01:20:12.940 - The Deputy Secretary issued it on March the 12th. 01:20:12.940 --> 01:20:15.020 - Okay then let me wrap up Mr. Chairman. 01:20:15.020 --> 01:20:16.500 - [Miss McCullum] And then if you could before you're done, 01:20:16.500 --> 01:20:17.937 I'd like you to yield but please finish. 01:20:17.937 --> 01:20:20.100 - I'd be more than happy to. 01:20:20.100 --> 01:20:23.310 The five Service Chiefs have no issues 01:20:23.310 --> 01:20:25.130 with transgender service members, 01:20:25.130 --> 01:20:29.410 and say it has not affected unit cohesion. 01:20:29.410 --> 01:20:32.517 For example at Admiral John Richardson said, 01:20:32.517 --> 01:20:36.057 "By virtue of being a Navy sailor we treat everyone 01:20:36.057 --> 01:20:38.067 "of those Navy sailors regardless 01:20:38.067 --> 01:20:40.887 "with dignity and respect that is warranted 01:20:40.887 --> 01:20:43.867 "by wearing the uniform of the United States Navy. 01:20:43.867 --> 01:20:48.180 "By virtue of that approach I'm not aware of any issues." 01:20:48.180 --> 01:20:49.960 Why is it that those in charge 01:20:49.960 --> 01:20:52.290 of leading and deploying transgender 01:20:52.290 --> 01:20:54.500 service members have no problem. 01:20:54.500 --> 01:20:56.510 And yet the administration apparently, 01:20:56.510 --> 01:20:58.103 or the department does? 01:20:59.290 --> 01:21:01.830 - So the policy that is going in effect 01:21:01.830 --> 01:21:05.610 is a policy that is applied to those 01:21:05.610 --> 01:21:07.680 that have been diagnosed with gender dysphoria. 01:21:07.680 --> 01:21:10.810 It is not a policy that says individuals 01:21:10.810 --> 01:21:13.310 that are transgender cannot serve in the military. 01:21:16.020 --> 01:21:19.260 - And what'd you say again gender dysphoria is? 01:21:19.260 --> 01:21:21.670 - Gender dysphoria, I, why don't you do 01:21:21.670 --> 01:21:24.590 a better job of defining clinically. 01:21:24.590 --> 01:21:27.270 - So clinically the definition of gender dysphoria 01:21:27.270 --> 01:21:29.250 is when an individual experience 01:21:29.250 --> 01:21:31.760 profound conflict between their gender 01:21:31.760 --> 01:21:33.220 identified at birth and the gender 01:21:33.220 --> 01:21:35.267 that they've identified with currently. 01:21:35.267 --> 01:21:37.640 And so oftentimes with that gender dysphoria, 01:21:37.640 --> 01:21:39.760 and it's a clinical diagnosis. 01:21:39.760 --> 01:21:42.330 It occurs in the minority of folks 01:21:42.330 --> 01:21:46.913 who are transgender members, personnel. 01:21:47.970 --> 01:21:50.810 There's a range of treatment for that 01:21:50.810 --> 01:21:54.210 transgender dysphoria that they're experiencing. 01:21:54.210 --> 01:21:59.210 And so it's a complete range of either counseling, 01:21:59.810 --> 01:22:03.010 in some cases depending on their dysphoria, 01:22:03.010 --> 01:22:06.480 they may require treatment with hormonal therapy, 01:22:06.480 --> 01:22:08.723 in some cases surgical therapy. 01:22:10.720 --> 01:22:12.400 - I will yield to Miss McCullum. 01:22:12.400 --> 01:22:14.500 - So lemme ask a question. 01:22:14.500 --> 01:22:19.420 So a person has gender dysphoria. 01:22:19.420 --> 01:22:23.823 They have gone through a transition. 01:22:24.850 --> 01:22:28.410 They've been in transition. 01:22:28.410 --> 01:22:29.603 It's all completed. 01:22:32.150 --> 01:22:35.533 Are they ineligible from enlisting? 01:22:37.960 --> 01:22:40.650 I mean because part of it I'm hearing from you 01:22:40.650 --> 01:22:43.990 is that person wouldn't be ready to deploy 01:22:43.990 --> 01:22:46.010 on a mission, mission notice. 01:22:46.010 --> 01:22:49.440 So it's either an issue with the person 01:22:49.440 --> 01:22:54.150 who's been diagnosed with transgender dysphoria. 01:22:54.150 --> 01:22:59.090 But if they've gone through operations, 01:23:00.180 --> 01:23:02.810 they're all done. 01:23:02.810 --> 01:23:05.900 They want to enlist. 01:23:05.900 --> 01:23:09.069 Then that's not an issue of that individual 01:23:09.069 --> 01:23:11.700 on not being eligible to be deployed 01:23:11.700 --> 01:23:14.530 because they would be going through a medical procedure. 01:23:14.530 --> 01:23:17.193 So what happens then? 01:23:22.160 --> 01:23:25.790 - It is a very complex situation. 01:23:25.790 --> 01:23:27.600 Depending on the type of care 01:23:27.600 --> 01:23:29.930 that a transgender individual has had 01:23:29.930 --> 01:23:32.583 to treat their gender dysphoria, 01:23:33.730 --> 01:23:37.030 if they remain stable after that transition, 01:23:37.030 --> 01:23:39.760 then there is an opportunity to consider them 01:23:39.760 --> 01:23:41.800 through waivers and other evaluations 01:23:41.800 --> 01:23:45.690 whether or not they can be accessed or join the military. 01:23:45.690 --> 01:23:48.070 One of the challenges with transition 01:23:48.070 --> 01:23:49.990 and the treatment for transition, 01:23:49.990 --> 01:23:53.900 if they go on to have complete surgical transition 01:23:53.900 --> 01:23:56.610 then by virtue of the surgery itself, 01:23:56.610 --> 01:24:00.170 because of our existing standards for accessions 01:24:00.170 --> 01:24:02.550 they may be disqualifying. 01:24:02.550 --> 01:24:07.487 So that's part of the challenge with that. 01:24:08.700 --> 01:24:13.523 - Well it would seem to me that this is not 01:24:13.523 --> 01:24:16.264 the black and white issue for many of us 01:24:16.264 --> 01:24:18.840 as the President has made it. 01:24:18.840 --> 01:24:21.640 But it also seems to me that if a person 01:24:21.640 --> 01:24:25.840 has made a decision to go through the operations, 01:24:25.840 --> 01:24:27.360 and wanna serve their country, 01:24:27.360 --> 01:24:30.430 and pass a physical, and be able to do it. 01:24:30.430 --> 01:24:35.300 And you know, that that should be available. 01:24:35.300 --> 01:24:38.060 But that should be clearly defined 01:24:38.060 --> 01:24:42.530 as to what would militarily disqualify them physically. 01:24:42.530 --> 01:24:44.850 If there would be an issue. 01:24:44.850 --> 01:24:48.300 And what would allow them to join if there isn't an issue. 01:24:48.300 --> 01:24:51.780 And there are waivers that are made all the time. 01:24:51.780 --> 01:24:54.670 So is there a written policy on this 01:24:54.670 --> 01:24:57.070 that someone can follow through, 01:24:57.070 --> 01:25:00.253 and there would not be subjective discrimination? 01:25:02.860 --> 01:25:04.853 - Yes we can share with the committee 01:25:04.853 --> 01:25:08.390 that the formal policy that lays out 01:25:08.390 --> 01:25:10.150 all the details both with regard 01:25:10.150 --> 01:25:12.870 to new accession standards, 01:25:12.870 --> 01:25:15.720 what the, how the new policy will apply 01:25:15.720 --> 01:25:18.950 or not apply to folks, when I say grandfathered 01:25:18.950 --> 01:25:22.020 in terms of prior to April 12th, but we can get that full-- 01:25:22.020 --> 01:25:25.215 - I'm talking about people who wanna enlist also 01:25:25.215 --> 01:25:28.440 who maybe have gone through the change. 01:25:28.440 --> 01:25:33.130 So let, I'm, I'd like to get some more information on this. 01:25:33.130 --> 01:25:34.690 Let me just for the record say 01:25:34.690 --> 01:25:37.430 I don't agree with the administration's decision. 01:25:37.430 --> 01:25:39.970 But I think there needs to be total clarity 01:25:39.970 --> 01:25:42.820 so there's not discretionary discrimination 01:25:42.820 --> 01:25:44.970 of someone after having gone through a sex change 01:25:44.970 --> 01:25:46.060 would wanna serve our country. 01:25:46.060 --> 01:25:47.390 They should be allowed to do so. 01:25:47.390 --> 01:25:48.223 Thank you. 01:25:49.890 --> 01:25:50.730 - Thank you Mr. Chairman. 01:25:50.730 --> 01:25:52.170 I yield back. 01:25:52.170 --> 01:25:53.003 I am. 01:25:54.530 --> 01:25:57.470 - Just on process, the new policy 01:25:57.470 --> 01:25:59.923 takes place April 12th. 01:26:01.191 --> 01:26:04.820 And the policy was precipitated a study that was performed. 01:26:04.820 --> 01:26:05.653 - [Mr. McCaffery] Correct. 01:26:05.653 --> 01:26:08.020 - And it changes the existing policy? 01:26:08.020 --> 01:26:08.853 - Yes. 01:26:08.853 --> 01:26:10.810 - Which was also precipitated by a study. 01:26:10.810 --> 01:26:11.950 - Correct. 01:26:11.950 --> 01:26:13.250 - And I assume there were medical 01:26:13.250 --> 01:26:15.340 professionals that did both studies. 01:26:15.340 --> 01:26:18.015 - Yeah, there was, it was a panel of experts 01:26:18.015 --> 01:26:21.900 including service line leadership 01:26:21.900 --> 01:26:24.103 as well as medical experts that provided input. 01:26:24.103 --> 01:26:27.733 - For the current policy and for the new policy. 01:26:29.260 --> 01:26:32.500 - I can't speak to the prior policy. 01:26:32.500 --> 01:26:35.280 But in terms of developing the policy 01:26:35.280 --> 01:26:38.320 that is going to be in effect next week, 01:26:38.320 --> 01:26:41.030 yes, that was a result of a panel of experts. 01:26:41.030 --> 01:26:43.190 - What do you think changed in that intervening 01:26:43.190 --> 01:26:46.760 couple of years, if we had two panels of medical experts 01:26:46.760 --> 01:26:48.000 come to different conclusions, 01:26:48.000 --> 01:26:49.823 what do you think changed there? 01:26:49.823 --> 01:26:54.823 - I don't want to speculate Mr. Chairman. 01:26:55.620 --> 01:27:00.380 I believe it was having a limited experience 01:27:00.380 --> 01:27:04.700 under the prior policy, and an opportunity, 01:27:04.700 --> 01:27:07.953 I think with a focus on then Secretary Mattis' 01:27:09.270 --> 01:27:10.880 focus on lethality and readiness, 01:27:10.880 --> 01:27:15.140 and how do we maximize deployability. 01:27:15.140 --> 01:27:18.380 That he directed a lot of changes in policies 01:27:18.380 --> 01:27:19.920 across the department with that focus, 01:27:19.920 --> 01:27:21.160 and this was one of them. 01:27:21.160 --> 01:27:22.402 - I do associate myself with my 01:27:22.402 --> 01:27:25.920 colleagues in total, and Mr. Diaz-Balart 01:27:25.920 --> 01:27:26.983 the time is yours. 01:27:29.020 --> 01:27:30.480 - Thank you very much Mr. Chairman. 01:27:30.480 --> 01:27:35.480 I wanna kinda go back a little bit to where we started. 01:27:36.490 --> 01:27:41.110 And there is obviously bipartisan frustration 01:27:41.110 --> 01:27:46.110 for the lack of, how slow the process has gone, 01:27:47.100 --> 01:27:52.100 as far as going to a one system of electronic records. 01:27:52.640 --> 01:27:54.630 I wanna associate myself with the statements 01:27:54.630 --> 01:27:56.040 that the ranking member Mr. Calvert 01:27:56.040 --> 01:27:59.590 made regarding this concept. 01:27:59.590 --> 01:28:02.650 And I, I don't wanna blame, I'm not blaming individuals. 01:28:02.650 --> 01:28:05.513 I think that the concept of government run healthcare, 01:28:06.990 --> 01:28:10.460 you know shows that it tends to be slower, 01:28:10.460 --> 01:28:13.010 more inefficient, over expensive, 01:28:13.010 --> 01:28:16.133 and sometimes the quality is also not there. 01:28:17.160 --> 01:28:19.661 So again, careful what you ask for sometimes. 01:28:19.661 --> 01:28:22.830 But Miss Cummings, during, 01:28:22.830 --> 01:28:27.830 so you mentioned that there are, this MHS GENESIS right, 01:28:28.070 --> 01:28:30.060 is gonna be done in phases 01:28:30.060 --> 01:28:31.616 in different parts of the country. 01:28:31.616 --> 01:28:34.210 So lemme pose this. 01:28:34.210 --> 01:28:36.110 So let's assume that there is a person 01:28:37.210 --> 01:28:42.210 who is now in a, serving in a part of the country 01:28:43.050 --> 01:28:46.083 where the GENESIS program is working, is functioning, 01:28:47.160 --> 01:28:48.650 is transferred out to one where 01:28:48.650 --> 01:28:52.220 the Legacy system is, what happens then. 01:28:52.220 --> 01:28:55.169 What system is that person into, and what happens then? 01:28:55.169 --> 01:28:56.462 And vice versa by the way. 01:28:56.462 --> 01:29:01.010 If they're in a place where the GENESIS system 01:29:01.010 --> 01:29:05.920 is there and they get transferred to either way, 01:29:05.920 --> 01:29:06.860 what happens? 01:29:06.860 --> 01:29:09.030 - So when we deploy MHS GENESIS 01:29:09.030 --> 01:29:13.290 to a new location we pull over a subset of data, 01:29:13.290 --> 01:29:17.460 and it's procedures, allergies, medications, immunization, 01:29:17.460 --> 01:29:22.113 and I forgot one of 'em. 01:29:22.113 --> 01:29:25.370 It is a set of data that has been identified 01:29:25.370 --> 01:29:29.060 by the clinical community as important to have 01:29:29.060 --> 01:29:31.490 at the first interaction that you have with a patient. 01:29:31.490 --> 01:29:33.320 We do that same thing when a new patient 01:29:33.320 --> 01:29:36.042 PCS's into the area, so if you were being seen 01:29:36.042 --> 01:29:40.070 in San Diego and you moved to Bremerton, 01:29:40.070 --> 01:29:42.790 the first time that your doctor 01:29:42.790 --> 01:29:44.760 and your clinical team sees you, 01:29:44.760 --> 01:29:46.767 they would pull that subset of data. 01:29:46.767 --> 01:29:50.090 And the time for how long we pull that data, 01:29:50.090 --> 01:29:52.910 again was clinically driven based on the data 01:29:52.910 --> 01:29:54.450 that's important at the time 01:29:54.450 --> 01:29:55.640 when you're seeing that person 01:29:55.640 --> 01:29:58.170 for their medical interaction. 01:29:58.170 --> 01:30:01.960 So as we, so that's how a new MHS GENESIS 01:30:01.960 --> 01:30:04.740 patient's data would be pulled into the system. 01:30:04.740 --> 01:30:08.540 If you were to go from an MHS GENESIS location 01:30:08.540 --> 01:30:11.520 to a Legacy location then we are using 01:30:11.520 --> 01:30:14.260 the Joint Legacy Viewer as the interoperability tool 01:30:14.260 --> 01:30:17.450 that we designed for interoperability with the VA. 01:30:17.450 --> 01:30:21.060 That is actually also our interoperability tool 01:30:21.060 --> 01:30:25.230 for DOD Legacy and DOD MHS GENESIS. 01:30:25.230 --> 01:30:28.730 So in both MHS GENESIS and our Legacy systems 01:30:28.730 --> 01:30:32.421 there is a link, you click a button that says JOV, 01:30:32.421 --> 01:30:36.430 and whatever patient you're seeing in the system, 01:30:36.430 --> 01:30:38.710 all of their data immediately pops up. 01:30:38.710 --> 01:30:40.460 And you can see all the data, 01:30:40.460 --> 01:30:44.280 not just from the DOD, but also from the VA, 01:30:44.280 --> 01:30:46.530 and from any commercial providers 01:30:46.530 --> 01:30:48.380 who we have a partnership with. 01:30:48.380 --> 01:30:50.590 So like here in the local area if somebody 01:30:50.590 --> 01:30:53.140 had been seen at a Nova, the data that, 01:30:53.140 --> 01:30:54.840 if they had gone to an emergency room, 01:30:54.840 --> 01:30:57.400 or were seen at a Nova that data 01:30:57.400 --> 01:30:59.560 would also pop up and be available 01:30:59.560 --> 01:31:01.160 through the Joint Legacy Viewer. 01:31:03.110 --> 01:31:05.090 - General West so there are obviously 01:31:05.090 --> 01:31:06.950 many, many military families that live 01:31:06.950 --> 01:31:10.970 in instillations in frankly really remote areas. 01:31:10.970 --> 01:31:13.921 So how would families who don't have access 01:31:13.921 --> 01:31:18.370 or easy access to TRICARE, and to the TRICARE network 01:31:20.850 --> 01:31:23.117 and how do they, how would they, 01:31:23.117 --> 01:31:26.780 and how do they get off base care? 01:31:26.780 --> 01:31:28.840 If again they don't have access 01:31:28.840 --> 01:31:32.453 to the TRICARE system in some area of the country? 01:31:33.800 --> 01:31:35.463 What access do they have? 01:31:37.830 --> 01:31:39.940 - Congressman they, so in the direct care system, 01:31:39.940 --> 01:31:41.610 we'll take Fort Irwin for example, 01:31:41.610 --> 01:31:44.080 which is considered a remote area. 01:31:44.080 --> 01:31:47.210 We do have a direct care system, a hospital there. 01:31:47.210 --> 01:31:50.388 It's limited in its sub specialties. 01:31:50.388 --> 01:31:51.680 So we have to rely on our network. 01:31:51.680 --> 01:31:55.190 That is kind of what our, what the default is, and has been. 01:31:55.190 --> 01:32:00.110 And we worked with our DHA partners who continually, 01:32:00.110 --> 01:32:01.230 and I don't wanna speak for Rocky. 01:32:01.230 --> 01:32:02.130 But I have experience. 01:32:02.130 --> 01:32:06.376 They've continually go out and look for additional 01:32:06.376 --> 01:32:09.730 partners in that specialty area that we need. 01:32:09.730 --> 01:32:11.120 We see the same thing in Alaska. 01:32:11.120 --> 01:32:12.240 Sometimes it's hard to do. 01:32:12.240 --> 01:32:13.461 But they work really hard to try to find 01:32:13.461 --> 01:32:16.020 those specialty providers. 01:32:16.020 --> 01:32:18.370 But short of that, I mean if they're not 01:32:18.370 --> 01:32:22.920 within the distance and they have to travel farther, 01:32:22.920 --> 01:32:24.940 the only option is then to ensure 01:32:24.940 --> 01:32:28.660 that their travel costs are reimbursed. 01:32:28.660 --> 01:32:30.510 But as far as the options it's either 01:32:30.510 --> 01:32:31.930 the direct care system what we have 01:32:31.930 --> 01:32:33.690 at the location, the facility. 01:32:33.690 --> 01:32:35.210 I mean we try to make sure that we look 01:32:35.210 --> 01:32:37.120 operationally to assigned providers. 01:32:37.120 --> 01:32:38.970 If we can't hire in those areas 01:32:38.970 --> 01:32:43.067 to assign those criticals capabilities at the MTFs. 01:32:43.067 --> 01:32:44.830 And we work with the Defense Health Agency 01:32:44.830 --> 01:32:49.270 to determine what capacities we lack. 01:32:49.270 --> 01:32:52.230 And they will try to make their Tricare network 01:32:52.230 --> 01:32:53.583 more robust in that area. 01:32:54.910 --> 01:32:55.743 - Thank you General. 01:32:55.743 --> 01:32:57.134 Mr. Chairman you know one of the things that says, 01:32:57.134 --> 01:33:00.110 this frustration that we all have, 01:33:00.110 --> 01:33:01.527 some have been dealing, some of you 01:33:01.527 --> 01:33:03.527 have been dealing it longer than others. 01:33:05.111 --> 01:33:06.654 (someone speaking off microphone) 01:33:06.654 --> 01:33:08.000 (laughs) 01:33:08.000 --> 01:33:10.463 I don't know who you're referring to Mr. Chairman. 01:33:11.870 --> 01:33:16.537 You know I, this issue of electronic health records 01:33:16.537 --> 01:33:21.340 is not only an issue that the federal government's 01:33:21.340 --> 01:33:25.470 had to deal with, private hospitals, systems about. 01:33:25.470 --> 01:33:27.770 It would be very interesting to see 01:33:27.770 --> 01:33:32.280 how some hospital systems, 01:33:32.280 --> 01:33:34.020 whether it's public or private 01:33:34.020 --> 01:33:36.765 who have gone on to electronic records. 01:33:36.765 --> 01:33:38.630 How long it took them? 01:33:38.630 --> 01:33:40.460 How much did it cost them? 01:33:40.460 --> 01:33:43.224 Just to compare that with the issue 01:33:43.224 --> 01:33:45.870 that we're dealing with here. 01:33:45.870 --> 01:33:47.020 Is this the norm? 01:33:47.020 --> 01:33:50.274 Is it just that technology is so messed up 01:33:50.274 --> 01:33:53.495 that in this area it doesn't work? 01:33:53.495 --> 01:33:55.180 It would just be very interesting 01:33:55.180 --> 01:33:59.840 to maybe get executives from healthcare systems, 01:33:59.840 --> 01:34:00.970 private hospital systems. 01:34:00.970 --> 01:34:02.940 I understand that the scale may be different, 01:34:02.940 --> 01:34:07.940 but, 'cause I just don't understand. 01:34:07.970 --> 01:34:09.860 - Gentleman yield just for a second. 01:34:09.860 --> 01:34:10.693 - Absolutely. 01:34:10.693 --> 01:34:15.445 - I think that from what I know Kaiser 01:34:15.445 --> 01:34:17.000 has been known to have the best 01:34:17.000 --> 01:34:18.810 medical record system in the country. 01:34:18.810 --> 01:34:20.922 I don't know if there's any disagreement with that 01:34:20.922 --> 01:34:24.270 for the largest provider that's out there 01:34:24.270 --> 01:34:27.440 that has a system that they put together. 01:34:27.440 --> 01:34:29.160 So it would be interesting maybe to talk to them 01:34:29.160 --> 01:34:33.160 because they have obviously have their act together. 01:34:33.160 --> 01:34:34.516 - I think it would be, Mr. Chairman 01:34:34.516 --> 01:34:36.045 I think it would be, thank you sir, 01:34:36.045 --> 01:34:39.314 I think it would be an interesting thing to know. 01:34:39.314 --> 01:34:40.470 Have others done it? 01:34:40.470 --> 01:34:43.416 Is it just impossible to do, nobody can do it. 01:34:43.416 --> 01:34:47.100 Or have others done it, maybe different scale, 01:34:47.100 --> 01:34:48.620 maybe again some different issues. 01:34:48.620 --> 01:34:52.120 But at least to get a frame of reference 01:34:52.120 --> 01:34:54.320 as to what we're dealing with here. 01:34:54.320 --> 01:34:56.450 Thank you, I yield back Mr. Chairman. 01:34:56.450 --> 01:34:58.480 - I'm gonna recognize Miss McCullum, 01:34:58.480 --> 01:35:00.840 but just parenthetically would add 01:35:00.840 --> 01:35:03.600 to the interchange that took place, 01:35:03.600 --> 01:35:05.170 because Mr. Crist question, 01:35:05.170 --> 01:35:07.050 this is not directed to the panel at all. 01:35:07.050 --> 01:35:10.300 But I just sayin' that we're trying to suck 01:35:10.300 --> 01:35:14.301 every last ounce of kindness out of society, 01:35:14.301 --> 01:35:17.047 can we be just kind to people, you know. 01:35:18.756 --> 01:35:19.660 Miss McCullum. 01:35:19.660 --> 01:35:20.673 - Thank you Mr. Chairman. 01:35:20.673 --> 01:35:23.240 I'm gonna submit my questions for the record. 01:35:23.240 --> 01:35:26.210 But I'm gonna put on the record what they are. 01:35:26.210 --> 01:35:29.225 One of the things I would like to have 01:35:29.225 --> 01:35:31.630 come back to me, and it might be an overall 01:35:31.630 --> 01:35:33.780 DOD policy or it might be a policy 01:35:33.780 --> 01:35:36.340 within the branches of the service. 01:35:36.340 --> 01:35:40.000 And I know you also work with Coast Guard and others 01:35:40.000 --> 01:35:42.221 so I'm including all of 'em. 01:35:42.221 --> 01:35:44.860 How the department tracks service members 01:35:44.860 --> 01:35:47.860 exposure to harmful chemicals and pollution 01:35:47.860 --> 01:35:49.530 across their service history, 01:35:49.530 --> 01:35:52.210 whether it's the new emerging issue 01:35:52.210 --> 01:35:53.920 that the Department of Defense is dealing with. 01:35:53.920 --> 01:35:56.320 It's not a new emerging issue for my constituents, 01:35:56.320 --> 01:35:59.010 but PFOA is in ground water, 01:35:59.010 --> 01:36:02.420 whether it is serving in South Korea 01:36:02.420 --> 01:36:06.010 dealing with air pollution that comes over from China. 01:36:06.010 --> 01:36:08.575 Whether it's some of the work that they've, 01:36:08.575 --> 01:36:10.080 that they're working on, 01:36:10.080 --> 01:36:14.110 whether it's lead, lead in paint, 01:36:14.110 --> 01:36:16.720 there's still a lot of asbestos exposure. 01:36:16.720 --> 01:36:19.710 But then that also comes back to how are we capturing 01:36:19.710 --> 01:36:22.710 things that can get brought home 01:36:22.710 --> 01:36:26.090 to service members family. 01:36:26.090 --> 01:36:28.820 Asbestosis is something that we know 01:36:28.820 --> 01:36:31.010 that's sometimes transferrable on clothing, 01:36:31.010 --> 01:36:32.430 lead can be the same way. 01:36:32.430 --> 01:36:35.570 And if you're a child and you're with your parents 01:36:35.570 --> 01:36:37.960 and they're being deployed, and it's air pollution 01:36:37.960 --> 01:36:39.437 you're exposed to that to. 01:36:39.437 --> 01:36:42.220 The other thing I would like to understand more. 01:36:42.220 --> 01:36:45.620 I believe that the DOA and VA apparently held 01:36:45.620 --> 01:36:49.370 a closed door symposium last month on burn pits. 01:36:49.370 --> 01:36:52.100 So hopefully there's some progress being made. 01:36:52.100 --> 01:36:53.890 Many of us are very frustrated. 01:36:53.890 --> 01:36:55.500 We have veterans who are frustrated. 01:36:55.500 --> 01:36:56.930 Family members who are frustrated. 01:36:56.930 --> 01:37:00.100 So I'm wondering if you can share with the committee 01:37:00.100 --> 01:37:02.680 any conclusions from last month's meeting 01:37:02.680 --> 01:37:04.700 between agencies and if there's anything 01:37:04.700 --> 01:37:06.130 that we should be looking at doing 01:37:06.130 --> 01:37:08.660 as we put our budget forward. 01:37:08.660 --> 01:37:12.210 Last but least I'm gonna end on a bit of a happy note. 01:37:12.210 --> 01:37:14.210 There is some therapies out there 01:37:14.210 --> 01:37:16.500 that we know that are working that engage families, 01:37:16.500 --> 01:37:18.350 and veterans, and service members 01:37:18.350 --> 01:37:19.880 through the creative arts. 01:37:19.880 --> 01:37:23.610 I've had the opportunity to work 01:37:23.610 --> 01:37:26.090 and see at the Intrepid Center, 01:37:26.090 --> 01:37:27.579 some of the great work that's going on. 01:37:27.579 --> 01:37:31.360 I chair the Committee on Interior Environment. 01:37:31.360 --> 01:37:34.450 We had some veterans groups in support 01:37:34.450 --> 01:37:37.145 of some of the work that's going on with the NEA. 01:37:37.145 --> 01:37:40.980 The NE, the NEH is also doing things 01:37:40.980 --> 01:37:45.110 through writing and the great creativity 01:37:45.110 --> 01:37:48.850 that can happen there, so if you could let us know 01:37:48.850 --> 01:37:51.777 what we can do, not just funding, 01:37:51.777 --> 01:37:54.860 with the current funding that's being 01:37:54.860 --> 01:37:57.840 transferred between the NEA and the DOD, 01:37:57.840 --> 01:38:00.860 and the NEH and the DOD. 01:38:00.860 --> 01:38:03.730 But what do you need in your toolbox? 01:38:03.730 --> 01:38:06.820 If because there might be new programs 01:38:06.820 --> 01:38:09.660 that we can bring on, expansive that we can do that, 01:38:09.660 --> 01:38:12.480 it's not enough money in my budget to do, 01:38:12.480 --> 01:38:14.670 but we might wanna look at the Department 01:38:14.670 --> 01:38:17.768 of Defense and the VA being part of this. 01:38:17.768 --> 01:38:18.960 And I wanna thank you all for your work. 01:38:18.960 --> 01:38:20.720 And I know you do the very best you can 01:38:20.720 --> 01:38:22.050 to keep our service men and women 01:38:22.050 --> 01:38:22.960 and their families healthy. 01:38:22.960 --> 01:38:25.193 Thank you Mr. Chair, those are for the record. 01:38:26.720 --> 01:38:28.310 - I'm gonna recognize Mr. Calvert. 01:38:28.310 --> 01:38:29.973 But it has been brought to my attention 01:38:29.973 --> 01:38:33.460 that the Kaiser system has 12.2 million 01:38:33.460 --> 01:38:36.740 members and are entirely electronic. 01:38:36.740 --> 01:38:39.810 DOD and VA have 10.2 million. 01:38:39.810 --> 01:38:41.688 So don't wanna pile on or anything. 01:38:41.688 --> 01:38:42.630 (laughter) 01:38:42.630 --> 01:38:43.463 Mr. Calvert. 01:38:45.790 --> 01:38:47.250 - Thank you Mr. Chairman, I'm gonna yield 01:38:47.250 --> 01:38:48.535 part of my time to Mr. Carter. 01:38:48.535 --> 01:38:49.735 He had a quick question. 01:38:50.950 --> 01:38:52.410 - I've got a really quick question. 01:38:52.410 --> 01:38:55.270 Right now we do drug testing focusing 01:38:55.270 --> 01:38:58.670 on amphetamines, methamphetamine, 01:38:58.670 --> 01:39:01.110 marijuana, cocaine, and opioids. 01:39:01.110 --> 01:39:03.390 But there's a proliferation of synthetic drugs 01:39:03.390 --> 01:39:06.570 that are out in the marketplace 01:39:06.570 --> 01:39:09.520 that these kids get their hands on. 01:39:09.520 --> 01:39:11.643 I just wanna know what we're doin' 01:39:12.730 --> 01:39:16.240 as it relates to readiness for testing 01:39:16.240 --> 01:39:18.690 for these synthetic drugs that new ones 01:39:18.690 --> 01:39:21.580 pop up literally overnight everywhere. 01:39:21.580 --> 01:39:23.140 And I wanna know, 01:39:23.140 --> 01:39:25.105 I'd like the service members to tell us 01:39:25.105 --> 01:39:27.355 what we're doing about those synthetic drugs? 01:39:29.720 --> 01:39:31.180 - You think we could get that answer 01:39:31.180 --> 01:39:33.600 submitted for the record and get that to the chair. 01:39:33.600 --> 01:39:34.470 - [Mr. Carter] Thank you. 01:39:34.470 --> 01:39:35.303 - Appreciate it. 01:39:36.857 --> 01:39:39.110 - I have a quick question also. 01:39:39.110 --> 01:39:42.473 Explain the golden hour in terms of it, 01:39:43.650 --> 01:39:45.420 that we can all understand. 01:39:45.420 --> 01:39:46.870 How will the provision of medical care 01:39:46.870 --> 01:39:48.940 be different as we face near peer adversaries 01:39:48.940 --> 01:39:51.820 as opposed to counter insurgencies? 01:39:51.820 --> 01:39:55.410 How will you get care in denied areas, 01:39:55.410 --> 01:39:56.880 and what is the plan to address 01:39:56.880 --> 01:39:58.610 casualties if one of our aircraft carriers 01:39:58.610 --> 01:40:00.690 were attacked by China for example. 01:40:00.690 --> 01:40:02.533 You know the recent speech where he, 01:40:03.460 --> 01:40:06.954 admiral in the Chinese Navy said we will sink, 01:40:06.954 --> 01:40:10.313 first thing we'll do is sink two aircraft carriers. 01:40:11.611 --> 01:40:12.890 And what sort of planning has been undertaken 01:40:12.890 --> 01:40:14.480 to address the need for medically evacuate 01:40:14.480 --> 01:40:16.930 thousands of sailors for example, 01:40:16.930 --> 01:40:18.523 in the event of such a strike. 01:40:19.450 --> 01:40:21.320 - Yes sir I'll take that. 01:40:21.320 --> 01:40:25.290 So the golden hour we were able to achieve in Afghanistan, 01:40:25.290 --> 01:40:27.280 which was time of injury until time 01:40:27.280 --> 01:40:30.139 under the care of a damage control surgical team. 01:40:30.139 --> 01:40:32.240 So we were able to operationalize 01:40:32.240 --> 01:40:35.220 a network of services and some facilities 01:40:35.220 --> 01:40:37.460 in Afghanistan to allow that to occur. 01:40:37.460 --> 01:40:40.130 So no matter where a casualty occurred 01:40:40.130 --> 01:40:41.330 they were under the control of a damage 01:40:41.330 --> 01:40:43.420 control surgical team within an hour. 01:40:43.420 --> 01:40:46.880 We will be challenged, speaking for the Navy, 01:40:46.880 --> 01:40:48.191 to be able to do that in the expanse 01:40:48.191 --> 01:40:52.450 of peer competition against adversaries 01:40:52.450 --> 01:40:54.680 that have the ability to project sea power. 01:40:54.680 --> 01:40:58.356 And so we are addressing that in several different ways. 01:40:58.356 --> 01:41:03.356 One is increasing the training and surgical capability, 01:41:04.138 --> 01:41:07.740 or casualty care capability of the medical 01:41:07.740 --> 01:41:11.305 personnel onboard ships, and with operational units. 01:41:11.305 --> 01:41:13.130 That's the centerpiece of the whole 01:41:13.130 --> 01:41:16.020 corpsman trauma strategy that I spoke 01:41:16.020 --> 01:41:18.280 about in my opening statement. 01:41:18.280 --> 01:41:21.090 To allow them to not only resuscitate casualties, 01:41:21.090 --> 01:41:24.480 but keep those casualties alive until evacuation. 01:41:24.480 --> 01:41:26.340 The other area that we're focusing on 01:41:26.340 --> 01:41:29.370 is the concept of moving to the next 01:41:29.370 --> 01:41:32.370 generation of at sea care. 01:41:32.370 --> 01:41:34.200 Right now we have hospital ships. 01:41:34.200 --> 01:41:35.790 Those are likely not going to meet 01:41:35.790 --> 01:41:36.820 our needs in the future. 01:41:36.820 --> 01:41:39.810 We've got to look at taking the medical capability 01:41:39.810 --> 01:41:42.930 and distributing that out across larger areas, 01:41:42.930 --> 01:41:45.220 smaller platforms, larger more robust 01:41:45.220 --> 01:41:47.750 teams on existing platforms. 01:41:47.750 --> 01:41:49.983 So that's our strategy within the Navy sir. 01:41:54.757 --> 01:41:56.730 - Thank you sir. 01:41:56.730 --> 01:41:59.910 Absolutely so in the multi domain battle environment 01:41:59.910 --> 01:42:01.380 where we may not have air superiority 01:42:01.380 --> 01:42:03.890 that is a concern and issue of how do we make sure 01:42:03.890 --> 01:42:07.750 that we can enhance prolonged field care. 01:42:07.750 --> 01:42:12.070 In fact that's one of the Army's top challenges 01:42:12.070 --> 01:42:14.490 is how do we make sure we have that prolonged care. 01:42:14.490 --> 01:42:15.920 So it's similar to the Navy. 01:42:15.920 --> 01:42:17.670 We have the expeditionary combat medic, 01:42:17.670 --> 01:42:19.560 meaning that we are providing 01:42:19.560 --> 01:42:22.118 more capability at point of injury. 01:42:22.118 --> 01:42:24.300 Some of the research initiatives, 01:42:24.300 --> 01:42:26.510 freeze dried plasma, things that don't take a lot 01:42:26.510 --> 01:42:28.690 of logistical support to maintain. 01:42:28.690 --> 01:42:31.050 So to have that to be able to reconstitute that 01:42:31.050 --> 01:42:32.132 and give that at point of injury 01:42:32.132 --> 01:42:34.060 extends the time that you can manage 01:42:34.060 --> 01:42:38.810 a patient in an environment if evacuation is not immediate. 01:42:38.810 --> 01:42:39.680 So those are just some of the things 01:42:39.680 --> 01:42:41.724 our research, increased training, 01:42:41.724 --> 01:42:45.490 and other autonomous evacuation vehicles. 01:42:45.490 --> 01:42:48.560 I know those are in the future. 01:42:48.560 --> 01:42:50.336 But there are some prototypes of having 01:42:50.336 --> 01:42:52.580 unmanned aircraft to go in if there's 01:42:52.580 --> 01:42:56.173 a non permissive environment in the future. 01:42:58.810 --> 01:42:59.849 - Yes sir. 01:42:59.849 --> 01:43:01.870 In the Air Force very similar. 01:43:01.870 --> 01:43:05.199 We're increasing our capability of giving 01:43:05.199 --> 01:43:08.860 trauma level training to not only all of our medics, 01:43:08.860 --> 01:43:10.200 but even to all of our Airmen 01:43:10.200 --> 01:43:13.370 so that they can provide care on the ground, 01:43:13.370 --> 01:43:14.800 and save somebody's life. 01:43:14.800 --> 01:43:18.660 We're also putting damage control capability 01:43:18.660 --> 01:43:21.850 far forward into the environment 01:43:21.850 --> 01:43:24.820 so that our ground surgical teams 01:43:24.820 --> 01:43:26.800 right now have the capability of performing 01:43:26.800 --> 01:43:29.750 10 surgeries without resupplying. 01:43:29.750 --> 01:43:31.270 The other thing that we're looking at 01:43:31.270 --> 01:43:33.020 is in a denied environment, 01:43:33.020 --> 01:43:35.380 again might not have air superiority. 01:43:35.380 --> 01:43:38.250 So we're looking at planes, trains, and automobiles 01:43:38.250 --> 01:43:40.760 to evacuate patients out of that area 01:43:40.760 --> 01:43:42.780 and get them into the next level of care. 01:43:42.780 --> 01:43:46.370 And also enhancing and increasing our holding capability. 01:43:46.370 --> 01:43:48.781 Where we might not be able to air vac them, 01:43:48.781 --> 01:43:51.040 or move them out of that area 01:43:51.040 --> 01:43:53.810 as quickly as we would like to. 01:43:53.810 --> 01:43:56.420 And so we're gonna increase our holding capability 01:43:56.420 --> 01:43:59.533 to maintain life until we can get them out. 01:44:05.780 --> 01:44:09.150 - Mr. McCaffery the fiscal year budget 01:44:09.150 --> 01:44:13.130 20 justification books see a reduction 01:44:13.130 --> 01:44:17.063 and realignment of about 16,413 billets. 01:44:24.060 --> 01:44:29.060 So that we're on the same page definitionally 01:44:29.670 --> 01:44:31.850 how would you characterize a billet. 01:44:31.850 --> 01:44:33.980 What do you mean by that? 01:44:33.980 --> 01:44:37.130 - It's a position that is authorized 01:44:37.130 --> 01:44:39.510 and has funding tied to it. 01:44:39.510 --> 01:44:40.650 - Okay. 01:44:40.650 --> 01:44:44.390 And my understanding of those almost, 01:44:44.390 --> 01:44:46.207 I guess by the time we are done, about 18,000 01:44:46.207 --> 01:44:51.207 but let's say 16,413, they all will be 01:44:52.980 --> 01:44:57.980 eliminated in fiscal year 20 under the proposal. 01:44:58.040 --> 01:45:00.363 - So if I could back up. 01:45:01.350 --> 01:45:05.850 So the numbers that are in the President's budget for 2020, 01:45:05.850 --> 01:45:09.860 and in 2020 it's about 14, 14.5 additional. 01:45:09.860 --> 01:45:14.290 And for 2021 is the 16,000. 01:45:14.290 --> 01:45:18.780 That's based upon the military department's 01:45:18.780 --> 01:45:22.000 doing an analysis of what are the medical 01:45:22.000 --> 01:45:24.941 manpower requirements they need to meet 01:45:24.941 --> 01:45:27.507 Combatant Command operational requirements. 01:45:27.507 --> 01:45:30.110 And that, comparing that analysis 01:45:30.110 --> 01:45:32.140 with the current staffing levels. 01:45:32.140 --> 01:45:36.820 And so in areas where the staffing levels 01:45:36.820 --> 01:45:40.286 were in excess of those operational meta requirements, 01:45:40.286 --> 01:45:43.050 those positions have been identified 01:45:44.310 --> 01:45:47.110 to be repurposed by the military departments 01:45:47.110 --> 01:45:50.710 for other operational readiness priorities. 01:45:50.710 --> 01:45:55.710 The billets, the 14,500 in 2020, 01:45:56.820 --> 01:46:01.820 they show all coming, coming off or coming out in 2020. 01:46:02.320 --> 01:46:06.288 I would characterize that as a budgeting 01:46:06.288 --> 01:46:08.780 way to show that those billets 01:46:08.780 --> 01:46:12.403 are gonna come out of the medical account so to speak. 01:46:15.600 --> 01:46:17.610 Over time, and the departments have, 01:46:17.610 --> 01:46:21.300 and I'll let my colleagues speak to this in more detail. 01:46:21.300 --> 01:46:25.410 Actually have movement of bodies of people 01:46:25.410 --> 01:46:28.340 from those billets into the medical billets, 01:46:28.340 --> 01:46:31.323 have that happen over a periodic transition 01:46:31.323 --> 01:46:34.280 over about three to four years through attrition. 01:46:34.280 --> 01:46:37.720 - You have five years, and my understanding for 20 01:46:37.720 --> 01:46:41.562 is it would be 2218 according 01:46:41.562 --> 01:46:44.390 to the documentation we've received. 01:46:44.390 --> 01:46:49.163 In 2020 it is 2218 of those 16,413. 01:46:55.610 --> 01:46:57.573 - I'm not clear in terms of, 01:46:58.870 --> 01:47:03.870 so in the 2020 budget for 2020 it's again, 01:47:04.350 --> 01:47:08.200 roughly 14,500 positions that are-- 01:47:08.200 --> 01:47:09.033 - Eliminated. 01:47:10.030 --> 01:47:14.530 But the designation, as far as the... 01:47:16.640 --> 01:47:19.363 by attrition, right, those are, yeah. 01:47:24.009 --> 01:47:25.400 The document here in front of me 01:47:25.400 --> 01:47:28.233 says 2,218 going away in 20. 01:47:29.810 --> 01:47:32.570 But all of them are being eliminated in 20. 01:47:32.570 --> 01:47:34.504 - Yeah in terms of the medical manpower-- 01:47:34.504 --> 01:47:37.860 - 2218 are attributed, then why are 2218 01:47:37.860 --> 01:47:39.840 attributed to fiscal year 20? 01:47:39.840 --> 01:47:42.707 - That I'm not clear why only the 2000 01:47:42.707 --> 01:47:44.683 are attributed - according to the document. 01:47:45.560 --> 01:47:48.080 The budget documents that I have, 01:47:48.080 --> 01:47:52.573 have the full 14,000 coming out in 2020. 01:47:57.520 --> 01:48:00.957 - This says 17,991. 01:48:10.669 --> 01:48:12.919 (whispers) 01:48:33.030 --> 01:48:37.050 All of the billets are goin away this year, 01:48:37.050 --> 01:48:39.140 in fiscal year 20. 01:48:39.140 --> 01:48:43.570 - The billets are off, out of the medical account, yes. 01:48:43.570 --> 01:48:45.993 In 2020 but-- 01:48:45.993 --> 01:48:48.680 - They're not in the medical accounts anymore? 01:48:48.680 --> 01:48:49.513 - [Mr. McCaffery] Correct. 01:48:49.513 --> 01:48:53.390 - Now that decision as to how many billets 01:48:53.390 --> 01:48:56.440 could be moved, and my understanding is, 01:48:56.440 --> 01:49:00.530 a fair number of them may not even be filled at this moment. 01:49:00.530 --> 01:49:01.400 - [Mr. McCaffery] That is correct. 01:49:01.400 --> 01:49:05.000 - There may be, but you're counting on attrition. 01:49:05.000 --> 01:49:08.930 - Well about 2000, I have to go check 01:49:08.930 --> 01:49:10.460 to make sure I've giving you accurate numbers, 01:49:10.460 --> 01:49:14.300 but I believe about 2000 across the services, 01:49:14.300 --> 01:49:17.463 2000 of those billets are currently unencumbered. 01:49:18.359 --> 01:49:20.690 So that is, that's part of the equation. 01:49:20.690 --> 01:49:25.690 - And you said that that's based on recommendations 01:49:25.810 --> 01:49:28.880 by I assume the Surgeon Generals. 01:49:28.880 --> 01:49:30.260 - By the military departments. 01:49:30.260 --> 01:49:33.320 So the military departments came up with, 01:49:33.320 --> 01:49:36.740 again, after analyzing-- 01:49:36.740 --> 01:49:38.120 - When you say military departments 01:49:38.120 --> 01:49:40.080 are you talking about these three individuals, 01:49:40.080 --> 01:49:41.580 or are we talking about somebody different? 01:49:41.580 --> 01:49:43.780 - Well when I speak about the military departments 01:49:43.780 --> 01:49:46.140 I'm talking about the ultimate leadership 01:49:46.140 --> 01:49:47.490 of the military department. 01:49:49.250 --> 01:49:51.150 - Like the Secretary of Defense? 01:49:51.150 --> 01:49:52.780 - Well like the Secretary of the Army, 01:49:52.780 --> 01:49:56.490 the Secretary of the Navy, the Secretary of the Air Force. 01:49:56.490 --> 01:49:58.360 - Let me ask the question a different way then, 01:49:58.360 --> 01:50:00.683 'cause I'm just not getting any of this at all. 01:50:01.640 --> 01:50:04.490 Before the decision was made to eliminate 01:50:04.490 --> 01:50:09.490 17,991 billets in fiscal year 20, 01:50:10.100 --> 01:50:13.923 and transfer them to various places on the planet earth. 01:50:14.830 --> 01:50:17.600 Were the three Surgeon Generals 01:50:18.640 --> 01:50:21.870 asked their opinion and asked to provide 01:50:21.870 --> 01:50:25.440 their Secretaries with their estimate 01:50:25.440 --> 01:50:27.587 as to what their needs are? 01:50:27.587 --> 01:50:31.590 - I would need to defer the Surgeons General in terms of, 01:50:31.590 --> 01:50:33.990 - Let me ask the Surgeon Generals. 01:50:33.990 --> 01:50:37.340 Were you consulted as to what you believed 01:50:37.340 --> 01:50:40.410 your needs would be in these next five years 01:50:40.410 --> 01:50:42.420 going for how many billets you would need? 01:50:42.420 --> 01:50:44.393 I'm just asking, were you consulted. 01:50:47.010 --> 01:50:47.843 - Sir as part of-- 01:50:47.843 --> 01:50:49.210 - [Chairman] I'm not asking what you told anybody. 01:50:49.210 --> 01:50:51.010 I'm just sayin' were you asked? 01:50:51.010 --> 01:50:53.093 - Yes, sir as part of the Army process, 01:50:54.170 --> 01:50:56.640 I provided my advice to the Army 01:50:56.640 --> 01:50:58.240 senior leadership based upon their, 01:50:58.240 --> 01:50:59.790 - [Chairman] And I'm assuming that's 01:50:59.790 --> 01:51:01.480 true for the other two. 01:51:01.480 --> 01:51:04.240 - Sir the department leadership made a change 01:51:04.240 --> 01:51:06.410 in its planning guidance and that's what 01:51:06.410 --> 01:51:08.105 drives our force requirements. 01:51:08.105 --> 01:51:12.140 That's basically a leadership decision 01:51:12.140 --> 01:51:15.343 applied across the entire Navy for that. 01:51:16.280 --> 01:51:18.723 - Were you asked your opinion Admiral? 01:51:19.609 --> 01:51:22.800 - For the reductions? 01:51:22.800 --> 01:51:23.633 - [Chairman] Yeah. 01:51:23.633 --> 01:51:26.960 - Only in so far as operational planning requirements. 01:51:26.960 --> 01:51:28.550 - Right okay. 01:51:28.550 --> 01:51:30.363 And Air Force, yes. 01:51:31.582 --> 01:51:33.032 So then my question would be, 01:51:34.460 --> 01:51:38.120 I assume these recommendations, 01:51:38.120 --> 01:51:40.260 opinions as to what the needs would be 01:51:40.260 --> 01:51:43.650 for the services were delivered 01:51:43.650 --> 01:51:46.383 to someone making these cosmic decisions. 01:51:48.260 --> 01:51:53.030 Could I ask, were the number of billets in total 01:51:54.510 --> 01:51:58.963 that were recommended to be put at risk, 01:52:00.210 --> 01:52:05.210 was more than 17,991, was it less, was it the same? 01:52:11.090 --> 01:52:14.650 My question would be is there a difference 01:52:14.650 --> 01:52:19.650 as to what we're seeing and what I'm just thinking 01:52:19.970 --> 01:52:22.073 the Surgeon General's said they needed? 01:52:24.760 --> 01:52:28.120 - Well again, making sure that I, 01:52:28.120 --> 01:52:32.370 - Could the committee be supplied with the data 01:52:34.340 --> 01:52:37.240 as to what the original recommendations were? 01:52:37.240 --> 01:52:38.790 - The original recommendations 01:52:38.790 --> 01:52:41.020 from each of the military departments? 01:52:41.020 --> 01:52:43.270 - [Chairman] I assume that's what I'm askin' for, yeah. 01:52:43.270 --> 01:52:44.370 - I don't see why not. 01:52:44.370 --> 01:52:45.203 - Okay. 01:52:50.950 --> 01:52:55.950 The next question I have is, as far as the... 01:53:10.060 --> 01:53:12.880 Medical personnel are gonna be removed 01:53:12.880 --> 01:53:17.210 at some point in time from some positions, 01:53:17.210 --> 01:53:18.960 am I correct in understanding that? 01:53:21.420 --> 01:53:25.463 They will not be removed until the risks are mitigated, 01:53:26.750 --> 01:53:28.500 if I'm correct on that. 01:53:28.500 --> 01:53:32.953 Who makes those determinations as to risk mitigation? 01:53:38.180 --> 01:53:41.120 - Sir, sir for the billets that are coming 01:53:41.120 --> 01:53:45.310 offline in FY20, those positions are not being filled 01:53:45.310 --> 01:53:48.350 now as they become vacant, as people PCS. 01:53:48.350 --> 01:53:49.960 We're workin' with our personnel command 01:53:49.960 --> 01:53:51.880 to identify those that have got 01:53:51.880 --> 01:53:54.880 critical impact to the fleet, and to remote areas. 01:53:54.880 --> 01:53:57.360 And put personnel in in those locations 01:53:57.360 --> 01:54:00.260 even as the billets come offline, we'll work through this. 01:54:00.260 --> 01:54:02.890 But there are billets that are coming offline, 01:54:02.890 --> 01:54:04.600 that were not being filled now 01:54:04.600 --> 01:54:06.607 because people cannot complete a full three year tour 01:54:06.607 --> 01:54:09.173 for a billet that's coming off in FY20. 01:54:11.880 --> 01:54:14.860 - Another question I would have Mr. McCaffery 01:54:14.860 --> 01:54:18.040 is the military medical and dental 01:54:18.040 --> 01:54:22.520 requirements report is classified? 01:54:22.520 --> 01:54:23.563 - [Mr. McCaffery] Correct. 01:54:24.502 --> 01:54:26.010 - Could I ask why? 01:54:26.010 --> 01:54:30.260 - It is tied to the 721, require the department 01:54:30.260 --> 01:54:33.600 to identify at the military medical 01:54:33.600 --> 01:54:37.310 manpower requirement to meet a variety 01:54:37.310 --> 01:54:41.270 of scenarios including vetted operational plans 01:54:41.270 --> 01:54:43.280 that are classified, and so the numbers 01:54:43.280 --> 01:54:46.080 tied to a particular scenario. 01:54:46.080 --> 01:54:48.760 So we have shared that report to Congress. 01:54:48.760 --> 01:54:52.493 But we've done so in a way to protect that classification. 01:54:53.860 --> 01:54:56.710 - I can appreciate the concerns about operations. 01:54:56.710 --> 01:54:57.940 But it makes it very difficult 01:54:57.940 --> 01:55:01.260 for the committee to have open conversations 01:55:01.260 --> 01:55:04.482 and ask others who might be qualified 01:55:04.482 --> 01:55:06.100 to pass judgment as to whether or not 01:55:06.100 --> 01:55:10.393 the recommendations are positive or not. 01:55:11.921 --> 01:55:13.330 Do you have a response to that? 01:55:13.330 --> 01:55:14.880 - Well we would be happy to work 01:55:14.880 --> 01:55:17.294 with the committee in any way to-- 01:55:17.294 --> 01:55:18.530 - No but I'm gettin' your opinion. 01:55:18.530 --> 01:55:20.720 I mean if I'm lookin' for somebody else's opinion, 01:55:20.720 --> 01:55:21.740 does this make any sense? 01:55:21.740 --> 01:55:23.390 I can't talk to anybody about it. 01:55:24.815 --> 01:55:25.653 It's classified. 01:55:27.210 --> 01:55:29.320 - It's classified, but I believe 01:55:29.320 --> 01:55:31.430 there are procedures by which we could, 01:55:31.430 --> 01:55:33.262 we could meet with the committee 01:55:33.262 --> 01:55:36.620 in certain areas, skiffs that we could 01:55:36.620 --> 01:55:37.453 have those kinds of conversations. 01:55:37.453 --> 01:55:41.170 - You could, but we can't talk to other people about it, 01:55:41.170 --> 01:55:43.660 to get another opinion about it, that's what I'm saying. 01:55:43.660 --> 01:55:44.770 - [Mr. McCaffery] I see. 01:55:44.770 --> 01:55:46.820 - And the report was given to us, 01:55:46.820 --> 01:55:50.620 as I understand it, two years late. 01:55:50.620 --> 01:55:51.453 - [Mr. McCaffery] That is correct. 01:55:51.453 --> 01:55:52.286 - Why is that? 01:55:53.440 --> 01:55:58.153 - It, number one, it is, we had a couple of things 01:55:58.153 --> 01:56:01.200 going on as Admiral Faison mentioned, 01:56:01.200 --> 01:56:02.568 we had started to put together 01:56:02.568 --> 01:56:06.970 the manpower requirements prior to the change 01:56:06.970 --> 01:56:08.440 in the National Defense Strategy 01:56:08.440 --> 01:56:09.870 in terms of some of the scenarios 01:56:09.870 --> 01:56:11.640 that we were planning for. 01:56:11.640 --> 01:56:14.513 We had each of the services identify, 01:56:15.470 --> 01:56:17.620 using their particular methodologies, 01:56:17.620 --> 01:56:19.840 what their requirements were. 01:56:19.840 --> 01:56:24.130 Having to have that vetted then by the joint staff, 01:56:24.130 --> 01:56:27.461 by agencies within the office of the Secretary. 01:56:27.461 --> 01:56:32.461 And what we put forward, a couple of weeks ago, 01:56:33.080 --> 01:56:36.550 is that first cut of what we were able to come up 01:56:36.550 --> 01:56:41.150 with in terms of, based upon one particular 01:56:41.150 --> 01:56:45.190 vetted and approved O plan, as well as another scenario, 01:56:45.190 --> 01:56:47.980 what the medical manpower requirements were. 01:56:47.980 --> 01:56:49.840 We have also committed in the report 01:56:49.840 --> 01:56:52.723 that we recognize we have more work to do. 01:56:53.720 --> 01:56:55.960 What one of the things the Congress 01:56:55.960 --> 01:56:58.210 has asked us to do is actually move 01:56:58.210 --> 01:57:02.780 from separate service specific methodologies, 01:57:02.780 --> 01:57:05.033 to come up with a department wide 01:57:05.033 --> 01:57:08.560 kind of common methodology to identify joint requirements. 01:57:08.560 --> 01:57:09.823 So we're working on that now. 01:57:09.823 --> 01:57:11.740 - If I could ask one followup. 01:57:11.740 --> 01:57:13.973 And Miss Kaptur's not had a chance, 01:57:15.014 --> 01:57:16.660 and my colleagues may, 01:57:16.660 --> 01:57:20.140 are we gonna see additional justifications 01:57:20.140 --> 01:57:23.590 relative to the reductions we're seeing? 01:57:23.590 --> 01:57:25.134 Do you think document was adequate 01:57:25.134 --> 01:57:27.210 after being two years late? 01:57:27.210 --> 01:57:32.210 - In the reductions, so the 721 report 01:57:32.719 --> 01:57:34.890 doesn't speak to reductions. 01:57:34.890 --> 01:57:39.175 It is just identifying what the medical 01:57:39.175 --> 01:57:40.517 manpower requirements already are. 01:57:40.517 --> 01:57:42.500 - You can't talk about that. 01:57:42.500 --> 01:57:45.340 I'm lookin' at numbers here and I can't talk about it. 01:57:45.340 --> 01:57:48.580 - But the numbers with regard to the reductions that are-- 01:57:48.580 --> 01:57:51.440 - Some numbers are less than other numbers. 01:57:51.440 --> 01:57:53.963 I hope I'm not breaking any state secret here. 01:57:55.420 --> 01:57:57.320 So I call it a reduction. 01:57:57.320 --> 01:57:58.500 - [Mr. McCaffery] Some numbers are-- 01:57:58.500 --> 01:58:01.410 - Are you gonna provide any more justification 01:58:01.410 --> 01:58:04.330 for the content and recommendations 01:58:04.330 --> 01:58:06.470 in that report that was two years late? 01:58:06.470 --> 01:58:08.040 - Yes, yes, yes we will. 01:58:08.040 --> 01:58:09.710 Because we have committed to that, 01:58:09.710 --> 01:58:12.200 that we have more work to do on that report. 01:58:12.200 --> 01:58:14.150 And we've committed to have that done, 01:58:14.150 --> 01:58:16.470 I believe by the end of the summer. 01:58:16.470 --> 01:58:19.530 - Okay, Miss Kaptur very briefly. 01:58:19.530 --> 01:58:20.363 - Thank you. 01:58:20.363 --> 01:58:21.390 Thank you Mr. Chairman very much. 01:58:21.390 --> 01:58:23.050 I hope others haven't asked these questions. 01:58:23.050 --> 01:58:26.620 Thank you all for your patriotic service to our country 01:58:26.620 --> 01:58:28.510 during a most difficult period of time, 01:58:28.510 --> 01:58:31.060 almost a quarter century at war. 01:58:31.060 --> 01:58:32.250 Thank you for your strength. 01:58:32.250 --> 01:58:35.363 Thank you for your love of country. 01:58:36.370 --> 01:58:38.113 My questions, I have two. 01:58:39.010 --> 01:58:41.810 One related to the cost of pharmaceuticals. 01:58:41.810 --> 01:58:44.550 And I think Admiral Bono you may be 01:58:44.550 --> 01:58:47.670 the best person to answer this but I'm not sure. 01:58:47.670 --> 01:58:49.820 Does the department use a system 01:58:49.820 --> 01:58:52.400 of negotiated pricing with pharmaceutical companies, 01:58:52.400 --> 01:58:54.950 or competitive bidding in order to arrive at prices 01:58:54.950 --> 01:58:57.100 where the pharmaceuticals that you procure? 01:58:58.700 --> 01:58:59.533 - Thank you ma'am. 01:58:59.533 --> 01:59:00.366 Yes ma'am. 01:59:00.366 --> 01:59:01.380 What we do is we negotiate 01:59:01.380 --> 01:59:03.410 with the pharmaceutical companies. 01:59:03.410 --> 01:59:05.430 We do go for the best price for that. 01:59:05.430 --> 01:59:08.440 We also negotiate for rebates. 01:59:08.440 --> 01:59:10.170 And this is constantly evaluated 01:59:10.170 --> 01:59:13.260 as the prices change with certain pharmaceuticals. 01:59:13.260 --> 01:59:15.000 - Alright could I ask you, could you provide 01:59:15.000 --> 01:59:18.160 us with the list of the 10 most frequently 01:59:18.160 --> 01:59:22.510 dispensed medications or preparations that you use? 01:59:22.510 --> 01:59:25.560 Whether it's blood supplements, or heparin, 01:59:25.560 --> 01:59:28.020 or whatever it is, most frequently used, 01:59:28.020 --> 01:59:31.467 and the cost of that for the last fiscal year, 01:59:31.467 --> 01:59:34.092 and the estimated cost this year? 01:59:34.092 --> 01:59:36.740 And then the 10 most expensive preparations, 01:59:36.740 --> 01:59:37.770 whatever those might be. 01:59:37.770 --> 01:59:39.743 Is that easily accessed through your system? 01:59:39.743 --> 01:59:41.910 - Yes ma'am, we could provide that for you. 01:59:41.910 --> 01:59:42.810 - Alright. 01:59:42.810 --> 01:59:45.890 Would it be the same as the VA, do you know, the numbers? 01:59:45.890 --> 01:59:47.450 - Well it'd be slightly different 01:59:47.450 --> 01:59:49.120 because our populations are different. 01:59:49.120 --> 01:59:51.263 - Okay, alright. 01:59:52.100 --> 01:59:56.570 I note that 71% of pharmaceutical drug market share 01:59:56.570 --> 01:59:59.960 is controlled by three pharmacy benefit managers. 01:59:59.960 --> 02:00:02.070 Do you know what percentage of drug prices 02:00:02.070 --> 02:00:03.730 paid by the Defense Health Program 02:00:03.730 --> 02:00:05.953 is paid to pharmacy benefit managers? 02:00:07.280 --> 02:00:08.520 - I have to take that one for the record 02:00:08.520 --> 02:00:10.310 ma'am to look that one up. 02:00:10.310 --> 02:00:11.313 - Okay. 02:00:13.397 --> 02:00:15.260 Do you think that if you used a system 02:00:15.260 --> 02:00:16.560 of competitive bidding you would get 02:00:16.560 --> 02:00:18.510 a better price than negotiated pricing? 02:00:19.460 --> 02:00:21.880 - I'm open to exploring any ways 02:00:21.880 --> 02:00:24.140 to get the best price of our medications. 02:00:24.140 --> 02:00:25.180 - Do you have any idea, can you provide 02:00:25.180 --> 02:00:30.180 us with a chart that shows over a period of time, 02:00:30.800 --> 02:00:33.700 take five years, 10 years, how much the cost 02:00:33.700 --> 02:00:38.140 of the 10 preparations that I asked for in each category, 02:00:38.140 --> 02:00:39.457 what, how the price has gone up? 02:00:39.457 --> 02:00:40.840 - Yes ma'am we can provide that. 02:00:40.840 --> 02:00:43.640 - Would insulin fall into that, one of those two tables? 02:00:44.570 --> 02:00:48.713 - Actually most of our top medications, 02:00:49.589 --> 02:00:52.123 insulin would not be in the top 10. 02:00:53.300 --> 02:00:54.160 - Alright do you know how much 02:00:54.160 --> 02:00:56.210 you're paying per bag of heparin? 02:00:56.210 --> 02:00:57.190 - I don't know that right now 02:00:57.190 --> 02:00:58.663 but I can get that information for you. 02:00:58.663 --> 02:00:59.530 - Alright if that is not on the list, 02:00:59.530 --> 02:01:00.710 could you please provide it? 02:01:00.710 --> 02:01:01.781 - [Admiral Bono] Yes ma'am. 02:01:01.781 --> 02:01:05.380 - Also on insulin, I'm very interested in that as well. 02:01:05.380 --> 02:01:07.040 - [Admiral Bono] Yes ma'am. 02:01:07.040 --> 02:01:12.020 - Finally, life expectancy for Americans 02:01:12.020 --> 02:01:13.890 fell again last year because of the opioid 02:01:13.890 --> 02:01:17.210 and suicide crises, and within the US military 02:01:17.210 --> 02:01:19.010 2018 finished with the highest 02:01:19.010 --> 02:01:21.990 numbers of suicides among active duty personnel 02:01:21.990 --> 02:01:23.300 in at least six years. 02:01:23.300 --> 02:01:26.150 Those were largely concentrated in the Guard and Reserve. 02:01:27.186 --> 02:01:30.720 How can access to the quality of mental health care 02:01:30.720 --> 02:01:34.680 for those in the Guard and Reserve 02:01:34.680 --> 02:01:38.910 be as excellent as you provide for active duty members 02:01:38.910 --> 02:01:41.283 at facilities like the Intrepid Center? 02:01:42.370 --> 02:01:43.300 Is there something we can do 02:01:43.300 --> 02:01:45.430 through the Uniform Military Health Services 02:01:45.430 --> 02:01:50.430 to recruit more doctors who will specialize 02:01:50.740 --> 02:01:54.510 in neuropsychiatric disciplines and behavioral sciences. 02:01:54.510 --> 02:01:56.740 Is there something we can do through that system. 02:01:56.740 --> 02:01:59.180 We are 100,000, a 100,000 doctors 02:01:59.180 --> 02:02:01.010 short across this country. 02:02:01.010 --> 02:02:03.780 I've asked myself the question, what more could we do? 02:02:03.780 --> 02:02:07.130 I asked the heads of West Point, Annapolis, 02:02:07.130 --> 02:02:09.350 and the Air Force Academy what they could do 02:02:09.350 --> 02:02:11.200 to recruit more doctors. 02:02:11.200 --> 02:02:13.270 They each graduate maybe five. 02:02:13.270 --> 02:02:15.160 And I said, why can't we increase that number? 02:02:15.160 --> 02:02:16.940 And they sort of stepped away from the table. 02:02:16.940 --> 02:02:18.590 That was a shocking answer to me. 02:02:19.630 --> 02:02:21.760 So is there anything you can recommend 02:02:21.760 --> 02:02:23.593 on the Guard and Reserve side, 02:02:25.270 --> 02:02:27.410 can we construct Intrepid Centers 02:02:27.410 --> 02:02:28.900 where we have a lot of Guard and Reserve 02:02:28.900 --> 02:02:30.813 individuals across the country? 02:02:31.740 --> 02:02:34.770 - So I'll take a stab at this one first. 02:02:34.770 --> 02:02:36.750 And then for my colleagues who have 02:02:36.750 --> 02:02:39.640 the Guard and Reserve in there, in their components. 02:02:39.640 --> 02:02:41.430 One of the things that we're looking 02:02:41.430 --> 02:02:44.330 at is how we can make the healthcare benefit 02:02:44.330 --> 02:02:47.060 more equitable for our Guard and Reserve. 02:02:47.060 --> 02:02:48.680 So that is one of the things that we're looking at. 02:02:48.680 --> 02:02:50.550 And that's a more comprehensive look 02:02:50.550 --> 02:02:52.650 that would also include behavioral health. 02:02:54.000 --> 02:02:56.720 - [Miss Kaptur] Anyone else wish to comment? 02:02:56.720 --> 02:02:58.150 - A similar answer to that for our 02:02:58.150 --> 02:02:59.100 Guard and Reserve colleagues. 02:02:59.100 --> 02:03:00.740 Of course when they are activated 02:03:00.740 --> 02:03:02.910 they have access to the care that we have 02:03:02.910 --> 02:03:05.110 in our Direct Care System, our MTFs. 02:03:05.110 --> 02:03:07.030 But they also receive their care 02:03:07.030 --> 02:03:09.850 when they're not drilling or activated 02:03:09.850 --> 02:03:14.850 through a contract healthcare delivery system, 02:03:15.650 --> 02:03:18.780 that manages their readiness and can provide care for that. 02:03:18.780 --> 02:03:20.224 Or if they have their own insurance 02:03:20.224 --> 02:03:22.470 they can see providers within their own area. 02:03:22.470 --> 02:03:24.010 So it's a little bit more difficult 02:03:24.010 --> 02:03:25.870 to have a one size fits all program 02:03:25.870 --> 02:03:27.770 for all of our Guard and Reservists. 02:03:27.770 --> 02:03:31.980 Especially those that vary by state in our Guard population, 02:03:31.980 --> 02:03:33.970 and then with our Reserve population as well. 02:03:33.970 --> 02:03:34.880 - I would hope you would look at 02:03:34.880 --> 02:03:36.789 distance learning and distance treatment 02:03:36.789 --> 02:03:40.700 as one of the solutions for what we need across the country. 02:03:40.700 --> 02:03:42.210 I don't wanna go over the generous 02:03:42.210 --> 02:03:44.311 time the Chairman has allocated to me. 02:03:44.311 --> 02:03:45.144 (coughs) 02:03:45.144 --> 02:03:48.090 But if someone could send me information 02:03:48.090 --> 02:03:50.480 on Intrepid Centers, how we fund them, 02:03:50.480 --> 02:03:51.660 how we could fund them. 02:03:51.660 --> 02:03:53.730 Our part of the country has none. 02:03:53.730 --> 02:03:55.900 And I was extremely impressed with what I saw 02:03:55.900 --> 02:03:57.500 when I went over to Walter Reed. 02:03:58.580 --> 02:03:59.413 Thank you. 02:04:01.670 --> 02:04:02.503 - Judge Carter. 02:04:06.320 --> 02:04:08.700 And we've got about two minutes. 02:04:08.700 --> 02:04:12.360 - Question, not going into this transgender thing. 02:04:12.360 --> 02:04:15.140 But I just, I had a question that I asked 02:04:15.140 --> 02:04:16.890 the Sargent Major of the Army about 02:04:18.290 --> 02:04:20.460 the debate that was going on. 02:04:20.460 --> 02:04:22.600 And it was explained to me that 02:04:22.600 --> 02:04:27.600 the debate was about deployability on the medical issue. 02:04:28.310 --> 02:04:32.240 Any disease that you contract or that you have 02:04:32.240 --> 02:04:36.810 which requires, if your health requires 02:04:36.810 --> 02:04:41.630 you to have some kind of treatment ongoing, 02:04:41.630 --> 02:04:44.010 keeps you from being deployed, 02:04:44.010 --> 02:04:47.830 isn't that right, isn't that the policy of the military? 02:04:47.830 --> 02:04:52.500 Like I don't know, it would be diabetes. 02:04:52.500 --> 02:04:56.230 We have to have shots everyday for something. 02:04:56.230 --> 02:04:59.243 Then you would not be deployable is that correct? 02:05:00.590 --> 02:05:02.640 Isn't that the issue? 02:05:02.640 --> 02:05:05.740 Ongoing treatment keeps you from being deployable? 02:05:05.740 --> 02:05:06.843 Therefore you're not, 02:05:06.843 --> 02:05:09.253 that's why the new policy was written. 02:05:10.270 --> 02:05:12.250 Because there have to be hormone treatments 02:05:12.250 --> 02:05:15.410 that go on after a certain period of time, 02:05:15.410 --> 02:05:16.700 therefore you're not deployable 02:05:16.700 --> 02:05:21.030 because you gotta have those to function normally? 02:05:21.030 --> 02:05:24.240 - The approach of the new policy does indeed, 02:05:24.240 --> 02:05:26.620 it builds upon the issue you're raising. 02:05:26.620 --> 02:05:30.010 And it's ties to a medical condition, 02:05:30.010 --> 02:05:31.110 whatever the medical condition-- 02:05:31.110 --> 02:05:32.600 - [Judge] Whatever the medical condition. 02:05:32.600 --> 02:05:35.179 - There's you know, the surgeons can probably speak 02:05:35.179 --> 02:05:38.020 more informatively in terms of what are some 02:05:38.020 --> 02:05:40.330 of the most common ones, but, 02:05:40.330 --> 02:05:42.340 it's around a particular medical condition, 02:05:42.340 --> 02:05:44.707 and how it affects your deployability, 02:05:44.707 --> 02:05:47.430 and your ability to do a particular job. 02:05:47.430 --> 02:05:50.020 That is what is reviewed and evaluated 02:05:50.020 --> 02:05:52.920 to make a determination of can you serve, 02:05:52.920 --> 02:05:56.370 or can you get a waiver, that sort of thing. 02:05:56.370 --> 02:05:57.930 - That's what I was told. 02:05:57.930 --> 02:06:00.530 And it wasn't a discrimination issue. 02:06:00.530 --> 02:06:02.820 It was a deployability issue. 02:06:02.820 --> 02:06:03.810 Really when it comes down to it 02:06:03.810 --> 02:06:06.200 on anybody that's got anything wrong with them, 02:06:06.200 --> 02:06:09.230 keeps them from being deployed, then it ultimately, 02:06:09.230 --> 02:06:13.230 they're not able to serve in the military. 02:06:13.230 --> 02:06:14.063 - [Mr. McCaffery] Correct. 02:06:14.063 --> 02:06:15.957 - Thank you, Mr. Diaz-Balart. 02:06:18.030 --> 02:06:19.930 Thank you very much, we are adjourned.