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Senator GLENN. Thank you, Admiral.

General Becker. STATEMENT OF LT. GEN. QUINN H. BECKER, U.S. ARMY, SURGEON

GENERAL OF THE ARMY General BECKER. I would like to, Mr. Chairman, just submit an abbreviated statement and I submit my full statement for the record.

Senator GLENN. It will be included. General BECKER. Medical readiness is our number one priority. We are soldiers. I am a soldier, and we want to take care of our soldiers.

We are improving our posture to do that during wartime. This year we have purchased to date 101 field medical sets, that is DEPMEDS sets. That is very near the target. We will field 15 of these by the end of this year. These DEPMEDS sets of course increase the capability of our field units considerably and replace the old MUST sets.

The major problem in readiness remains in Reserve personnel. We have the New STRAP program that the Congress has given us and we just recently got the recruiters, the AGR strength that we needed to run that program. We believe that with this new program we will be able to recruit the critical specialties in both medicine and nursing that we need to fill our Reserve units. These are, of course, the orthopedic surgeons, the general surgeons, the anesthesiologists, the OR nurse, and the nurse-anesthetists. We have already had some success with this program.

Peacetime health care, of course, as Admiral Zimble said, is very tightly linked with wartime readiness. We do provide quality care. We have high quality practitioners. We have taken many measures to improve that over the last 3 to 4 years.

The 1988 budget provided by the Congress was good. It allowed us to increase our PRIMUS clinics and we appreciate this committee's help for that.

However, several deductions have been made that have put us considerably below the 1987 level. Now, we have been able to gather a little money and this afternoon or early in the morning we will release a message stating that we will continue to honor civilian prescriptions. This has been a problem out in the field, as you know. We are still short money to finish the year. We will continue to try to find the resources to, at least, return to our 1987 level of effort.

In the future, the use of CHAMPUS money in our catchment areas will give us the diversity we need to take care of our patients and I believe save a considerable amount of money.

We are suffering a physician loss at a rate higher than anticipated. There is a pay differential problem. You mention that in your statement, I believe, and that is real.

What we want to do is to use our direct care facilities to the maximum amount and thereby train our people for their wartime mission and save considerable CHAMPUS dollars.

That is the end of my statement and I stand ready for your questions.

[The prepared statement of General Becker follows:]

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PREPARED STATEMENT OF LT. GEN. QUINN H. BECKER,

U.S. ARMY, SURGEON GENERAL OF THE ARMY Mr. Chairman and Members of the Committee, I am Lieutenant General Quinn H. Becker, The Surgeon General of the Army. It is an honor to have this oppo unity to appear before your sub-committee to discuss the Army Medical Department (AMEDD). I value your interest and acknowledge the vital role your support will have in the future.

The AMEDD is tasked with performing four separate, yet interrelated, health care missions. Our primary mission is to

a high state of medical readiness to support combat and contingency operations. This includes support to Army field commanders in maintaining a physically and mentally fit force. Equally important, though, are missions to insure a quality peacetime health care delivery system for all authorized beneficiaries; provide Graduate Medical Education and other health care training to support both the wartime and peacetime mission; and conduct extensive research to protect the lives of soldiers who are deployed world-wide. Our day to day operations support each of these missions.

At the outset, I would like to express my appreciation to the Members of this Committee for several specific actions affecting health care delivery as contained in the 1988 DOD Authorization Act. The permission to pursue expansion of the PRIMUS program will assist in improving access to primary care for our beneficiaries. Additionally, the guidance contained in the Conference Report to exempt medical personnel from participation in the Officer Reduction in FY 1988 will not only assist in medical readiness but will also contribute to maintaining peacetime health care capabilities.

Medical readiness is our number one priority. Significant resources have been devoted to improving our medical readiness posture in recent years and that effort is continuing. An important step in this direction was the establishment within my office of a separate Readiness Division. This division identifies medical readiness issues, recommends solutions and monitors all medical readiness enhancement initiatives which affect the Active Army as well as the National Guard and the Army Reserve. Although we have achieved admirable progress in correcting our medical readiness shortfalls, critical equipment and personnel deficiencies remain, particularly in the reserve components. However, there are plans and resources approved to alleviate these shortages.

As you know, we began a significant medical materiel acquisition program in 1982 aimed at correcting deficiencies which spanned the entire spectrum of combat casualty care from medic aid bags to combat hospitals. The thrust of the hospital equipment initiative focuses on the procurement and fielding of Deployable Medical Systems (DEPMEDS), which is a quad-service effort to standardize equipment within all field type combat hospitals. The Total Army is involved with this initiative. Our plan calls for the fielding of DEPMEDS sets by 1993 with much of this equipment going to our reserve units. Fielding began last year with the 8th Evacuation Hospital at Fort Ord, California, and the 85th Evacuation Hospital at Fort Lee, Virginia, receiving the first DEPMEDS sets. A training set was delivered to the Academy of Health Sciences at Fort Sam Houston, Texas, for use at the Joint Medical Readiness Training Center. Two Reserve Component hospital units received Minimum

Essential Equipment for Training sets while two complete sets have been placed in POMCUS storage in Europe. When completed, this initiative will provide sufficient hospital sets to initially equip all theater hospitals. Also included in this modernization effort are newly designed aid station and clearing station sets, dental x-ray sets, air and ground ambulance sets, chemical decontamination kits and many other critical items of equipment.

Progress continues to be made in implementing new programs designed to alleviate the shortage of reserve component professional personnel. These initiatives have been designed to focus on specialty shortages of physicians and nurses in both the Selected Reserve and Individual Ready Reserve. Flexible training and membership options, such as the First Army Augmentation Detachment, along with recent legislative authorities to provide specialized training assistance and loan repayment are examples of these initiatives. Nonetheless, the most important effort to implement these initiatives and thereby resolve this problem is the expansion of our recruiting system. Active Guard/Reserve (AGR) personnel are essential for this recruiting effort. AGR positions authorized by the Congress for fiscal year 1988 have been instrumental in the establishment of a National Augmentation Detachment for this end. Continued support is necessary to build on these efforts to eliminate this shortage.

Training for AMEDD personnel remains a critical adjunct to readiness. We continue to support the Combat Casualty Care Course designed as a tri-service course to prepare military medical professionals to successfully function at the forward points of the casualty care system. This course is conducted by the Joint Medical Readiness Training Center located at Fort Sam Houston, Texas. Over a nine day period, in a field environment, students receive instruction in Advanced Trauma Life Support, patient evacuation, patient triage, preventive medicine, individual protection and patient care in an NBC environment, and support of combat operations. In response to a need identified by the Congress to expand and export the course for reserve component personnel, the AMEDD has worked with the Joint Medical Readiness Education Committee and the DoD Health Council to develop a plan to accomplish this action. Resources to support this effort are included in our fiscal year 1989 budget.

Readiness initiatives to reduce evacuation and hospital bed shortfalls in the European Theater are on track. These include the establishment of "warm base" hospitals which are pre-positioned general hospitals at the intended site of wartime use in a partially established mode. The use of existing facilities, such as former warehouses or factories, are ideally suited for this purpose and significantly shortens the time necessary to make these hospitals operational at the outbreak of hostilities. Last year, two such 'warm base" hospitals were established; the first located in The Netherlands and a second one in England. We are pursuing the establishment of eight more of these facilities in Europe. Ground evacuation capabilities are improving as well. The activation of German reserve ambulance bus and ambulance train units to move our casualties is progressing. Rapid deployment teams remain ready. Last September, we successfully deployed the US Army Europe Contingency Hospital to Turkey as part of the "Display Determination 87" exercise.

One of the significant milestones to further improve our medical readiness is the recent completion of the Medical Readiness Strategic Plan. This plan requested by the Congress and developed by the Assistant Secretary of Defense (Health Affairs) comprehensively documents the many actions necessary to ensure a high state of medical readiness consistent with the needs of the Services and realities of funding. Achievement of these objectives will be a long-term venture and one that requires the support and cooperation of the Services and the Congress. The Medical Readiness Strategic Plan provides a framework from which these competing medical readiness needs can be evaluated and prioritized for action within the program budget process.

Another important AMEDD mission is the provision of peacetime health care. While it is not our sole mission, it is a significant and highly visible benefit of military service. It is an entitlement established by the Congress to which the AMEDD strives to provide the highest quality of health care services consistent with available resources. Its successful execution is interwoven in the daily accomplishment of our multifaceted mission of maintaining medical readiness, conducting research, and educating health care providers. To this aim, the AMEDD operates 49 hospitals along with numerous health and dental clinics world-wide. We also provide military staff for the Brooke Army Medical Center operated under the executive agency of the United States Air Force as part of the San Antonio Joint Military Medical Command.

We point with pride to the peacetime health care services provided in our medical treatment facilities. Over the past several years, workload accomplished by these AMEDD facilities has remained relatively constant. On an average day, we admit 1,111 patients, have 6,046 beds occupied, assist with the birth of 115 children, and provide care for some 58,582 outpatients. While the number of admissions has actually risen, Army hospitals continue to experience a decline in the average length of patient stay which decreased from 5.8 days to 5.5 days between fiscal years 1986-1987. This decrease is reflective of the national trend which results, in part, from technological advancements, such as the use of lithotripters to non-surgically remove kidney stones, along with changing treatment practices like ambulatory surgery.

care.

In spite of productivity enhancements, the AMEDD has not kept pace with the growing beneficiary population's demand for health

We are not using our medical treatment facilities to full capacity and the most significant factor limiting full utilization is staffing. Consequently, when a patient's need cannot be accommodated within the direct care system, we must refer the patient to the civilian sector under the CHAMPUS program. This alternative is frustrating for our providers, more costly, and generally not as acceptable to our beneficiaries as care in the direct system. Review of CHAMPUS non-availability statements issued by our facilities indicates that in fiscal 1984 Army hospitals accommodated 93.7 percent of our patients. In fiscal 1987 the accommodation rate declined to 92.3 percent.

The practice of peacetime health is medical readiness.

On a

daily basis our clinicians and technicians perform their "go-to-war" duties. An adjunct to this readiness is the training of AMEDD personnel. Our Graduate Medical Education Programs are nationally recognized as a valuable asset. These programs ensure that there are trained physicians available to treat the medical needs of our patients. This means that infants are delivered by obstetricians and fractures are set by orthopedists. The largest source of physicians entering the Army is from the Health Professions Scholarship Program (HPSP) and the Uniformed Services University of the Health Sciences (USUHS). These physicians are not specialty trained when they enter active duty. While they are undergoing residency training they are at the same time delivering care to DoD beneficiaries. The Graduate Medical Education environment provides a solid basis to sharpen and challenge the skills of all participants in the training process as well as providing daily experiences that ensure readiness on the battlefield.

Concern for our soldiers and their families is reflected in the Army Medical Enhancement Program developed over the past several years, endorsed by the Congress, and initially executed last fiscal year. The objective of the medical enhancement program is to improve the accessibility and the quality of care in medical treatment facilities. The first objective is creation of a primary care model for all active duty families. The second objective is to improve the patient appointment system. This includes hiring more clerks and receptionists as well as installing automation to assist in managing the scheduling process while providing excellent data for management. A third objective is to obtain additional ancillary support personnel nurses, physical therapists, occupational therapists, dieticians, corpsmen, lab, pharmacy and radiology technicians. These additional personnel will increase support for physicians in the clinical environment, relieve physicians from performing nonclinical duties, improve provider productivity and the effectiveness and efficiency of the health care delivery system, and support the Army Family Action Plan through improved access for military family members to care.

The medical enhancement initiative is a bold program requiring the overall support of the Army Staff ensure that adequate resources are available to make it happen. This undertaking will provide some 4,000 additional workyears to support medical activities over the course of the program. A significant philosophy is reflected in the Army decision to support this quality initiative. It is that the soldier who knows that his or her family is well cared for is a soldier more dedicated to fight on the battlefield. Simply stated, health care for the soldier and his family is a readiness issue.

Initial results from our first year of implementation show that

objectives of this enhancement program are being met. Access and service to our beneficiaries is improving. Reported highlights of the program from individual facilities indicate that additional nursing and other ancillary staff have helped return nurses to patient care, improve intensive care service, reduce surgery backlogs, reduce emergency room waiting times, provide respiratory therapy services, improve nutrition care, reduce pharmacy waits, expand radiology services, meet national accreditation standards, and even establish an open heart surgery program at one location.

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