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during which funds can be obligated. It would allow transfers between fiscal years.

The primary concern with both approaches is that they would allow the outlay ceilings to be breached, which we cannot allow to happen.

But I want you to know that we are going to do everything we can to be sure that this $4 billion in transfer authority is given to the Secretary with the idea that he puts an emphasis on the medical services.

Thank you, Madam Chairman.

Mrs. BYRON. Let me now touch on some of the issues that had come up at some of our field hearings. I will get down now to specifics. We have talked about all of the overalls.

At Okinawa and Clark, we heard many complaints about the shortfall in physician staffing. I think that was a surprising experience to us, because we were under the impression from previous hearings that our overseas locations got priority medical staffing, followed by isolated or remote areas of the United States. We have also found by field hearings that that isn't true either.

We heard many of the complaints about staffing at the naval hospital in Okinawa. The Navy wasn't the only problem, Admiral, that we encountered on our travels. The Air Force only has one ophthalmologist in the Pacific-one for the entire area.

If these locations are getting staffing priorities—and it certainly wasn't apparent to us or the beneficiaries-how do you ensure that the active duty families stationed abroad have access to adequate medical care?

Admiral ZIMBLE. First let me say that we are staffing our overseas—and I just came back from 3 weeks in the Pacific region-we are staffing our overseas better than we have ever staffed it.

Mrs. BYRON. Then it must have really been horrible.
Admiral ZIMBLE. That is exactly right; it was.

We are staffing it now at the expense of some of our hospitals in the continental United States, to the point where we are eroding that seed corn, that vital element, the graduate medical education program. As I think I have told you before, we have reduced the surgical billets at Portsmouth from four to two; we have had to reduce urology from two to one; the anesthesia program is on probation-all at Portsmouth, all because we can't give them the case mix they need to meet the residency review committee.

But I digress. Let me go back to Okinawa. When I was there and talked with the staff--and not only did I talk with the staff but I talked with the commanding general of the Third MAF, General Norm Smith, and several of the other CG's. They all told me that they felt that Okinawa was giving far better support than they had seen in the past and they were satisfied.

The problem is that not only do we take care of those dependents that are sponsored, that accompany their husbands, but we take care of unsponsored dependents who decide on their own to show up. To me, it is a great concern because we are not staffed to take care of them, we will never turn them away from our doors when they need medical care, and I have great concerns about their wellbeing. I have discussed this with both the CNO and with the commandant of the Marine Corps, and we are looking at ways of addressing this problem. But the problem does become more acute with the nonsponsored dependent. Furthermore, we don't do an overseas screening for the nonsponsored dependent.

Mrs. BYRON. One of the things—and I wasn't going to really address this to you because I have got a lot of other questions to address to you, but in the Far East field hearings we heard a great deal of concern about the impact of the noncommand-sponsored dependents, and the other category that we heard time and time again mentioned was the extended family which has access to the facilities, particularly the medical facilities overseas. I think the magnitude of the extended family issue is one that I find very difficult to address.

Would you kind of briefly give us an outline on the eligibility of both of those groups for medical care? They count on determining the size of the facility and the staffing requirements when we are looking at those.

Admiral ZIMBLE. First of all, they are hard to count. It is hard to know how many we are talking about, and they are eligible by law; they have statutory eligibility for care.

Mrs. BYRON. The extended family, how far down-General Chesney, feel free to get into this dialog also-how far down does the extended family extend?

General CHESNEY. It is really a personnel question.

Mrs. BYRON. Well, I asked it of the personnel people last week, and it really impacts on your medical facilities.

General CHESNEY. If I remember, it is a mother or father or a child less than 21 years of age that lives with or gets a large majority of their welfare, their income, from that person--a dependent mother or father, for instance.

Mrs. BYRON. We are dealing with a lot of mothers-in-law, fathersin-laws, et cetera.

General CHESNEY. That is true. A dependent parent-in-law is eligible for care

Mrs. BYRON. Is that true in the States?
General CHESNEY. Yes—and can come in and get an ID card.

Admiral ZIMBLE. They are not eligible for CHAMPUS care, but they are eligible for care in our facilities. Overseas, in the Pacific Region especially, we are the only game in town, so that's where they come.

Mrs. BYRON. I know; I know.
Mr. Ravenel.
Mr. RAVENEL. Thank you, Madam Chairman,

I would just make the observation now that those folks, if they are not eligible for CHAMPUS care but they are eligible for care in the facilities, they are preferred beneficiaries. Wouldn't you say so?

Admiral ZIMBLE. That is certainly one way of looking at it. Overseas in the Pacific Region, CHAMPUS is very seldom the issue. In Japan there are good state-of-the-art facilities, but the differences in the culture and the differences in the language almost proscribe a great deal of CHAMPUS utilization,

In Okinawa, we really are the only game in town. In Guam, there is one civilian hospital with most of the patients preferring to the Philippines, it is Clark or Subic, and Subic, sir, is Naples in a quonset hut-not very much.

Mr. RAVENEL. Admiral, your demonstration project down there, where you are going to conduct a survey and you are going to sign everybody up-either they sign up for care in your facilities or by CHAMPÚS—that would not irrevocably commit them to-

Admiral ZIMBLE. No.

Mr. RAVENEL. They could transfer; is that right? What you are trying to do is really trying to find out how many people want to use the facilities so that when you go to the contracting out you will be able to contract for what you need. Is that it?

Admiral ZIMBLE. I have not seen the full proposal yet. There are several items in that proposal that are absolutely critical. The first one is that Naval Hospital, Charleston, has the right of first refusal on the care of a patient. No matter what way we enroll them, first of all, we think we can provide good care to the limit that we have it available. We need to have that patient population as much as they need us.

We are trying to provide for graduate medical education in Charleston. We have a fine family practice program, and in order to maintain that program we need a cross-section of patients from pediatrics through geriatrics. We want to make sure that we keep our facility as well occupied as possible either with our own providers, with contract physicians and CHAMPUS providers that come into our facility, as we described, and then when we get to that element we will have a health care finder, someone who can, on a case management basis, help these patients find the appropriate care, effective quality care, at the most reasonable and efficient cost. We can be far more supportive of our beneficiaries in that way. That is what we are looking for.

Mr. RAVENEL. Madam Chairman, I would just like to say for the record that it is not the quality of Navy care in my particular area that has ever been at fault, because we get many, many letters and calls, going around and seeing people just commenting on the quality of the care, which is excellent. The problem has always been the availability of care.

Thank you, Madam Chairman.

Mrs. BYRON. Let me follow up on what my colleague has said. The nonavailability statement update that we had, as you know, in one hearing last year at Camp LeJeune, and it now appears that the situation there is worse, not better, than when we were there 8 months ago, in July. Looking at the nonavailability statement data, 942 nonavailability statements were issued for the first quarter of 1988 compared with 650, 749, 616, and 678, respectively, for the four quarters of 1987. It is a 26 percent increase above the worst quarter's performance last year.

What is happening? What has happened to the additional medical staff that we were told were going to be assigned to LeJeune because of its remote nature? We looked at the numbers at Pendleton, the numbers of population, the problems in those two areas, and the numbers of physicians. I think you were in the office when Secretary Webb and I talked at great length about the matrix of where the Navy physicians and health care people were, looking at trying to address remote areas more than at Pendleton which has an availability.

It is my understanding that LeJeune has lost medical personnel, both functional augment Code U personnel attached to the Navy hospital and the assets of the fleet marine division because of deployments. Have they gotten better or worse since last summer? What has happened?

Admiral ZIMBLE. Well, they are actually getting worse.

Mrs. BYRON. We come by and check on it, come back and tell you that you've got a critical problem, we get the Secretary involved in trying to address it, and then it gets worse.

Admiral ZIMBLE. Yes.
Mrs. BYRON. Maybe it's better we don't look.
Admiral ZIMBLE. Absolutely not. I think it is a question of taking

a your time to get these things corrected. What happens in our bureaucracy is that the decisions that are made 2 and 3 years ago get cued up to go into the computers and we have things that happen far beyond decision points. We did see some minor fluctuations in physicians and some significant fluctuations in the nurse corps. We are addressing that. I assure you we will, in fact, get those billets. The last few that eroded away are going to be replaced, and it is a personal concern of mine to ensure, because the CHAMPUS alternative in Onslow County is chock-a-block.

Mrs. BYRON. It isn't there.

Admiral ZIMBLE. The contracting which we hope to provide there and have some funds for probably is going to have difficulty because, again, there are not that many civilians to take on the contracting, but we are going to try.

The CRI that we hoped we could have that might have assisted in that area didn't come to fruition. We haven't set the CRI initiatives for California and Hawaii. Therefore, I am left with very few alternatives except to try to recruit and retain more medical department personnel in Camp LeJeune, and that is an effort we are doing.

In addition, we have contracted for NAVCARE, and that seems to be effective. It is going through some growing pains, but it does seem to be effective.

I will tell you that the Assistant Secretary of the Navy for Manpower and Reserve Affairs, in very good faith, told Mr. Lancaster that he was going to designate LeJeune a remote area, and did so.

Mrs. BYRON. So remote it gets nothing.

Admiral ZIMBLE. Well, the problem results from the fact that "remote area” does not exist in the lexicon of the terminology at Military Personnel Command, and they didn't see that as meaning anything more than the routine, fair share staffing. Priority staffing refers only to enlisted, and that was not the term that was applied.

I have recently directed that we transmit to NMPC a commitment to meet the intent of Mr. Untermeyer's letter in that we will consider it remote but we will give it the very highest priority in both officer and enlisted staffing possible, given our inventories, funding program, et cetera. But it is a vital concern to me. Having very warm place in my heart for Marines and I want to make sure they get the care that they deserve.

Mrs. BYRON. I don't think I have met a more compassionate, more dedicated hospital commander than Captain Margulies in his position there, and I find him a superb naval medical officer operating with an enormous difficulty in that.

Admiral ZIMBLE. All of my commanding officers have that situation.

Mrs. BYRON. Some are better than others.

Mr. RAVENEL. Because I am an old Marine and was at that hearing, just permit me one suggestion to the admiral.

I'm not aware of their names, I am aware of Duke University, but you all just might consider chatting with them as you have been in negotiations with our medical university about the problem down at LeJeune and perhaps address in your short intermediary term staffing problems.

Admiral ZIMBLE. Eastern Carolina University is one that is closest to LeJeune and does give us some support. But we are looking to every alternative that we can find.

By the way, it is very difficult to make comparisons between hospitals. We have a hospital at Camp Pendleton. It serves approximately the same population, yes, but the difference between those two is, Camp Pendleton is a family practice hospital; and the demography there and the relationship with civilian institutions for graduate medical education makes that a more suitable site for the training

Mrs. BYRON. I understand that, but many of the population there have an option of CHAMPUS where at LeJeune you do not have the community hospital or the basic physicians that are available to meet the needs.

Admiral ZIMBLE. I understand that, but I have a GME obligation I can't jeopardize as well.

Mrs. BYRON. Let me ask each of you, do we have any hospitals on the drawing board? General Chesney, do you have any Air Force hospitals currently on the drawing board?

General CHESNEY. Starting from scratch, you mean?
Mrs. BYRON. Starting from scratch and rehabs.
General CHESNEY. No, we have no new ones.
Mrs. BYRON. Or increasing bed capacity.

General CHESNEY. We have many hospitals in the Out-year Medical Construction Program that is being run by DOD, Defense Medical Facilities Office, that are to be upgraded, but in general we do not increase the size of those during

Mrs. Byron. They are not increasing the bed size?

General CHESNEY. Not increasing bed size, and primarily because our number of patients continues to go down, and that is in keeping with what is happening in civilian hospitals across the United States. Out-patient clinics, we should grow; in-patient is not increasing

Mrs. BYRON. Out-patient clinics, we should grow; and are we going to be able to staff those?

General CHESNEY. We gradually will, yes. We are working at that; we will try, yes.

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