UNCLASSIFIED

STATEMENT BY

MAJOR GENERAL GALE S. POLLOCK
CHIEF, ARMY NURSE CORPS
COMMANDING GENERAL, PACIFIC REGIONAL MEDICAL COMMAND
COMMANDING GENERAL, TRIPLER ARMY MEDICAL CENTER
U.S. ARMY PACIFIC COMMAND SURGEON
TRICARE SENIOR MARKET MANAGER, HAWAII
PROFESSIONAL FILLER SYSTEM (PROFIS)
COMMANDING GENERAL, 18TH MEDICAL COMMAND
DIRECTOR OF HEALTH SERVICES, U.S. ARMY HAWAII (INSTALLATION)

SENATE COMMITTEE ON VETERANS AFFAIRS
UNITED STATES SENATE

109TH CONGRESS

FIELD HEARING ? HAWAII

11 JANUARY 2006

NOT FOR PUBLICATION
          UNTIL RELEASED BY THE
          SENATE COMMITTEE ON VETERANS' AFFAIRS

Statement By
Major General Gale S. Pollock

 Mr. Chairman and distinguished members of the Committee, thank you for the opportunity to share information about the collaborative relationship and initiatives under the auspices of the Department of Defense (DoD) ? Department of Veterans Affairs (VA) Joint Venture in Hawaii.  As Commanding General, Tripler Army Medical Center (TAMC), I represent the largest military medical treatment facility in the entire Pacific Basin.  TAMC's area of responsibility spans more than 52% of the entire Earth's surface and provides medical support to nearly 400,000 beneficiaries, including active duty service members of all branches of service; their eligible families; military retirees and their families; veterans; and many Pacific Island Nation residents.
 In 1991, Undersecretary of the Army and the Deputy Secretary of Veterans Affairs approved the basic concept of a Joint Venture for Hawaii. What was initially conceived as a small veteran's hospital adjunct to the medical center, now is a vast twenty million dollar sharing agreement spanning inpatient and outpatient services and non-medical support, such as security, meals and housekeeping. Beginning in 1997, the VA began to relocate administrative and health care services to the TAMC campus.  Construction and renovation to portions of the medical center infrastructure have resulted in both new and relocated veteran services on the Tripler campus.  By 1997, both the parking structure and the Center for Aging were completed. In 2000, the renovation of the E-Wing of TAMC and the Ambulatory Care Clinic were completed and operational. The relocation resulted in increased workload for both TAMC and the VA Pacific Islands Healthcare System (VAPIHCS).
 A collaborative of this magnitude requires diligent planning and oversight. Both the VA and TAMC have dedicated staff to ensure the exploration and development of collaborative efforts.  On a daily basis, VA patients represent a large part of our workload.  For example, during the last month my hospital census was 131 patients.  Approximately 30% of those patients are veterans.  Additionally, an average three of 12 daily admissions from the emergency room are veterans.  The VA operated psychiatric ward averages nine psychiatric patients a day. 
Over the years, additional clinical staff has been hired to accommodate the growing VA workload, forming a reliance on the inpatient reimbursement from the VA.  While there are Medical Treatment Facilities (MTFs) with excess capacity that can accommodate some workload within their minimum staffing requirements without adding significantly to their costs, that is not the situation at Tripler. 
While reimbursement is essential to a successful DOD/VA partnership, it is not the primary motivation.  For the military, caring for veterans represents a continuation of the services we provided when they were active duty.  In fact, when I talk to audiences regarding the relationship between the active duty and the veteran populations I say the active duty are ?veterans in training?.  Our ultimate status will be as veterans.  Another dimension of caring for the veteran is that the illnesses and surgeries associated with aging are very relevant to keeping active duty medical personnel trained and ready for our battlefield mission.  We need to stay competent caring for acutely ill patients.  At Tripler we have a robust graduate medical education program spanning 10 different medical specialties and training 220 physicians per year.  Our graduate medical education occurs in Orthopedics, Radiology, Urology, Medicine, Obstetrics & Gynecology, Psychiatry, ENT, Pediatrics, Family Practice and General Surgery.  We have found that these programs benefit from caring for the veterans population.
Our current DoD/VA sharing agreements cover a wide variety of patient care services including inpatient care, outpatient specialty services and ancillary support.  We also partner for facility support for housekeeping, security and medical maintenance.  I am particularly proud that the medical center's Nutrition Care Division prepares all the meals and nourishments for the 50-bed VA Center for Aging facility.  We continuously receive positive feedback on our meals from the VA beneficiaries residing there. 
One major initiative is the Cooperative Separation Process/Examination Memorandum of Understanding (MOU) of June 2005, designed to create a coordinated effort between DoD and the VA on Oahu for a single separation physical exam through the VA with specialized services primarily performed through the MTFs.  The separation physical, performed while the service member is on active duty, is not only convenient to the military member, it eliminates duplicative physical exams for service members who leave the military and file disability claims with the VA.  Thus it is cost effective to both the VA and the DoD.
This year, there have been approximately 90 claims filed with 44 physicals completed.  Currently, we are working through some minor disconnects with the VA on the process of returning the physical paperwork to the proper points of contact as well as the process of informing the member of the benefit eligibility and how to receive it.  TAMC, along with the other MTFs on Oahu are working with the VA to refine the process and ensure the physical return of the paperwork allowing the active duty service member to separate from the military in a timely manner. 
Recently several new initiatives have been undertaken under the Joint Incentive Program and the Joint Demonstration Project. Development of several Joint Incentive Fund proposals totaling $4 million have been completed and funded including computer-aided design/computer-aided manufacturing for orthotics and prosthetics, a chronic dialysis center for veterans and a joint pain management improvement project.  All three of these initiatives will improve access to care to our joint beneficiaries and decrease wait times.  The Hawaii Collaborative was also selected as one of eight sites to serve as a demonstration project.  Our Collaborative proposes to meet the need of establishing a structure and process to jointly assess, execute, and evaluate improvements in the following:  Health Care Forecasting and Demand; Referral Management and Fee Authorization; Joint Charge Master Based Billing development; and Knowledge and Document Management.  The collaborative expects to garner benefits from these demonstration studies including improved planning and programming for resource sharing (e.g. facility construction, joint staffing, joint purchase of services in the community, etc); improved budget forecasting; improved monitoring of access, workload, and budget execution for the Collaborative; improved access to documents for information exchange within the Collaborative; improved continuity of patient care; and improved fiscal resource management.
 We have also undertaken a joint approach in planning for pandemic flu response. We continue to explore opportunities and initiatives that allow the Services and VA to share staffing representing effective fiduciary stewards of our government resources.  In the past month, we've signed two new sharing agreements.  The first agreement relocates the Post Traumatic Stress Disorders (PTSD) Residential Rehabilitation Program (PRRP) from Hilo to TAMC.  This facility currently provides residential PTSD services to veterans with chronic PTSD.  However, once relocated to TAMC, the PRRP will be able to treat active duty members too.  The current PRRP program admits patients as a cohort group, and provides a seven-week program of integrated treatment, including but not limited to PTSD symptom management, communication skills, anger management, relaxation training, behavior therapy, trauma focus therapy, adjustment counseling, substance abuse and relapse prevention treatment, and general health education.  The second agreement is in support of a Clinical Investigation study titled ?Women's Deployment Stress and Health: A Pilot Study".  The principal investigators include providers from both TAMC and VAPIHCS.  The primary objective of the study is to explore the relationship between deployment stress and women's health in a population of women returning to Oahu from deployment to Iraq or Afghanistan.  We have also undertaken a joint approach in planning for pandemic flu response.  We continue to explore opportunities and initiatives that allow the Services and VA to share staffing, and remain effective fiduciary stewards of our government resources.
As with most merger type activities, there are barriers that impede unfettered, efficient coordination.  I believe, however, most of our Joint Venture barriers are systemic in nature. 
Despite the barriers we confront, we continue to work together diligently to devise local solutions.  The Pacific Telehealth & Technology Hui is an agency that represents a partnership between TAMC and the VA.  The DoD/VA Interoperability Project is a healthcare systems interchange initiative focused in three distinct areas - Pharmacy Bi-Directional Data Interchange, Common Data View (Janus) and Laboratory Interoperability.  The Pharmacy Bi-Directional Data Interchange allows providers on both the DoD and VA sides to order and receive prescriptions from either information system.  The common data view presents patient data (demographics, lab, pharmacy, etc) to be viewed on a common screen.  Finally, the laboratory interoperability allows lab orders and results to be communicated between both systems.  The common goal of these initiatives is to improve patient care by developing interfaces to allow the electronic sharing of pertinent patient information between the VA, DoD and other clinical data providers.
In terms of DoD VA/ joint venture development, our future is now.  We are ahead of most localities in that we are already one of the most functionally integrated joint ventures.  Instead of two freestanding medical centers, we have only one emergency room; one inpatient medical, surgical, and psychiatric service; and essentially one major specialty outpatient service.  We have integrated clinical services for psychiatric on call support, hospitalist support, nephrology support and psychology services.  However, this functional integration is just the beginning. 
While we are ahead of most of the other joint venture sites in the nation in developing our sharing agreements and establishing policies and procedures, there are still opportunities for continued development of our Joint Venture.  The two key determinants when developing opportunities for improved coordination are expansion of our patient care services to care for more patients and elimination of redundant overhead.  We have worked diligently to develop initiatives for VA Chronic Dialysis, shared pain management resources and expanded orthotic/prosthetic support to veteran patients through the Joint Incentive Fund.  However, additional opportunities for improved coordination and cooperation are numerous. 
There is local VA and DoD top management support to make Tripler a model joint venture site.  In this respect, countless hours have been invested by both activities to improve our joint venture.  In order to perpetuate sharing between VA and DoD entities, national initiatives applicable to all types of sharing should continue to be developed.    Information systems are evaluated for applicability to sharing, and solutions to systemic issues should be identified and resolved expeditiously.  We must address and resolve the barriers to achieve our ultimate goal - high quality care for our respective beneficiaries in a seamless healthcare system.