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Mr. Chairman and members of the subcommittee, as the Commanding General of the Great Plains Regional Medical Command and Brooke Army Medical Command, I appreciate the opportunity to speak with you on the relationship between the 10 Army Hospitals in the Great Plains Regional Medical Center and the Veterans Health Administration as it relates to patients injured while serving this great nation in the Global War on Terrorism (GWOT). I believe my testimony will help this committee to understand the various ways and means in which we are working to optimally serve our Soldiers.

I can assure you that Medical Treatment Facilities within the Great Plains Regional Medical Command have continued to improve upon preexisting relationships with the Department of Veterans Affairs (VA) to provide compassionate, quality health care to restore the physical and psychological health of wounded Soldiers with dignity and respect. Our organizations have improved upon the ability to coordinate and synchronize to provide the military members and veterans with superb, seamless care. Later today, Colonel Bernard DeKoning, Commander of the Darnall Army Community Hospital at Fort Hood, Texas will provide testimony that provides further examples of this improved coordination which provides our Soldiers the optimal post deployment health care.

Brooke Army Medical Center has a long standing and productive relationship with the Veterans Health Administration in San Antonio. Prior to the conflicts in Iraq and Afghanistan, Brooke Army Medical Center and the VA began several joint sharing initiatives. These include the following: laboratory support, hearing aides, nursing training, radiology services, bio-medical equipment and devices, nuclear medicine studies, gynecology services, burn care, teledermatology, ethylene oxide (ETO), sterilization services, sleep lab studies and laundry support. These initiatives have resulted in more efficient use of federal resources, lower overall health care costs and consistently improved our ability to deliver integrated health care.

In addition, the leadership of both Department of Defense (DoD) facilities in San Antonio and the VA have created a new formal collaborative effort in San Antonio called the Federal Healthcare Consortium that meets monthly. Collaboration from this body has resulted in new initiatives including: invasive cardiology and cardiothoracic surgery services, joint credentialing, laboratory data sharing, a joint Northside San Antonio clinic, a joint pager system, intensive care optimization, rehabilitization, and physical examination coordination from the DoD health care system to care provided in the VA.

In the arena of patient care, we have had a long history of caring for "dual" eligible beneficiaries, as well as transferring Soldiers from ongoing DoD care into the VA system following their discharge from military service.

Brooke Army Medical Center plays a vital role in United States Army readiness by providing patient care to our Soldiers and other military beneficiaries, Graduate and continuing Medical Education for Army doctors, nurses, and medics, and also through medical research. These missions have proven to be critical to the Army success on the Global War on Terrorism. We are inextricably linked to health care delivery that occurs on the battlefield today. Doctors, nurses, and medics that are assigned or have trained at Brooke Army Medical Center are delivering care to our forces in Iraq. Since the war began, Brooke Army Medical Center continues to care for casualties that have returned from forward care, through medical evacuation, back to our medical center. Among the many professional accolades that our preeminent institution possesses, the most powerful credential remains the testimony of the Soldiers and beneficiaries that receive medical care at our institution.

The advent of the Global War on Terrorism demanded increasing collaborative efforts between the DoD and VA health systems. Since January 2003, we have received at Brooke Army Medical Center 1,321 Soldiers evacuated from the forward theatres of operation around the world for both medical and surgical issues.

1,112 patients were evacuated from Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), or Operation Noble Eagle (ONE). The remaining Soldiers came from other areas where the U.S. Army has deployed Soldiers such as Bosnia and Kosovo. Over 60% of the OIF/OEF/ONE Soldiers that we have received are Reserve or National Guard Soldiers.

Most of the Soldiers (66%) have been treated and released back to active duty status or have been released from active duty back to their Reserve or National Guard units. Thirty-four percent (34%) of the Soldiers have progressed to needing a Medical Evaluation Board (MEB). The MEB is initiated when a physician believes the Soldier has reached a maximum therapeutic state and yet, is still unable to meet regulatory retention standards or can not meet a full fitness for duty status. The MEB includes a due process system of ensuring that Soldiers have a fair and equitable opportunity to represent themselves prior to separation due to a medical condition. This includes an opportunity to challenge the findings and ask for other opinions from military and civilian physicians.

Of the 1,321 Soldiers treated at Brooke Army Medical Center, 452 Soldiers have entered the MEB process. Approximately 30 percent of the Soldiers have completed the process. We anticipate the majority of these Soldiers will receive ongoing care at VA facilities.

The care that the Soldiers will need after completing the MEB process and transitioning into the VA system are characterized by the following:

1) 20 Soldiers (4.4%) burn care
2) 20 Soldiers (4.4%) mental health
3) 24 Soldiers (5.3%) cardiology
4) 34 Soldiers (7.5%) neurology
5) 51 Soldiers (11.2%) neurosurgery
6) 92 Soldiers (20.4%) general medical care
7) 95 Soldiers (21%) orthopedics
8) The remainder of the care needed (25.8%) is dispersed across all the other medical and surgical services.

Some specifics on the type of care we have provided illustrate the kind of world class health care our Soldiers are receiving. Incorporated into Brooke Army Medical Center is the Army’s Institute for Surgical Research which commonly referred to as the Burn Center. This is the only DoD Burn Center. The 40 intensive care beds and staff provide care to all DoD, VA, San Antonio and SW Texas Civilian patients, and State Department approved patients from throughout the world. The Burn Special Medical Augmentation Team (SMART Team) has made 18 flights to pick up seriously burned Soldiers from the Global War on Terrorism. Later in this hearing, you will receive testimony from LTC (Dr) Lee Cancio, our current chief of the Burn Center. He will outline the state-of-the-art burn care provided for Global War on Terrorism patients, to civilians from South Texas, and other military members injured all around the world.

Twenty severely burned Soldiers have been hospitalized and extensively treated at the Burn Center. In addition, there have been 67 other Soldiers treated for burns as inpatients. Some of these Soldiers will have significant health care needs for reconstructive plastic and hand surgery. Brooke Army Medical Center also houses one of the two DoD Amputee Centers of Excellence and has treated 83 inpatient and over 300 outpatients. These patients include 40 mine blast trauma patients and 17 amputees.
Staff from the local Veterans Affairs, including representatives from the Audie L. Murphy Veterans Hospital in San Antonio, provide support and information to those Soldiers leaving the Army due to physical disability.

Within Brooke Army Medical Center, there are two Department of Veterans Affairs employees from the Health, Benefits and Services Division, who work in our medical center to ensure we have a coordinated and seamless health care transition for these Soldiers.

One of these employees is a clinical social worker who has consulted on more than 270 cases of OIF/OEF patients. He provides in-depth briefings on VA health benefits to include the two years of medical care available after separation at any VA facility for disease or health issues relating to active duty performance.

In addition to the consultations, the VA social worker has coordinated 128 referrals requiring intensive case management with the gaining VA medical centers across the United States.

Brooke Army Medical Center is credited with providing the second greatest number of referrals to the Department Veterans Affairs. Walter Reed Army Medical Center provides the greatest number of referrals. Our medical center case managers and the VA social work staff member assess patients and determine the appropriate course of treatment with our physicians to include follow-up appointments and referral. Our medical center experience has been that the medically boarded patients receive specialty clinic follow-up within ten days at their receiving VA hospital or clinic with the coordinated efforts through the presence of imbedded VA staff.

Brooke Army Medical Center also has a VA liaison representative who started at the hospital in the Spring of 2003. To date the benefits liaison has provided consultation to more than 800 OIF/OEF patients.

The liaison reviews benefits and coordinates for those benefits that may be provided to medically discharged Soldiers. To date, the representative has processed 85 claims from Soldiers deployed for the Global War on Terrorism. Soldiers in the process of separation from the Army file claims to obtain VA benefits. Examples of these special VA benefits include several OIF Soldiers who have applied for the $9,000 allowance known as the Automobile Grant to use towards the purchase of a specially equipped vehicle. In addition, the VA pays costs to specially adapt the car and train the individual driver. In addition, several veterans have been processed for the Special Adapted Housing Allowance of up to $50,000 to modify homes for veterans who have lost the use of extremities and need modifications to hallways, bathrooms, doorways, and such.

I would like to provide the stories of two specific Soldiers which provide living testimony to the outstanding quality of the health care system that is provided to our Soldiers. It begins on the battlefield, the Air Force evacuates them to our Army hospitals, like Brooke Army Medical Center, and seamlessly coordinates their follow on care with the VA.

Corporal Robert E. Jackson Jr., is 22 years old and was injured in OIF in February 2003. He was deployed with the 186th Military Police out of Fort McCoy, Wisconsin, as a member of the Iowa National Guard. He suffered bilateral below the knee amputations, with 6 percent body surface burned, vocal cord paralysis and permanent damage to his right hand. He has received bilateral prosthesis in addition to his other care. He has completed extensive care that includes four major operations, multiple revisions along with rehabilitation. He has now completed his care with the medical board process, receiving a 100 percent disability. His follow on care has been professionally and fully coordinated with the Des Moines VA hospital. He plans to attend college and become a physician, specifically a radiologist. He is a Purple Heart recipient, married with two young daughters ages 2 and 4. Corporal Jackson could not be here today because he is has achieved his goal of returning with his unit to the state of Iowa as they come home from their deployment to Iraq today.

Now let me introduce to you Staff Sergeant Rashaan Canady, age 26, who was injured near Bagdad in Operation Iraqi Freedom, in April 2003. He was deployed out of Fort Stewart, Georgia, as part of the 3rd Infantry Division. He suffered a traumatic amputation of the right arm below the elbow and shrapnel injuries to his face and right eye. Staff Sergeant Canady has received extensive surgical, psychological, and physical therapy. Through no less than heroic efforts on his part coupled with our professional health care he has now received and can utilize a state-of-the art right arm and hand prosthesis. Throughout his long recovery, he has continued his education towards his bachelor degree and we have, together, coordinated for his follow on rehabilitation and medical at VA hospital Wilmington, North Carolina. He is both a Purple Heart and Silver Star recipient. He plans to attend school in Wilmington, North Carolina, and pursue a career in public service. Staff Sergeant Canady is married and has a six-year old daughter.

These men are just two examples of America’s most precious asset, the young men and women who wear our nation’s uniform and defend our nation’s freedoms. They have both been an inspiration to their fellow Soldiers, to our medical staff, to those Soldiers who are still in the process of recovering from their injuries, and I would submit, to their fellow Americans.

Conclusion:

Mr. Chairman, in my testimony today I have shared with you some of the ways and means that Brooke Army Medical Center has cared for the injured Soldiers and transitioned them to the Department of Veterans Affairs health care system.

As partners in this most important process, we are committed to providing state-of-the-art health care for America’s sons and daughters injured on the battlefield. We will ensure that our Soldiers and America’s veterans never forget that we were there for them and provided them with optimal and seamless care in both the DoD and VA health care systems. We believe that our efforts to date are clear examples of the kind of efforts that should serve as a role model for how the DoD and VA health care systems can be optimally integrated. However, we are continuing our efforts to further identify and refine ways and means to enhance our coordination and integration.

I want to thank you again for your time and I am available for your questions.

Information on BAMC:

Brooke Army Medical Center is a tertiary care regional referral center for a 16 state area encompassing 10 Military Treatment Facilities and 22 outlying clinics. It operates as a Center of Excellence for orthopedics, burn, trauma, and amputee care. The hospital is also noted for cardiology and cardiothoracic surgery, and offers advanced oncology, and ophthalmology care.

The hospital staff provides inpatient care in a 219-bed facility, 1.5 million square foot, state-of-the-art facility that has the expansion capability of 368 beds.

Forty beds are devoted to the Army Institute of Surgical Research, which operates the renowned "Army Burn Center” – the only Department of Defense Burn Center.

As the Army's only certified Level 1 trauma center, Brooke Army Medical Center receives more than 1,800 emergency room visits each month. Many trauma patients are civilians treated under a local military-civilian trauma consortium agreement.

Brooke Army Medical Center further provides specialty care within the disciplines of Internal Medicine, Surgery, Pediatrics and OB/GYN. Other clinics available at Brooke Army Medical Center include:

Allergy and Immunology
Audiology Clinic
Behavioral Medicine
Cardiothoracic Surgery Clinic
Dental / Oral and Maxillofacial Surgery
Family Medicine Services
Geropsychology Services
Hematology/Oncology
Pathology
Pharmacy
Physical Medicine and Rehabilitation
Social Work
Women's Imaging Center

Brooke Army Medical Center’s 58-outpatient specialty clinics record a million patient visits each year. The hospital sustains over 60 accredited educational programs that include 25 Graduate Medical Education Programs, eight nursing programs, 18 enlisted allied health and medic phase II training along with additional programs in administration and allied health specialties. GME programs include 270 Army and 250 Air Force residents and interns.

Brooke Army Medical Center’s staff of almost 3,000 includes 1,500 military and 1,500 civilians who are augmented by contractors and volunteers.

Brooke Army Medical Center’s annual operating budget is $200M. The hospital has a total workforce of over 3,200 personnel to include military and DA civilian employees, plus over 500 volunteers.

An “Average Day at Brooke Army Medical Center” includes a census of 128; 24 admissions, 3 for civilian emergencies; 2,900 clinic visits; 3,000 laboratory procedures and 7,000 prescriptions filled.

In cooperation with the Air Force's nearby Wilford Hall Medical Center at Lackland AFB (the regional TRICARE lead agent), Brooke Army Medical Center serves 185,000 local beneficiaries.

Joint agreements:

Brooke Army Medical Center currently has 13 VA-DoD Resource Sharing Agreements with another 5 agreements under development.

13 Current Agreements:

Laundry support – provided to Brooke Army Medical Center from the Kerrville VA. Brooke Army Medical Center pays 47.5 cents per pound as opposed to a market rate of 55 cents per pound paid by Methodist Hospital or 51 cents per pound by WHMC

Laboratory Support – Provided by Brooke Army Medical Center to Audie Murphy Medical Center. Brooke Army Medical Center provides approximately 14 different lab tests for the VA, at CMAC minus 10% or approximately 80% of commercial lab test rates. This provides Brooke Army Medical Center with approximately $12K in reimbursements from the VA annually.

MOA for VA Contract for Hearing Aides – Provides discounted rates to Brooke Army Medical Center for the purchase of hearing aides and hearing aide batteries to Brooke Army Medical Center beneficiaries. Discounts obtained through piggybacking on the VA’s nation-wide contract.

Nursing, MOA for Training – Training affiliation between Brooke Army Medical Center and VA. Brooke Army Medical Center sends their nurses to the VA for training and case mix diversity. This is a gratis arrangement.

Radiology Services – Currently under review due to a reduction in Brooke Army Medical Center radiology capacity.

Bio-Medical Equipment and Devices – Brooke Army Medical Center piggybacks on a VA centralized contract. Brooke Army Medical Center Medical Maintenance estimates savings of approximately $500K annually.

Nuclear Medicine – Brooke Army Medical Center provides scans to Audie Murphy Medical Center. Under review and negotiation on reimbursement rate (90% of CMAC).

GYN Services – Brooke Army Medical Center provides both Oncology and D&Cs to Audie Murphy. Currently under revision, not due to price, but a refinement of process. Reimbursement based on 90% of CMAC.

Burn Care – Brooke Army Medical Center provides burn care to all VA patients nation-wide. Under revision on reimbursement rates, since burn rates are so unique from normal CMAC charges.

WHMC / AUDIE l. MURPHY MED CEN – Alternate site agreement which shifts medical care to one of our three Federal partners, in case one of the three facilities is taken out of service for emergency or contingency reasons.

Teledermatology – Brooke Army Medical Center provision of tele-dermatology services (consultation) to Temple VA. Now finalized and signed by both parties. Reimbursement based upon 90% of CMAC.

ETO Sterilization Services – Brooke Army Medical Center gave Audie Murphy our sterilizers, in exchange for VA providing ETO sterilization services to Brooke Army Medical Center until 2007. Brooke Army Medical Center wanted to get out of the ETO sterilization because it is a somewhat out-dated technology. Reimbursement based on bartered agreement – equipment for services.

Sleep Lab – Services provided by Brooke Army Medical Center to Audie Murphy VA. Agreement has been in effect since 2002. Reimbursement based upon 90% of CMAC.

Five Developing Agreements:

Invasive Cardiology and Cardio Thoracic Surgery Services – Provided by Brooke Army Medical Center to the Temple VA at 90% of CMAC. Provides the VA with quality services at a discounted rate, while augmenting the hospital’s GME programs.

Joint Pager Services – A tri-party arrangement between BAMC, WHMC, and Audie Murphy to gain economies of scale discounts through pooling of lease requirements. All parties pay a fair share of their respective bills.

Joint Credentialing – Another tri-party arrangement with BAMC, WHMC, and Audie Murphy to gain economies of scale discounts. Business plan is still in development.

Laboratory Data Sharing & Interoperability (LDSI) - An agreement between Brooke Army Medical Center and Audie Murphy to evaluate the feasibility of sending-out lab tests with the intent to have test results electronically transmitted from Brooke Army Medical Center directly into VISTA. STVHCS has been utilizing the reference lab at Brooke Army Medical Center for more than five years. Having the test results electronically submitted would reduce the chance for human error during manual entry (current practice). LDSI is a VA developed methodology currently being tested at VAMC Hawaii with Tripler AMC. Business plan is still in development.

Operation Enduring Freedom / Iraqi Freedom – Places VA representatives at Brooke Army Medical Center to assist Soldiers undergoing medical retirements to make a seamless transition from the DoD to VA system. Awaiting final signature by VA. Also a gratis arrangement.