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Media Roundtable with Michael Dominguez, Bill Carr, and Brig. Gen. Michael Tucker from the Pentagon, Arlington, Va.

Presenters: Principal Deputy Undersecretary of Defense for Personnel and Readiness Michael Dominguez, Deputy Undersecretary of Defense for Military Personnel Bill Carr, and Assistant Surgeon General for Warrior Care and Transition Brig. Gen. Michael S. Tucker
November 30, 2007
            MODERATOR: All right. We're going to get started. I'm sure we'll have a few more people joining us.
            (Cross talk.)
            MR. DOMINGUEZ: I wish I could do that. Well, actually, you know, all three of us.   (Off mike.)
            MODERATOR: Well, thank you for your follow-up interest to the release that we put out yesterday. And today we want to highlight one of many of the things the department's been working on which is the disability evaluation system, this pilot program which many of you have written about. 
            But today to kind of give you an overview and talk about this I think you know most of the individuals here but let me introduce them briefly. 
            We do have Mr. Michael Dominguez who's the principal deputy undersecretary of Defense for personnel and readiness. And then most of you are familiar with Mr. Bill Carr also, the deputy undersecretary of Defense for personnel policy. And you've all gotten to know recently Brigadier General Michael Tucker who's the assistant surgeon general for warrior care and transition. 
            And, again, I think we'll start with Mr. Dominguez kind of giving you a quick overview of what we've been doing over the last several weeks and months and then get into specifically the pilot program which we think has a lot of merits for the future.
            MR. DOMINGUEZ: Great. Thanks, Brian (sp).
            Okay. Last February when it became evident that we had some problems in our continuum of care for the wounded warrior and their families, the president, secretary of Defense, secretary of Veterans Affairs all took immediate action as did the military department secretaries and chiefs by the way. 
            Among the actions that were taken immediately were the commissioning of several studies and groups and commissions to look at this problem and help us understand what the situation was, what happened, why it happened and what we ought to be doing about it. 
            So those reports and commissions and task forces began reporting in in the spring -- early spring with the first one being the Secretary Marsh and Secretary West's independent review groups reported out to Secretary Gates. 
            In that time period in about March, April, Deputy Secretary England and Deputy Secretary Mansfield from the VA -- the two of them realized that our two departments or two Cabinet agencies needed to work closely together on these challenges. And the two of them then established what we call the Senior Oversight Committee. So that committee oversees then the evaluation of the reports and recommendations and actions that are being recommended to us by all of those study groups as well as the stuff we discover ourselves. So they set up the Senior Oversight Committee. They chair -- it involves the senior leadership from the two departments. So the undersecretaries of the VA, it's our military department secretaries and chiefs and several of the undersecretaries. 
            Again, that group's been meeting weekly since about mid-May and there's a lot of work going on in trying to process all the outside group recommendations as well as the things we are discovering ourselves. 
            Underneath, then, the SOC, we set up several different task forces to work on selected pieces of this continuum of care for the wounded warrior. And we're calling them lines of action. These are joint task forces; they involve DOD and VA and they have participation from the military services as well as Office of the Secretary of Defense. 
            What I'm going to do is go down a list of those line of actions and tell you for each one of them what their significant accomplishments were so far and that ends with the one we're here to celebrate today which is this beginning of the disability evaluation system pilot that started this week. And then we can go into more detail on how that pilot operates and how the two Cabinet agencies are involved and then what the benefit is for the service members. 
            So we had eight lines of action. Starting at the top, line of action eight dealt with pay benefits and compensation. And in this area, I have to compliment the Defense Finance and Accounting Service because they did extraordinary work once they understood that as we Medevac people out of the combat theater and they transition from, say, Iraq to Landstuhl and then back here into the National Capital Region, the law governing military pay and benefits is very specific and some entitlements have to stop and start at very precise times. If you don't do that quickly and agilely, what happens is you pay people resources they're not entitled to have by law. 
            DFAS jumped in and they fixed that problem. And so we're now making sure that wounded warriors coming out of the theater have their entitlements adjusted commensurate with their status as they’re going through and they're not creating indebtedness in the family of a wounded warrior. And that's, again, superb work by the Defense Finance and Accounting Service. 
            Line of action seven deals with our legislative initiatives and their triumph was they were deeply involved in shaping the legislative proposal that came out of the recommendations of Senator Dole and Secretary Shalala in their commissions. And they formed then this really transformational legislative proposal that the president introduced to the Congress last month. 
            Line of action six was a group we set up to just think about this process as if nothing else existed. We call them the clean sheet. And what they've been doing is -- so you would expect them to come up with what would be an ideal system unbounded by any constraints and their principle achievement has been to seed ideas into everybody else's work so that it helps provoke people to, you know, reach a little further and think a little bolder. 
            Line of action five dealt with facilities and the significant accomplishments there are really twofold. One is that we have developed and approved standards for where wounded warriors or wounded or injured or ill people in the armed forces, you know, will stay. So we have facility standards that describe the conditions of the facility in which somebody will live and it has to be matched to their particular medical conditions and needs. 
            And the second big initiative from that -- from line of action five is the acceleration of the Walter Reed transition from its current location to the Bethesda campus and the commitment that we will maintain the highest quality of service and operations at Walter Reed until those operations transition from Walter Reed to Bethesda and that while that high-quality service is being maintained, we will also take care of the staff who are doing that so that people won't have to worry about their job, they can stay focused on delivering high-quality service.
            Line of action four had to do with data and the interchange of data between the DOD and the VA. And I hope most of you know that the departments -- the two departments, VA and DOD, have committed in public -- they are committed to the development of the joint inpatient medical record so that -- it's an electronic record we would use in the DOD and the VA would use in their facilities and their hospitals and that we're -- report out from a contractor telling us what the next step on that journey is is due next month. 
            The second thing in the data business, we have done an enormous amount of data exchange so that the two departments can share information that are necessary to both sides for the conduct of our business and the conduct of or delivery of service to the veterans servicemen and women and their families processing out and becoming veterans. And a key part of that was the CIO swap. We sent our health IT CIO over to be the CIO of VA and they sent theirs over to us. And that went for about six months before we I think swapped that back. But we did a CIO swap to stimulate that data interchange and really break down the barriers there. 
            Line of action three really focused on this whole challenge of care and case management. And the crowning jewels there include -- and I said jewels in plural because there's several here. The first is the implementation of the Federal Recovery Coordinator Program. And that's again emanated out of the Dole-Shalala commission recommendations. And this is a federal recovery coordinator so it's not a DOD; it's not a Labor; it's not HHS; it's not VA; it's a federal recovery coordinator who's charged with operating across the seams of that department and of all those departments ensuring that the care is being delivered, that the expectations of families and wounded and being met and that we are being competent and effective in meeting our obligations to these beneficiaries. 
            The next piece, I think, in this area is the development by the military services of the concept of the triad of care where every seriously injured wounded or seriously injured servicemember is surrounded by a primary care physician, a case manager and a squad leader or a, you know, a leader from military line organization. And connected to that is then the development and fielding of these line organizations and the Warriors in Transition units in the Army which is a program that General Tucker here oversees for the Army and then the comparable program in the Marine Corps, the Wounded Warrior Regiments. But there's significant changes on the ground in the care management and case management. 
            Line of action two is where you're focused on the psychological health and the traumatic brain injury challenges. And our focus on there has been on building capacity in our two cabinet agencies, DOD and VA, to deliver this care. We will table a press release today announcing the opening of the center -- the DOD Center of Excellence in Traumatic Brain Injury and Psychological Health. And we are using -- through that center of excellence focusing enormous amount of research into psychological health and traumatic brain injury. And we are getting people -- qualified practitioners to help with focus on prevention and psychological resilience in our force and that includes deploying people down into line units with this mission of helping commanders with having their force deal with combat stress and be ready for the stresses of combat. 
            And that leads us now to line action one was really a focus on the disability evaluation system. And Bill Carr here will talk about the pilot project that started on the 26th of November -- the pilot in reformed and revised disability evaluation system. 
            And what I can tell you about that is that this is about as good as it can get within the current statutory framework of the DOD's role in disability evaluation and the DVAs. That -- and we have -- in this pilot we are -- we've compressed or we plan to compress the cycle time by about half from the point of a medical practitioner recognizing that of an injured service member needs to go through the disability system to start that journey to the point where they'll begin receiving benefits if they're in fact separated. That cycle time should be reduced in half. 
            The key features you'll see is a single formal medical evaluation physical that will be used both by the DOD for our purposes of determining fitness to serve and by the VA for their purpose of determining the level of disability an individual has incurred and, therefore, what benefits they're entitled to. And it features a single rating per condition that an individual has that will be used both by the DOD in determining the degree of disability and whether you're separated or retired and by the VA for determining the level of benefits that you're entitled to. 
            And I believe as a longtime Washington insider that it is a significant event that two Cabinet agencies have found a way to bridge the boundaries in their organizations such that one Cabinet agency, the DOD, agrees to be bound by decisions made by officials in another cabinet agency, the VA, and that the other Cabinet agency, the VA, agrees that those decisions will be the ones they use as well in their internal businesses to accomplish the mission of that cabinet agency and that department. 
            And so that's the kind of overview of what we've been doing. Bill will talk to you about the disability system. But we're up here to talk to you about all of those. And General Tucker in particular can talk to you about things under the purview of the Senior Oversight Committee but that are really the initiatives of the military department's secretaries and chiefs where they're actually out changing the system on the ground and doing the face to face with individual soldiers and injured and their families. 
            And so, Bill, overview of the DES reform.
            MR. CARR: Thank you. I'm Bill Carr. I'm deputy undersecretary for military personnel policy. As Mr. Dominguez mentioned when we started off we had divided into groups and lines of action. And one of them of course was the disability system because it was characterized as unfriendly, redundant and lethargic. And so what were we going to do with that in order to transform it in a meaningful way yet stay within current law? And in a moment I'll present to you what the answer to that is that we started this week. I'm not sure, Jonathan, if we've got the -- oh, that's good. 
            This slide simply says that there were a number of studies that informed us -- you're familiar with them, they're in the public record if you need any of these we can get them to you -- but a number of different studies, whether it was Dole-Shalala, the department's own internal review group -- all tended to say about the same thing -- faster, more compassionate, less adversarial and, by all means, more effective. And so I think we've done those things. 
            And I'll show just one slide that summarizes what we've done to remain within current law and yet move bureaucratic mountains in order to have a system that's friendlier to the members and to their families. And that's portrayed on the slide that you see behind me. 
            Typically -- and I'll just stay with the top part of this because that's really the punchline of the changes we made -- what did we eliminate that allowed us to accelerate and simplify? And to explain that, I'll explain the line at the top. Typically, if I had a serious injury such as a very -- a very injured knee, then I would go the hospital to the emergency room for treatment. And in this case I'll talk about an injury in the United States that can certainly be, and this case is, often someone injured in theater. But let me stay with any kind of military injury because any of those are certainly being operated in this pilot program. 
            But if I had a serious injury to my knee, let's say from a training accident, I went to the hospital and I was treated and I would then be -- a judgment would be made as to whether or not that knee was so badly compromised that I couldn't very likely continue in this career. If that was the case, I'd be referred down the hall to the Medical Evaluation Board. They would look at it, assemble the facts about my knee, and if they were persuaded that it was a career-ender, for example, then they would document that and pass it up to a Physical Evaluation Board. There's one of those in each military department -- three of them in Army, spread around the nation, one in the department of the Navy and the Air Force -- and they would look at it, judge if I was fit or unfit for the military, and then if I was unfit, award a rating. 
            If I was rated at 30 percent or greater, then I was retired because that's what the law says; less than 30 percent, I would be given the severance payment and separated because that's what the law says. But then I'd go across the street to VA and start the process all over again. You see at that line that says separation, I would go across the street to VA, submit a new claim, have another physical exam -- this time by VA but looking at the same stuff -- and then VA would issue its rating which would differ from the rating DOD had done and then I would be receiving VA benefits. And you can see the redundancies that are in there. 
            So essentially what we've done in designing the new process that's starting this week in the National Capital Region and then when we worked out any kinks, we'll continue to expand until we've covered the remainder of the Defense Department is that we have eliminated the things you see the "X" through. 
            Now to explain how they're eliminated, let me go to the bottom of the slide to describe that same bad leg working its way through the system. I had my injury to my leg; physician looked at it -- I'm in the yellow region -- and it looks like a career-ender. I go to the medical board -- that olive sort of area -- and that -- they have decided that sure enough I've got a real problem. 
            Here's where the first difference starts. As soon as I know that I may be headed for a career-ending circumstance, then I fill out a VA claim form -- mind you I'm still on active duty -- and I list not only the problem that I've presented for, my bad knee, but any other thing that was of concern to me -- hypertension, that's not unfitting, oral meds, treated, you'd stay on active duty, but I'd list it because it is a malady that I would like to have evaluated and it could be service connected. 
            I list all of those, I go to a physician and a VA-certified doctor will give me the physical using a template that VA honors. For example, if I have a bad knee, the template will say, "Doctor, check the range of motion in the knee." And so they follow that template, document the things that VA needs and I have therefore a comprehensive physical exam addressing anything that was wrong with me. I then send that back to the Medical Evaluation Board, they'd look at it and send it on just as they had in the past. 
            But importantly when it gets to the Physical Evaluation Board which is the highest level normally within a military department with the power to separate and to award benefits -- when it gets to that level, I've got every -- all these facts, and I then will make a judgment as to whether or not I am fit or unfit. If I'm unfit, then back to VA because we'll send that file to a VA rating panel so that if I do -- if I am unfit, what is the percentage disability associated with that knee? Is it 20 percent or 30 percent? There's a book that tells you that. And so -- (inaudible) -- follow a book, the VA's schedule of rating disabilities. 
            And they -- we look at it, so does VA -- and you look at that book and it says that if the flexion in your knee is only 70 degrees then you're such-and-such percent disabled. And you can name any malady in the human body system and there's a percentage of crosswalk for the medical condition. 
            So they have done that and they send it back. Remember, I was at the Physical Evaluation Board; here came the follow on Carr. I've got a bad knee, looks like a career ender, going to be unfit, is unfit, send it to VA. VA tells me how unfit by percentage. And DOD then finalizes the case informing Carr that he has 30 percent disability for his knee and 10 percent hypertension but only the knee is unfitting. 
            It's interesting that I have hypertension but that doesn't cause me to separate from the military. But I do know about it because when I do separate from the military for that knee -- and again since it was 30 percent, it's a military retirement -- less than that would be a severance pay -- I leave with my military retirement, I walk across the street and there's where those other two X's come in. VA already knows who I am. They gave me the physical. They gave me the rating. And so my benefits will start immediately within days -- within a month but within some number of weeks. 
            But I don't have to wait the requisite six months or so that it took here before and I immediately have my benefits. So that's the fundamental skinny-ing down we've done on this. And it's big because we -- for an agency, a federal agency to accept the work of another agency is not trivial. We have said, "VA, whatever you say, we'll accept -- can't have it any other way. If we're going to take it, we take it. However you do it, we'll do it." But you can't have them do it and second guess -- you'll get nowhere. So VA will make the rating, we'll accept it -- and that's that. And so if they say 30 percent on the knee, then that's 30 percent on the knee.
            Let's say, however, just to close out that little turquoise box, there is due process. If they said, "You know that knee is 20 percent" and I said, "Well, I think it's 30," then I will have a session with a VA disability review officer and VA will look at the rule of their decision and that person has the authority to change it. They might say, "Okay, on second review, it's 30, not 20." And if they do that, that's what the military's going to do before you separate -- you'll go out on 30 (percent) not 20 (percent). So there is a chance to appeal and have due process about the rating. 
            So that really is it in a nutshell in that we have slashed redundancy, simplified, made it visible. But before we ever started this, this past Monday for Walter Reed, Bethesda and Malcolm Grow -- before we ever started that, we had -- we asked services to have soldiers for example go through it. Ideally it would be soldiers who had been through the old system go through this new one and comment on it. And that proof of concept was quite favorable. And this is the progress that we've delivered to the families on the promise we made that we would make improvements. And we did those. 
            And with us as Mr. Dominguez mentioned is Brigadier General Mike Tucker. I mentioned Army did a proof of concept and I'll pass it over at that point and he can pick it up from there on that and whatever else at Walter Reed might be of interest to you.
            BRIG. GEN. TUCKER: Good afternoon. My name's Brigadier General Mike Tucker. I'm the assistant surgeon general for warrior care and transition. We did the proof of concept that Mr. Carr discussed with eight soldiers -- four junior enlisted soldiers and eight senior NCOs and officers. All of these were veterans of the old system so to speak and we put them through the system as been described by you -- described by Mr. Carr. Every one of those soldiers to include their families had positive comments about this system that it was more streamline, it was more efficient. And it helped benefit soldiers and their families much better than the older system did. And simply stated, a single exam, a single rating and before discharge -- that the rating occurs before discharge is one of the key factors. 
            MR. DOMINGUEZ: Okay. With that, so that's a deep dive into the disability system reform that's now being piloted National Capital Region and I remind you that I highlighted a whole range of things that are being done as well as highlighting some of the things I didn't talk about but that is happening on the ground at the initiative military chiefs and secretaries. 
            And we're open to your questions about all of those things. 
            So why don't we start there. Sir?
            Q     One of the things that was documented in congressional hearings was the differences in the way the services handled their own ratings, like sleep apnea, I think the Army was less sympatric to awarding disability -- high disability ratings on sleep apnea that VA might and so forth. And I don't know how the other services, whether that was universal. But what did you have to do to streamline or to make universal the kind of rating system that each service handles?
            MR. CARR: It's to simply say one place will do it. So you eliminate the disparities. In this case we've said, VA and they've chosen St. Petersburg so it's a strong operation of theirs to get a demo to get us off to a good start, super qualified, talented. 
            So henceforth if there is sleep apnea which probably wouldn't be a reason for unfitness or separation but it could certainly be part of your life. If I'm going out for the bad knee and I had sleep apnea, then VA will rate that sleep apnea. One person, one rating process, one outcome, no variability.
            Q     Which is by definition everything will become universal within the way this process is handled among the services.
            MR. CARR: Yes, sir. Correct.
            MR. DOMINGUEZ: Now, as they may have to expand as we expand to more than the St. Petersburg rating panel. But this is what these VA rating panels do for their lives so, you know, the repetition and the experience gets them, you know, down the learning curve training program to standardize the stuff. So we've also beefed that up so -- to deal with that same issue.
            Q     Just a quick follow though, will there be the disparity between the services in what they consider unfitting conditions?
            MR. CARR: There could be and that's their right. So there could be and that the commissions have all said that's kind of their business. So a Marine might be judged on a criterion or on a fact pattern that is slightly different for an airman. Could be -- I wouldn't rule it out.
            MR. DOMINGUEZ: Because unfitting is related to your military skill and your grade. And the question is, can you do that job? And so that is going to differ across the services.
            Yes sir.
            Q     But, sir, is there a possibility or let's actually get into sort of a common way to give a soldier found unfit given the -- I'm sorry, not unfit but initially unfit by the MEB for their job to move to another job across the board in different services?
            MR. CARR: It's part of the process of reaching an unfitness determination is ruling out the possibility of migration to another occupation. And so that is an endemic part of the separation. In other words, that we would not separate for example a soldier or a Marine who were capable and interested in moving to another career field
            Q      As part of the MEB process?
            MR. CARR: As part of the MEB.
            Q     Now, is that formalized across the board in all the services?
            MR. CARR: The services approach it differently today and the MEBs are serviced through one of their service hospitals so you'll find some variability but -- in terms of how they do it. But what they do to consider the possibility of other occupations is -- exists across all of them. But I can't say it's uniform and exact in terms of how they approach it. But the outcomes are comparable and the procedures are similar. 
            Q     Is there essentially a box that has to be checked that says Specialist Jones was given an opportunity to review of a variety of possible alternative --
            MR. CARR: I'm confident we haven't sent a form in a box for that because of the implicit duty accepted by the services that they shall do that. To do otherwise is to waste human capital. 
            MR. DOMINGUEZ: I do -- I would like to say though that the process that we've just been though over the last several months has really brought a lot of that joint flavor and joint focus and awareness to the problem. And we're announcing today an important milestone on our journey. We are not done. And so there are more things to work -- this is one of the areas we need to continue to keep some focus on.
            Q     Okay. 
            You also talked about an acceleration of the Walter Reed transition from the present location to Bethesda.
            MR. DOMINGUEZ: Right.
            Q     Can you give us an update on how much faster that might be taking place?
            MR. DOMINGUEZ: Let's see, the -- we'll have to get some information from Mr. Growney (sp) to you on that. But I think, you know, we were shooting for in the neighborhood of a year earlier to be able to transition functions into the new National Military Medical Center at Bethesda.
            Q     Would that be 2010?
            MR. DOMINGUEZ: Again, we'll follow up on the with the exact information so -- yes, sir?
            Q     Is there any concern with having the VA doing the ratings and having that initial exam that troops will feel like they're being pushed out before, just simply seeing a VA personnel rather than seeing a military personnel think, "Jeez, they're trying to get me out already."
            MR. CARR: They won't necessarily be able to always know, but I do know that they know -- that anyone involved in this is aware that they have a serious problem or they wouldn't be before the Medical Evaluation Board. Therefore, it would not be surprising to them that in the course of having a transaction with a physical it is about how damaged is this body system that we're looking at. And so I don't think they'd mind what agency was looking so long as it's competent and complete. But I don't think they'll necessarily always be aware of whether -- where the physical exam comes from.
            MR. DOMINGUEZ: Yeah, they don't necessarily have to appear physically before the rating panel. That's why the VA rating panel's in St. Petersburg.
            MR. CARR: Right. Now, your question on physical examination
            Q      On the exam seeing the VA personnel in there --
            MR. DOMINGUEZ: But here, again, there's a leadership issue. And we are poised to deal with that because the military service secretaries and chiefs have put these chains of command. So there's a line chain of command so the guy's got a squad leader and he's got a platoon leader and company commander and there's people to talk to. There's a case manager if you need that, right, to talk to. 
            And so if you've got anxiety, if you've got questions, if you're concerned about what's happening to me, what are they trying to do, there's places to go. The first place to go is the chain of command because that's why they're there. And by the quick action from the chiefs and the secretaries, that chain of command's now in place.
            Go here.
            Q     How will this pilot be evaluated because this is a lengthy process and things can snowball and be bad before you catch them?
            MR. CARR: Yeah, there's a --
            Q     And as a follow-up, if you don't mind, when do you thing you'll be able to roll out a universal plan across the board?
            MR. CARR: Two comments -- one as far as the evaluation, there's a protocol that guides this. So we didn't go in and say, "Let's do it this way." It is very precise including the information that has to be collected, how it's collected and categorized. And so we'll know for example if someone declined a procedure, how long it took for that procedure to be scheduled, accomplished, get the feedback, every time node or quality node in that network has documentation and the data collection plan that allows us to judge whether or not the pilot's effective. 
            If it is ineffective in certain areas, we make the tweaks. And as we make the tweaks then that leads to the second question which is, okay, then how should we proliferate? When tweaks are done, we're ready to proliferate. And at that point it says, to where? 
            Well, where can we go to accomplish the training? First, where's the wounded warriors at that we haven't covered like Brooke -- that would have a priority. And how many can we take on in the next go-round and still have them trained and qualified in time. And you kind of work in there. 
            So service, what do you want to do? Bear in mind you want to cover wounded warriors -- I'd expect to see Brooke. Having said that, how do you want to schedule this thing. You know how many people were at those hospitals and so forth and when you to have to train them. And we create a coherent plan. So if we deliver and open it up, we perform it very well each time we do it.
            MR. DOMINGUEZ: But we don't right now have a time schedule for rolling it out, right? I mean our first objective is, let's do this, let's see how it unfolds, and as we learn, then we'll form some of those things. 
            MR. CARR: So the tweaks and the completion of the tweaks will lead to the proliferation.
            Q     And if I understand correctly, those tweaks will be made in real time.
            MR. CARR: Oh, yeah.
            Q     Meaning you're not going to wait until a year to --
            MR. DOMINGUEZ: Well, in fact Bill and I and our VA counterparts and representative from Dr. Casscells, Assistant Secretary of Health Affairs will meet weekly to see what happened this week. All right, what did we learn this week? You know, how many people are in? How long's it taking? So we're going to be kind of watching this in great detail.
            Q     Will the same group do the final evaluation or will that be done by the Senior Oversight Committee?
            MR. DOMINGUEZ: The decisions about, you know, going forward and how extensive and why and why would we make that recommendation -- those will be presented to the Senior Oversight Committee. The actual technical building the evaluation, collecting the data, arraying it and then putting some judgment on what does it mean is Mr. Carr's responsibility.
            Let's go over here again.
            Q     The hearings had also revealed that VA typically is more liberal with its rating system. I wonder, given that I think it's important for DOD, because if you are -- if they would typically get a 40 (percent) or 50 percent rating and you give it less than a 30 percent retirement benefits and TRICARE and so forth that are involved in that, was there any kind of compromise made between VA and DOD and they actually said to themselves, "All right, for this pilot and perhaps for the future we will be less liberal with these following conditions than we have been?
            MR. CARR: No. What would we expect if VA and DOD looked at the same knee? If they looked at the same knee as the Scott Commission pointed out, we did a test and found when we sent VA raters from St. Petersburg and the Physical Evaluation Board and the services together, they had about an eight point difference. In other words, if you were sort of one in the 20 range, then VA would look at it at about 28 -- not fatal, not -- you know, they're pretty close. You only get a difference in rating when you jump 10 percentage points. But again, that was average so there's going to be 20s, there'll be 30s, or, you know -- but it is an eight point on average difference. And the Scott Commission found over a sample of 30,000 that it was exactly that, just luck that we hit it with a sample of less than a dozen, but we had eight points and 30,000 sample was eight points. 
            So that's how close we are looking at the same condition. They are systematically higher. We accept that. Who knows which is right? If you're earnestly applying what we're seeing in that body system against the rating manual and systematically VA's a little bit higher, so be it -- we accept it. We don't question it.
            MR. DOMINGUEZ: But I do want to also point out though these same efforts will be working towards this process that did call out the need for better training, better experience, more experienced raters, and, you know, some careful monitoring of results so we can detect anomalies, you know, before they're disasters. So -- yes, sir?
            Q     This pilot is voluntary, is it not?
            MR. CARR: This is -- if someone really did not want to do it -- really did not want to do it, then they would not be in it. Our interest is in migrating to a single improved better for the soldier system. Almost any outcome here is going to be faster. As I pointed out in my answer to Tom, you could make an inference that it's more generous slightly. So there's not a downside. But there is an upside to them at the government to have one system operating instead of lots of systems. So we would like everyone to get onto this system. If it's going to distress someone, that's another matter. But it's not would you rather do this or that? It's more that this is going to be it. We will explain what it is and what's different but the expectation is that they would voluntarily and eagerly say, okay. If someone fully informed said, hold on, then we'll accommodate them.
            Q     So is this the system now with the three hospitals?
            MR. CARR: We are firing real bullets here -- yeah, for those coming through the system. 
            Q     Is that option actually presented or you just kind of go ahead with --
            MR. CARR: We'll take it in the event and someone said that I want the old system. The old system is there for them.
            MR. DOMINGUEZ: Right. We are not presenting the option of you can go this way or that way. Part of the reason for doing the proof of concept was run real soldiers through it and see what they said. And they all came back and said this is better. So this is -- for the National Capital Region, this is the way the disability system will work. 
            Again, in the case -- because we do have informed chains of command, informed case managers, informed federal recovery coordinators, we've all been trained on this new system for this region. If there's a problem that emerges, we'll adapt to that problem.
            MR. CARR: If -- there would be really unusual for someone armed with information might go, "Gee, I'd rather not." And then we'd talk. I could not imagine that if we explained it, after an explanation that that's not going to evaporate and they're not going to embrace this.
            Q     Just quickly, you said the walk throughs you worked involved eight soldiers, four enlisted and four officers?
            BRIG. GEN. TUCKER: Four senior enlisted and officers. Right.
            Q     Yeah. 
            GEN. TUCKER: The -- you know, the old system puts the services at an adversarial relationship with the soldier because it kept coming out one of the biggest complaints is, "Well, gee whiz, the service only gave me this but the VA gave me a much bigger rating. Why is the service who I served -- I served in the ranks of the Army or the Marines or whoever and they gave me this dismal rating and now the VA's giving me all of this, so why are they doing that?" Because it's law. So this is a good thing.
            Q    If I could follow that up, General. How else do you think it might change your bureaucratic structure? Will you be able to go without fewer medical personnel or will you be able to shift medical personnel to the frontline that used to be burdened with these disability physicals or do you expect to have costs that you didn't expect because there will be more personnel costs related to this use of the VA system?
            BRIG. GEN. TUCKER: I don't see any more personnel cost in this regard, I see enormous efficiency. I think it's too early to say whether or not we're going to need less doctors. We don't have enough as it is. We're in such a deficit for health care providers already. I can only see goodness though. I can only see -- this to me is a clear win-win.
            MR. DOMINGUEZ: Great. And we're going to have to --
            STAFF: One more question.
            Q     I just want to get clarification on the appeal process. You said that you thought it was a 20 and you wanted to go back to this review process. Is that a service appeal or is that an individual appeal? I mean --
            MR. CARR: Individual.
            Q     Okay, so the service cannot come back and say, "Hey, VA, I think this is not right." 
            MR. CARR: No, we have a duty. If we see something that's not right, we'll just automatically go back. I'd be surprised because as I say, we're -- to 30,000, we're within eight points. We tend to see things the same way. But if we saw something egregious, we have a duty no matter what, no matter whether the soldier says or not to go and say, "Now, wait a minute. We've got to understand this." And so we would do all of that. But typically the soldier would be the one who would report dissatisfaction and wouldn't know of it until the service had told them. And apparently they've accepted it.
            MR. DOMINGUEZ: Yeah, we were talking there about in terms of if -- we the official DOD got engaged in that dialogue that would be because there's some way out of tolerance. But VA people are world-class pros in this business. This is what they do. So that would be an unlikely situation. And we have committed ourselves as an institution to be bound by their expertise and their decisions in this. So that's how it's going to be. Again, we have monitoring mechanisms and we're talking all the time and Bill and I spend more time with VA people than we do with military service people nowadays.
            Q     Could you tell us real quickly about where you think you see Dole-Shalala in terms of legislative process and how if that passed in some form that could in fact impact your plans to expand this pilot to other installations?
            MR. DOMINGUEZ: I can't speak to where it is in the legislative process. I know the president has met with the leadership of Congress and told them that, you know, that he was behind it. In terms of what it would do, the revolutionary thing in this regard is it gets us out of the rating business at all. All we do is fit, unfit. And then we don't have to worry about a rating because it doesn't matter in our business. They're just retired. 
            And with that, we'll have to go. Thank you very much. Cynthia (sp) can, you know, hook you up with any of our staff of experts on any aspect of this that you might want to know more about. 
            And thank you very much for your time. I hope it was helpful to you.
            MR. CARR: Thank you very much.

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