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TESTIMONY OF MS GWENDOLYN BROWN DEPUTY ASSISTANT SECRETARY OF DEFENSE (HEALTH BUDGETS AND FINANCIAL POLICY) BEFORE THE SUBCOMMITTEE ON HEALTH COMMITTEE ON VETERANS' AFFAIRS U. S. HOUSE OF REPRESENTATIVES MAY 17, 2000
GWENDOLYN A. BROWN Deputy Assistant Secretary of Defense (Health Budgets and Financial Policy) Office of the Assistant Secretary of Defense for Health Affairs Ms. Gwendolyn Brown was appointed by President Clinton to serve as the Deputy Assistant Secretary of Defense for Health Budgets and Financial Policy in February 1995. She is the principal DoD official responsible for overseeing the Defense Health Program, which includes the $15 billion budget for the Military Departments and Defense components. She coordinates the Office of Health Affairs’ development, review, and issuance of Defense Guidance and the five year Program Objective Memorandum. Ms. Brown is responsible for submitting a balanced and comprehensive Department Health Budget and for congressional coordination of the submission. She works closely with the Military Services and components to promote cost-effective medical resource management policies and quality health care for over 8.2 million beneficiaries of the Military Health System (MHS). Ms Brown represents the Department with other Federal agencies to develop health financing policy, financial programs, and health system performance measures. She is the Department’s senior Health Program resource manager. Prior to her appointment, Ms. Brown was the chief of staff and legislative director to Congressman Julian C. Dixon, a senior member of the House of Representatives from California. Ms. Brown directed the Congressman's legislative agenda, managed his leadership activities, and was responsible for defense appropriations and foreign policy matters. Before joining Congressman Dixon's staff, Ms. Brown served as an international trade specialist at the U.S. Department of Commerce. She advised administration officials and company executives on the economic conditions and investment opportunities in the Middle East region and nontraditional markets. She has led several business trade missions to North Africa, and coordinated the first U.S.-Moroccan Joint Commission meeting in Rabat, Morocco. Ms. Brown has held faculty positions at the California State Polytechnic University at Pomona and at the University of Massachusetts. Ms. Brown has received numerous professional and civic awards. She was awarded the bronze medal--at that time, the highest medal of distinction awarded by the Department of Commerce for superior federal service. Ms. Brown received her Bachelor of Arts Degree from the University of California at Santa Barbara, a Masters Degree from the University of California at Los Angeles, and completed advanced graduate studies at the Fletcher School of Law and Diplomacy at Tufts University in Massachusetts. Ms. Brown, a native of Los Angeles, California, is married to Cameron Byrd. They have one daughter and reside in Maryland. Mr. Chairman, it is an honor for me to be here today representing Dr. Sue Bailey, Assistant Secretary of Defense for Health Affairs. I am pleased to have this opportunity to share with you and the members of the Subcommittee the Department of Defense’s (DoD) view on the promise, practice and future prospects for healthcare sharing with the Department of Veterans Affairs (DVA). Mr. Chairman, it is important for you to know that DoD values highly its sharing partnership with the VA. The men and women on active duty today will one day be veterans and become beneficiaries of the Veterans health system. Working in partnership, our two systems are better able to provide the healthcare our beneficiaries need. Although our two Departments have substantively different missions, we have come to rely upon an agenda for sharing that works -- an agenda based on the principle of mutual benefit. By focusing on joint efforts that benefit both Departments, we are discovering and creating unprecedented ways to capitalize on our respective strengths and expertise. As a result, our accomplishments are multiplying and our potential is exceeding expectations. Today, our commitment to pursue jointly this common goal involves leadership in its broadest sense. In an effort to revitalize sharing efforts by fostering an environment that supports collaboration and change, together we formed the DoD/VA Executive Council. The Council consists of the Departments’ respective chief health officers and their key deputies and the Surgeons General of the Military Departments and focuses on the areas of health care delivery, research, planning, information, policy, and performance. The Council, which was formalized in February 1998, oversees and facilitates a robust agenda of joint initiatives aimed at finding ways to improve beneficiary health in the system within available resources. Since the outset of the sharing program, established under the 1982 legislation, the vigorous partnering between VA and DoD facilities resulted in the growth of sharing from a few agreements in the early years to over 800 today. The number of sharing agreements continued to grow, even during the rightsizing of the Military Health System as part of the Base Closure and Realignment process. In its latest report on VA/DoD resource sharing, the General Accounting Office (GAO) emphasized the fact that our two healthcare systems are undergoing significant changes. That is absolutely correct, and as our respective healthcare systems continue to shape themselves for the future, we have agreed that our partnering is best strengthened through joint efforts that are of mutual benefit, or, at the risk of sounding trite, are win-win relationships. As our military forces and medical facilities downsize, opportunities for sharing emerge. One opportunity is in the cost-effective joint use of facilities. For example, VA Medical Centers are now occupying clinic space provided by nine military facilities as a part of VA's community based clinics program. The VA Medical Center at Murfreesboro, Tennessee and the Air Force’s Arnold Engineering and Development Center share space and medical services at VA’s outpatient clinic at the Air Force’s Tullahoma Base, about 50 miles southeast of Murfreesboro. At that clinic, five full-time VA clinicians provide primary care to about 2,000 area veterans and the base’s active duty beneficiaries. The success of the arrangement has brought more beneficiaries to the clinic, and the VA is considering expanding space at the clinic. Today, the Defense Department relies more frequently on our Reserve Component personnel to meet the National Security missions of our country. This reliance means activating Reservists who require physical exams, dental screenings and immunizations. Many of our Reserve Component units enter sharing agreements with VA facilities in order to meet these health requirements for their unit personnel. For example, The 81st Army Reserve Regional Support Command negotiated a regional agreement with four Veterans Integrated Service Network (VISNs) (VISNs 7,8,9 and 16) having medical centers located in seven southern states and Puerto Rico for VA to provide physical examinations, dental screenings, and immunizations to reservists. VA provides professional resources, clinical facilities, and supplies necessary for these services. Plans are being considered to expand these regional agreements to other parts of the country. In DoD's eyes, the value of this relationship remains high and the VA network of medical facilities continues to constitute an important component of the military healthcare system. Sharing with the VA is as important now as it has been at anytime since the 1982 enactment of the sharing legislation. The time and energy devoted by the two departmental staffs in the development and implementation of both traditional and innovative sharing programs represent clear testimony to the strength of the relationship. In that regard, in response to the GAO recommendation that DoD reassess its policy restricting sharing of direct medical care, we responded that DoD does not have a policy restricting VA/DoD sharing. In reevaluating the policy, DoD found that the policy has been misinterpreted in several instances. We now have a clearly stated policy on sharing, both with the DoD medical facilities and in the TRICARE networks. Our policy reaffirms and clarifies that all VA-DoD sharing agreements for the Supplemental Health Care Program (care provided to active duty and reserve personnel) are authorized and prompt payment will be made by the Military Treatment Facility (MTF) at rates negotiated in the agreements. The policy also reiterates the primacy of the National VA-DoD agreements for Spinal Cord Injury, Traumatic Brain Injury and Blind Rehabilitation for catastrophic care of active duty and reserve members. The pre-eminence of the VA in these specialties is unquestioned, and the DoD will provide a more systematic approach to inform MTFs, Lead Agents, and Managed Care Support Contractors of procedures to refer to VA facilities these serious traumatic injury cases. The DoD will ensure that our military members obtain the best quality care for Spinal Cord Injury, Traumatic Brain Injury, and Blind Rehabilitation and reimburse the VA’s centers of excellence at the full rates negotiated in these national agreements. We do note, furthermore, that sharing between DoD and VA may be subject in some respects to the medical privacy rules now being promulgated under the Health Insurance Portability and Accountability Act of 1996. The Department of Health and Human Services issued proposed regulations last October. HHS has stated that it expects to issue final regulations this year for the handling of personal health information, including information held by federal agencies. Both DoD and VA are participating with HHS in the inter-agency process to develop the final regulations. In the late 1980’s, escalating costs of health resources led the Department of Defense to initiate managed beneficiary care and aggressive cost controls in order to ensure that our patients continued to have access to high quality care. As a result, in 1993, the first regional contract for the new DoD managed care program, TRICARE, was awarded. A combination of military medical facilities and Managed Care Support contracted network providers, TRICARE now enables us to respond to the needs of our patients with no degradation in the quality of health care. To ensure that DoD beneficiaries continued to have access to a wide range of options, and that VA would continue as a key partner in our system of the future, we jointly developed a memorandum of understanding in 1995. That memorandum allows VA Medical Centers to negotiate with the TRICARE Managed Care Support Contractors to become contractor network providers. Since the implementation of that agreement, 138 VA medical centers, or roughly 80%, have negotiated agreements with the TRICARE contractors to provide health services. The enormity and complexity of the TRICARE contracts will occasionally lead to network problems related to provider billing and claims processing. Technically, these are contractual relationships between TRICARE contractors and their network providers. However, we have a strong commitment to our beneficiaries and network providers to facilitate solutions to these problems and to ensure continued quality healthcare. So, as we learn of specific problems, we work with both the contractors and the network providers, such as the VA facilities, to come to a prompt resolution. We have identified that some VA facilities are experiencing problems with claims payment, and are working with VA to gather necessary claims payment data in order to resolve the issue. Once we have the data, our contracting staff will expeditiously resolve the problem. An excellent example of sharing success that will carry into the future is that of joint DoD/VA acquisition of medical supplies. DoD and VA have signed a Memorandum of Agreement (MOA) that combines the strengths and buying power of VA with those of DoD. The expected result is to lower medical materiel costs and to eliminate redundancies in contracting. The goal of the MOA is to combine identical medical supply requirements from both departments and leverage that volume to negotiate better pricing. The organizational goals are to eliminate duplication of contracting effort and allow customers of both departments to select products and pricing that best meet their needs. DoD and VA will continue to contract for their own prime vendor distribution services but over time commodity contracts will be converted to VA contracts. Another major area of VA/DoD sharing continues to be joint venture construction or modification of healthcare facilities. At present, DoD and DVA participate in joint ventures at four sites: Albuquerque, NM; El Paso, TX; Las Vegas, NV; and Anchorage, AK. Planning and associated construction is underway for three additional locations: Fairfield (Travis AFB), CA; Honolulu, HI; and Key West, FL. These ventures involve sharing services, facilities, and staff. Each venture is unique based on the needs of the populations served, and they have proven to be very satisfying to the patients as well as successful in eliminating duplication. An example of this is the opening of the new VA/DOD joint venture replacement hospital at Elmendorf AFB in Anchorage, Alaska in May 1999. This is an Alaska VA Healthcare System and Regional Office and Air Force 3rd Medical Group jointly operated facility at Elmendorf Air Force Base. This 110-bed facility cost approximately $160 million; VA contributed over $11 million toward construction. Currently, VA staffs and manages the 10-bed intensive care unit. VA also provides staff for the emergency room, the integrated internal medicine/cardiopulmonary department, administration, patient services, utilization management, social work, credentialing, and surgical services. In FY 1998, VA patients accounted for a total of 282 bed days of care in the hospital. By comparison, in FY 1999, VA patients accounted for over 1,200 bed days of care. This one instance signifies a joint venture’s ability to help each partner achieve its missions and become stronger, more robust healthcare providers. DoD and DVA have also agreed to share existing automation and technology products and to collaborate on current and future developments. We have joined in medical automation research in the Defense Information Research Center. We have linked DoD's Composite Health Care System (CHCS) and VA's Veterans Health Information Systems and Technology Architecture (VISTA), successfully tested clinical laboratory data exchange, and accelerated evaluation of off-the-shelf software in the automation of patient records. Sharing information about our patients, particularly when our two agencies may treat the same patient is vital to continuity of care. DoD and VA, in conjunction with the Indian Health Service (IHS) continue to work on the Government Computer-based Patient Record. DoD and VA have a Memorandum of Agreement for the use of DoD's medical evacuation system. VA is participating in the development of evacuation information systems that will enable VA to enter patient data directly. When in full operation all of these systems will greatly ease the delivery of patient care. On December 7, 1999, the President directed federal agencies to take a number of actions to improve patient safety. DoD and VA are meeting that direction through collaboration on various efforts, such as the development of clinical practice guidelines. Together we are working on the presidentially directed Quality Interagency Coordination Task Force, or QuIC. The QuIC was established to enable federal agencies with responsibility for healthcare to coordinate their activities to measure and improve the quality of care and to provide beneficiaries with information to assist them in making choices about their care. Mr. Chairman, we have a deep commitment to preserving the health and well being of our military members and our veterans. In that regard, we have many activities underway to improve monitoring of individual health status and the continual medical monitoring and recording of hazards that might affect the health of service members, who will eventually become veterans. Following the tremendous efforts by both DoD and VA health personnel in creating and implementing the Comprehensive Clinical Evaluation Program (CCEP) and the Uniform Case Assessment Protocol (UCAP) for Gulf War veterans, interagency coordinating boards have been established. The Persian Gulf Veterans Coordinating Board, created in January 1994, provided direction and coordination on health issues related to the Gulf War. TheBoard has used three working groups, Clinical, Research, and Disability Compensation, to achieve very successful interagency cooperation and coordination. This coordinating board was the model for the recently established Military and Veterans Health Coordinating Board (MVHCB). Like the Persian Gulf Board, the MVHCB is chaired by the Secretaries of Defense, Veterans Affairs, and Health and Human Services. The purpose of the MVHCB is to ensure a fully coordinated, synergistic and interagency approach to enhance health protection for active duty personnel, veterans and their families relating to future deployments. The MVHCB has three working groups addressing research, deployment health and risk communications. DoD and VA share in research in addition tothat targeted to Gulf War Illnesses. Together, DoD and VA have funded biomedical research addressing post-traumatic stress disorder, infectious diseases, prostate cancer, traumatic brain injury, spinal cord injury, emerging pathogens, wound healing and repair, and research related to specific populations such as women and homeless veterans. Due to the combined size and resources of the VA and DoD health systems, as well as the geographic dispersion of the agencies' facilities, opportunities for sharing resources and saving federal dollars are many and significant. More than ever before, sharing among federal healthcare providers is relevant and necessary to support the cost-effective delivery of quality healthcare for federal beneficiaries. Through the efforts of our Executive Council we will continue to identify and pursue such agreements. In its report on VA/DoD sharing, GAO also recommended that the two Departments assess the current sharing programs to determine the changes needed to achieve our healthcare goals. We concurred with that recommendation. We also stated that the committee structure of the VA/DoD Executive Council permits us to work together to implement the recommendation. Mr. Chairman, we recognize that we must develop creative and innovative approaches to healthcare delivery in order to better serve our beneficiaries in this rapidly changing healthcare environment. Both DoD and VA healthcare systems face enormous challenges presented by this environment. Within the Department of Defense we must strive to meet these challenges with declining resources, growing expectations of our beneficiaries, and most importantly, with increasing requirements of operational missions. Mr. Chairman, the most important health mission of DoD is to preserve and to protect the health of our fighting forces. These men and women march, sail and fly into harm's way each time the Nation asks that they do so. We must be there for them in Bosnia, Saudi Arabia, Kosovo, and Korea. And we must assure them that we will care for their families' health needs while they are gone. Partnering with the VA is a significant collaborative effort that allows us to pursue new sharing models. These models will help both departments to meet our similar and our unique healthcare missions. Back to Witness List |