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Mr. McDADE. Are you confident that there is no shortfall there? Secretary MARSH. I think there is about a 5-percent shortfall in depot maintenance, but the plan is to allocate that 5 percent to older systems.

Mr. McDADE. Are we going to be looking toward out years, are we going to see these budgets at depots trending down?

Secretary MARSH. You see some trending down this year. You see it in the backlog of maintenance and repair. But I believe that the down trend, if you look at the total picture, is not going to be sharp or drastic.

For example, in the backlog of maintenance and repair, if you look at how we are overtaking the backlog, you will see there is a slowing this year in overtaking it compared to the past.

I don't foresee a sharp or significant drop in the depot maintenance funding because that has been an area where we have been trying to close the gap. Where you find this situation this year is in large measure a result of budgetary driven decisions. In the future, of course, it is going to be based on what the Congress does, too, sir. General WICKHAM. I would add to that, Mr. McDade, that the 1986 Gramm-Rudman sequestration led to a $2.9 billion reduction in Army budget authority. Since the President exempted much of the personnel accounts, the other accounts had to take their fair share. And depot maintenance took its fair share.

As the Secretary said, we tried to concentrate growth in backlog, the 5 percent into older items of equipment rather than new.

Mr. McDADE. I take it then that you are both comfortable that the depot maintenance program is funded at a level that is not going to cause any kind of a shortfall?

General WICKHAM. We are comfortable with the circumstances the way they are now. Of course, we would like to have 100 percent funding.

Mr. McDADE. Everybody wants 100 percent, but I am trying to get a handle on the fact that if it is the 5 percent cut that we are talking about

General WICKHAM. We can live with it.

Mr. MCDADE. OK.

Thank you, Mr. Chairman.

Mr. ADDABBO. Mr. Dicks.

MILITARY MEDICINE

Mr. DICKS. Secretary Marsh, General Wickham, I appreciate your presentation this morning.

One issue that I have been concerned about is this very serious shortfall that the Army has identified in ancillary support personnel in our military hospitals, particularly in emergency rooms, intensive care units and physician support.

It has become very clear to me, having the Madigan Army Hospital in my district and having talked to personnel including Surgeon General Becker that we have a very serious shortfall in skilled personnel in our military hospitals. Mr. Secretary, I would like to ask you and General Wickham to comment on that, because it seems to me that this is not an acceptable situation.

We are now seeing an escalation in the malpractice suits that are being brought against the hospitals. There has been a substantial increase in the judgments that the government has to pay. We really need to address this problem from the top down. We need to allocate enough personnel to those hospitals so that we don't have the situation where the hospital commanders tell you right up front that they don't have the personnel to do the job that has been required of them.

I would like to get your general reaction to that.

Secretary MARSH. First I would say that I suspect that General Wickham as well as myself agrees with the point you make.

I think, Mr. Dicks, that you have to look at Army medicine as to where it was and where it is today. The first thing that you would see is that the enormous doctor shortage that existed has pretty well been filled. It has not been filled, however, in the areas of surgical specialties. But it has been filled in the general physician requirements.

Now, in reference to the quality of those people, I think that statistics will show you that of the young physicians who are coming into military medicine today, three fourths of them are in the upper half of their medical classes. Although there is no requirement to do this, the Army is insisting that every Arny physician will have to be licensed. I think we have given them three years to do that.

Other areas where we have some critical shortfalls occur in the National Guard and in the Reserve on whom we place enormous emphasis in mobilization scenarios. In the active force, we have a special requirement for nurses, particularly nurses who have special nursing skills. We have shortages of other technical medical personnel in fields such as physician assistants and X-ray technicians. These are areas that we are seeking to address to try to remedy that in military medicine.

I would say to you that despite the abuses that have been heaped on military medicine, you are going to find in the areas of malpractice awards and standard of care that military medicine is better than the general medical care in the civilian populace. I think you will find that a number of people who look at hospitals will confirm that. I think that we can be proud of the military medicine that we have.

We need to address the areas of shortfall. We are seeking to establish a patient-to-physician relationship for every Army family. We are seeking to make changes in scheduling and in the handling of patients in the dispensaries in order to give them better care and to remove some of the irritants that are associated with medical care.

The other areas that you are talking about are areas many of which will require additional funding. Nevertheless these are high priority items in the Army. We want to address them consistent with the other missions that we have.

I think General Wickham might want to add to what I said. General WICKHAM. The Secretary has given a full answer there. We are moving in the direction of increased manning of all our hospitals. This is one of General Becker's proposals that I have approved. It will take us time to hire the extra doctors and civilians

to man the support facilities in the hospitals, but we are going to do that.

The family medical practice is ongoing and that will be instituted throughout the Army.

IMPACT OF GRAMM-RUDMAN-HOLLINGS ON MEDICAL CARE

I must add that the Gramm-Rudman sequestration of 1986 would have led to a 33-percent reduction of medical support for retirees and their dependents, if the Army had not taken steps to prevent this reduction in care.

Mr. DICKS. How would this have been done?

General WICKHAM. That would be done through reduced support in the medical facilities, longer waiting lines and less prescription drugs that might be available to them.

Mr. DICKS. Were they in a sense singled out or how was the decision made?

I know Secretary Weinberger has suggested that if we don't have enough money to fund our military hospitals and to staff them that one way of dealing with the problem is to reduce the patient load on those facilities. He has suggested-and I am not saying I support this, that you would reduce retirees and dependents using the facilities.

Is that what the Army would do?

General WICKHAM. The Gramm-Rudman sequestration process does not allow flexibility.

When we look at the medical account, we would try to minimize the impact and go from the bottom up in terms of eligibility. The active soldiers and their dependents get first priority. It is the retired community and their dependents that get the last call. That is where we would have had to take this reduction.

Mr. DICKS. How do you feel about that?

General WICKHAM. Badly. I think we have an obligation that we have inherited with the retired community. Once we begin to break faith with these people, I think we get skepticism from people that we want to stay in the military or come in in the first place.

MEDICAL SUPPORT PERSONNEL

Mr. DICKS. Last year this committee added $40 million; you were able to secure $20 million in conference for additional support personnel.

What is in your budget this year in terms of additional funding to deal with the personnel shortage?

Secretary MARSH. The medical enhancement budget figure is $24.8 million.

Mr. DICKS. That is to provide additional people. We gave you $20 million last year. Up $24.8 million over last year's including the $20 million that this committee added?

General WICKHAM. It is my understanding that it does, but let me verify that for the record.

[The information follows:]

Yes sir the $20 million the committee provided for FY 1986 is included in the total medical enhancement budget figure for FY 1987.

Mr. DICKS. We were in a serious situation at Madigan and I want to say on the record that I think that General Powell and General Becker have been exceedingly cooperative. They have been very open with us in the Congress and have not in any way tried to not make us aware of the facts. We appreciate that.

I think they have done a very professional job in handling a very difficult situation. I appreciate the cooperation that we have had. But they were faced with a situation last year where they almost pulled the accreditation of the Madigan facility. It is an old facility, one we are trying to help you rebuild through the military construction account. But this is a problem not only at Madigan. I am told at a number of your other hospitals there is a threat to accreditation because of staffing shortfalls.

It seems to me that the last thing we would want is for the accreditation of those hospitals to be placed in jeopardy. So I am glad to hear what I have heard today about dealing with this problem. I want to make that point because the Joint Commission on the Accreditation of hospitals does go in and looks at these hospitals, and they are saying you have these serious problems.

I know that we are getting better doctors and they are in the higher levels of their class. But that doesn't get down to the nurses and the other people that you have mentioned. Those are the people we have to get. I know it is going to take a period of time. But I wanted to raise this today and to emphasize how important I think this is, because we are out there sitting in a situation where these judgments are now against the government.

MEDICAL MALPRACTICE JUDGMENTS

Can you tell us what judgments were made against the Army last year for medical malpractice? Do you have the figures?

Secretary MARSH. We would have to respond to that for the record.

Mr. DICKS. Judgments are getting higher. As a lawyer, I watch what is going on out there and I am amazed at what juries are awarding, but there is the idea that the government is in the old deep-pocket situation and the awards are pretty substantial.

Secretary MARSH. I would have to furnish that for the record, Mr. Dicks.

[The information follows:]

During fiscal year 1985, the Army paid $12.8 million as a result of suits involving medical malpractice. In addition, the U.S. Army Claims Service paid $25.8 million as settlement of claims alleging improper medical care.

Mr. DICKS. I have a series of other questions that I would like to have placed in the record on Army Medical Programs and on ADEA.

[CLERK'S NOTE.-Questions submitted by Mr. Dicks and the answers thereto follow:]

MEDICAL PROGRAMS

QUESTION. The Committee recommended $40 million added to the budget to provide additional support personnel to address the staff shortages across Army hospitals. The conferees agreed to a final figure of $20 million. $7.7 million of these funds were earmarked

for Madigan Army Medical Center, where there were particular accredidation problems. How is the Army proceeding with allocating and expending these funds?

Secretary MARSH. Because funds were received after the beginning of the fiscal year, Madigan Army Medical Center will not have full year expenses for the additional support staff. Consequently, they have been allocated $5.4 million in FY 1986. They will receive the $7.7 million for FY 1987.

QUESTION. The Committee report requested the Army to provide (1) a quarterly report on the obligation of this funding and the employment levels at each of the medical centers that receive additional staff, (2) by April 8, 1986, a plan for achieving a 90 and 95 percent staffing level at medical facilities at the end of FY 1988, (3) a study of the actual peacetime staffing requirements for Army medical facilities 30 days after the enactment of this act, and (4) by September 30, 1986, the Army's staffing requirements for CONUS medical facilities during wartime. For the record, please advise us of the status of Army efforts to comply with this direction.

Secretary MARSH. The Army will provide a quarterly report on the obligation of funding and employment levels for the quarter ending 31 March 1986, since this will be the first quarter in which funds are available. A recent study of the peacetime staffing requirements, showed that treatment facilities were understaffed. However, in November 1985, the CSA approved initiatives which will increase authorizations or contract manpower in all medical facilities beginning with FY 1987. The initiatives, coupled with The Surgeon General's management actions to realign manpower authorizations to critical patient care functions, will significantly reduce the remaining shortfall. The resource display below indicates all treatment facilities will be brought up to at least a 90 percent staffing level by end of FY 1988 and a 93.9 percent staffing level by end of FY 1992. The Army will be initiating plans to achieve 95 percent staffing level at medical facilities at the end of FY 1988. The Army will also submit its staffing requirement for CONUS medical facilities during wartime by September 30, 1986.

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QUESTION. A major factor in the Committee's action was the fact that Army medical centers were in danger of losing accreditation unless staffing shortfalls in support personnel were addressed. What is the present situation on this issue, both for Madigan and for other Medical Centers?

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