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ideas or minds, if you are enrolled in a program, you are stuck with one doctor whether you like it or not. I know of no such pro gram actually. But there is going to be a major controversy with beneficiaries over a mandatory enrollment program. That is why, in the early stages of CHAMPUS Reform, the enrollment aspects are voluntary. There will be voluntary enrollment, to some degree, in the catchment area demonstrations.

But there is one other military medical reason why enrollment has a down side. I don't think it is insoluble, but it is a real down side. If we enroll people-for example, let's say we gave them two alternatives: they either enroll to get all their care at the military hospital, or they enroll in a contractor's program to deliver CHAMPUS. That way, everybody we have enrolled outside of the military hospital is no longer available to us to treat in our military hospital, and in those cases in which we are dealing with complex surgical procedures and the kinds of patients we need to maintain the quality of our graduate education, we would be cutting ourselves off from a whole bunch of patients who would be enrolled elsewhere. As I said, I don't think that is totally insoluble, but it is going to be hard.

Mrs. BYRON. It basically sounds like you will take care of their needs if you need them but, if you don't need them, move them off somewhere else.

Dr. MAYER. It is possible for you to jump to that conclusion, and that is not what I'm saying. What I'm saying is that it is those patients who have particularly burdensome health care needs we want to take care of.


Dr. MAYER. It just incidentally works out that that also serves the purposes of keeping our physicians well occupied, interested, well trained, which I know you are in favor of, because they are the ones that have to go to war.

Mrs. BYRON. Let me pursue one other area, and then Mr. Pickett, I think, has a question. This subcommittee has felt frequently that decisions are made that are not really intended to adversely impact the medical system but, nonetheless, quite frequently do. For example, let me cite the one that I used in my statement, and that was the Navy's recently fired numerous civilian temporary employees at Navy hospitals because, among other reasons, there was an influx of active duty personnel for the manning of the hospital ships, and the fact that the civilians were typing and keeping medical records and the things that are vital to a physician, and the active duty personnel, by and large, really didn't have the same type of skills didn't seem to enter at all into the decision making process, and, as a result, the already short-handed Navy hospitals are in worse shape than ever.

Could the situation have been avoided, given the dire straits of medical staffing? Isn't there some way to red flag personnel decisions that have necessarily adverse impacts on military medical assistance?

Let me cite once again Norfolk just because that is the one that I cited earlier on. What type of personnel are coming into those slots-machinist mates? boiler tenders? masters in arms? mess personnel? Are some yeomen coming in, and are those yeomen going

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to be attached to the hospital to pick up a little bit of the slack of those civilians that are no longer there, or how are we going to bridge this gap with the personnel?

Dr. MAYER. I can only answer that partly, and Admiral Zimble can answer

Mrs. BYRON. Well, I think it might be presented to him also, but you have the overall responsibility as DOD's health care official. I once got into an argument with a commandant when he told me that the young men in Lebanon were not his responsibility, and my feeling is that the commandant's men are his responsibility wherever they may be, and that is one of the strengths that we have seen in the Marine Corps. So in the health care area, your men are your responsibility, whatever hat or uniform they happen to be wearing

Dr. MAYER. I couldn't agree more, and I wish that attitude were more widespread.

The fact is that we are walking a very careful line. We are part of the team, and we try to be team players. We do, in my best judgment, have some special needs, some of which have gotten out of hand, like personnel problems in the Navy, that need to be attended to.

Now, in all fairness, the people who fly airplanes and the people who drive submarines and the people who run cavalry divisions all have special cases to make also. I can only plead a special case up to a certain point and then it is going to be counter-productive. I have been pleading a special case since I got to the Pentagon about the appalling state of our medical readiness when we first came. That has largely moved toward correction. I think it is better than half way toward being corrected.

We haven't neglected the peacetime health care system in the meantime, but it is a much harder thing for me to make a case that says we have got to be fenced, we have got to protect the personnel in hospitals, because I've got all the doctors that we are authorized to have, practically speaking, but it doesn't do me any good if 30 percent or 40 percent of that doctor's time is spent doing clerk-typist's work, typing up his own charts, running for his own reports. We need those ancillary people, and it has been very slow, the development of an awareness that it is lack of support staff that cripples us often. I can have the best surgeon in the world do an operation, but if there aren't sufficient nurses and corpsmen to man the

Mrs. BYRON. Dr. Mayer, I understand all of that. I'm the one that snoops around those hospitals, and I have people in the lab come say, “Mrs. Byron, can you give me just a minute of your time? We've got three new doctors in this facility, and they're cutting back five lab technicians, and we only have eight.” Those are the kinds of questions that I'm getting. I get an X-ray technician that comes to me and says, “We've got two X-ray machines. One of them hasn't worked for 6 months, and the other one is now broken." Those are the issues that I get with people coming out in the hallways to me when I wander around, because, as you know, I wander, and they tell me, “I'm so sorry, Mrs. Byron. On this base, we would love to show you the hospital, but it's late, and I know

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but a hospital never closes. Don't wake anybody up. I'll just go look around and talk to the people that are up." I'm sorry, but that's the way I am.

But I know what the problems are. We are just trying to sit here and fix the problems.

Dr. MAYER. What I am trying to say is that Admiral Zimble, General Chesney, and General Becker, and I are continuously attempting, within the limits of what we think is possible, to make the special case with the people we work for, the people we support.

Mrs. BYRON. Do those people understand that it costs twice as much in many cases to put it out on CHAMPUS as it does to do in house?

Dr. MAYER. They have certainly come to recognize that.
Mrs. BYRON. If not, we will readdress that once again.

Dr. MAYER. No. They have recognized that very, very clearly in the last couple of years as CHAMPUS has increased in cost so much.

The Congress has, in the past, dictated to the armed forces, one or another, that a certain percentage of their people or a certain percentage of their new accessions should be medical people or medical support people. You have got to leave the distribution pretty much up to the people running the system, the medical part of the system.

I am not asking you to do that. It would be improper for me to do so. But if it continues that our capability for caring for our patients continues to be eroded, whether it is by reductions in the officer strength, which is going to have a devastating effect if permitted to go on medically, or whether it is the attempt to substitute boilermakers-and I don't know that this happens, but the attempt to substitute boilermakers for yeomen, which wouldn't make any sense-if that continues, and if our ability to perform continues, therefore, to be eroded, then I think the only source of help is going to be enlightened Members of this body.

Mrs. BYRON. Mr. Pickett.
Mr. PICKETT. Thank you, Madam Chairman.

Dr. Mayer, you are the chief policy officer in the Department of Defense on health issues. Is that correct?

Dr. MAYER. That is correct.

Mr. PICKETT. It seems to me that the Department needs to make it clear to dependents and retirees and their dependents that either they are going to provide the medical services that these people think they are entitled to or that they are not. I think a clear statement one way or the other would help clear the air tremendously. It seems to be a place of limbo now as to whether or not these people are going to be eligible to get these services.

The second thing that I want you to focus on, if you would, is that in every hearing that I have been to, the military medical people have said that their requirements for services to all those people, whether it is retirees or active duty, can be met cheaper at Iess cost to the taxpayer if it is done with uniformed personnel. If that is true, why don't we have a policy of having the medical services provided by uniformed personnel like they have been in the past?

Could you answer those two things for me?
Dr. MAYER. Certainly, sir. Thank you.

The first question as to policy: There has never been a policy in the armed forces of the United States that we would not take care of, either directly or support as the law requires us to do, a certain percentage of the cost of obtaining care for any eligible person, a current member, a retired member, the families of those people, the families of deceased members.

The DOD policy is absolute, and it is dictated not only by the moral consciousness of the service leadership, but it is also dictated by law. There has never been any question that people who can't get into the hospital are still entitled by law, in an absolute entitlement, to have their services provided with the military department shouldering a substantial and legally prescribed portion of the cost.

The problem has been that a great many people have been used to getting their care in military hospitals, especially the retired population. The retired population has grown, and the ability of the hospitals to deliver all the care that was being asked for has diminished, partly because the demand has gone way up, people who are used to coming to hospital x go there and find out, “We can't take you; we don't have time in our clinic schedule," or, "We don't have a bed in this hospital, therefore you are going to have to seek care outside.” That patient is still entitled to have the Government pay for part of it. But the CHAMPUS system which does that has become an anachronism; it hasn't kept up with the modern practice of medicine; it is a financing system, but it is not adequate for today's financing needs.

So people who believe that by years of service they have earned the right to full-time, life-long medical care, in many cases, feeland it is understandable that they feel-that somehow the Government has backed off from that commitment. They haven't at all. The policy is what the law says: We will take care of every person in uniform, no matter what that person needs. We will, as a second priority, take care of his family, or her family, as long as we have a bed and the doctors to do it; and, when we don't, we will pay 80 percent of the usual and customary fee, with the patient picking up the rest. That is a policy that is established in the statute by the Congress, not by use.

It applies to the retired person the same. If we can possibly treat him in our hospital, we will; and it is to our advantage to treat him in our hospital, because it keeps our doctors occupied, interested, and skillful. If we can't take him, we can't take him, but if he lives within 40 miles of one of our hospitals, he must come first to our hospital, if he needs in-patient care, to see if we can take him, and if we can't, we give him a certificate.

We are going a step further now. We are giving him a certificate that he can take and go find his own medical care. We don't think that is quite fair. So we are now establishing a system in each branch of the armed forces that, if we have to turn a patient down for admission, we find the care for him. He doesn't have to take it, but we find out who in the community, what hospital can accept him; we directly refer him; we give him options.

So there is no difference in that policy since the law was first ment of active duty, their families, retired members, their families, families of deceased.

Now you had a second question.

Mr. PICKETT. The second question, Doctor, related to the factpardon me, Madam Chairman, if I repeat questions.

Mrs. BYRON. Go ahead.

Mr. PICKETT. Every medical officer that I have heard testify before this subcommittee concerning the provision of medical services says that, in their opinion as medical practitioners, not what the official military policy is, but in their opinion as medical practitioners, that the services can be provided at less cost to the United States Government with uniformed personnel than by going through the CHAMPUS or some other program, and if that is true, why isn't the Department interested in doing it the least expensive way?

Dr. MAYER. First, let me tell you that generally that is true. It is not true in all instances. The reason the Department of Defense hasn't said, "OK, it's a little cheaper to do it in the hospital; sometimes it is much cheaper to do it in one of our hospitals than let the patient go out on CHAMPUS”—the reason they haven't done that is because there is an absolute ceiling on the personnel, again, imposed by the Congress, as to how many people we can have in uniform.

So the medical departments, for all their protestations that maybe we can do it more cheaply if we do it in-house, will never get a big enough piece of the total military strength unless they are exempted. They would have to be exempted from congressional limits on the size of the armed forces. Then we could staff our hospitals up to the point where we could take care of much more of the case load than we do now.

I would like to repeat, we do 66 percent of all the care we give in our hospitals for retired and dependent people now, and 60 percent of all the out-patient care that we do is for retired and dependent people. So we are still doing the great bulk of that care. We could pick up much of the remaining 30 to 33 percent if we had more staff. We can't pick up all of it, because some of it is going to be accidents that occur far from anything, in the boondocks and places, but we could take care of more of it.

But if we had all the staff necessary to do that, we would have to expand the capital structure of the military health care system. I mean we would have to build some new hospitals. That is not a feasible proposal at this point because of the enormous cost of building hospitals.

So we could do better if we had more people, but we need significantly more people now just to do what we are doing now and to do it properly. So it has been the ceilings and the budgetary limitations which are imposed on medicine, as they are imposed on ordnance and flying hours and all the other concerns, that have kept us from moving farther toward taking care of the whole problem with uniformed people. We would like to do more.

Mrs. Byron. Mr. Ray, do you have any questions?
Mr. Ray. Just one.

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