Protecting the Health of Our Nation’s Active Duty Military and Families: Defense Health Agency Director Vice Admiral Raquel Bono

Raquel Bono

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Mark Masselli: This is Conversations on Health Care I'm Mark Masselli.

Margaret Flinter: I’m Margaret Flinter .

Mark Masselli: Well , Margaret more comings and goings in the president's cabinet ,
his choice to fill the vacancy left by the ouster of V.A. S ecretary Shulkin has taken
himself out of the running . Ronn y Jackson the White House physician withdrew from
consideration for secretary of Veterans Affairs .

Margaret Flinter: Well it seems that President Trump's choice to run the V.A. ran int o
opposition just about from the beginning Mark . W e know what a huge organization
the V.A. is it serves the health needs of some nine million Americans and employ s
350,000 medical professionals . B oth d emocratic and r epublican members of
c ongress had expr essed concern over his seeming lack of experience required to
run such a massive health agency .

Mark Masselli: I think the only silver lining in this cloud was that the Senate Veterans
Affairs Committee acts in a bipartisan way . B oth are very focus ing o n making sure
our veterans are well taken care of at the leadership level .

Margaret Flinter: We ll serving the needs of the nation's military is a strategically
complex task and that brings us to our guests today Vice Admi ral Raquel Bono is the
D irector o f the Defense Health Agency or the DHA which oversees the health needs
of the nation's military . She has decades of experience from her days as a field
surgeon during Desert Storm to now running this really quite massive organization .

Mark Masselli: V ic e A dmiral Bono will share some unique insights into the
challenges of delivering quality care from the battlefield triage to promoting
prevention and primary care for the entire population , really looking forward to that
conversation Margaret.

Margaret Fl inter: In deed we are . Lori Robertson will check in the managing editor of
Fact Check dot org . N o matter what the topic you can hear all of our shows by going
to chc radio . com or follow us on Twitter or iTunes .

Mark Masselli: As always if you have comme nts please email us at
[email protected] or find us on Facebook or Twitter we love hearing from you .

Margaret Flinter: W e'll go to our interview with Vice Admiral R aquel Bono of the
Defense Health Agency in just a moment .

Mark Masselli: F irst here is our producer Marianne O'Hare with this week's h eadline
n ews.

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Marianne O’Hare: I'm Marianne O'Hare with the se health care headlines . A nother

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Raquel Bono

health industry executive is being considered for a big job in the cabinet the V A
secretary post after the administration's pick to replace David Shulkin A scensions
CEO Tony Tersigni is considered a capable steward of a large health system . Wh ile
he doesn't help from a military background , h e's had significant experi ence working
with the VA health system partnering with the Veterans Choice Program which was
launched after a long wait times came to li fe in 2014.

There are several other reported names on the list acting VA S ecretary Robert Wilkie
who has been praised a s doing a quote , “G ood job .” B y the president also mentioned
recent Cleveland Clinic CEO Toby Cosgrove who helped turn Cleveland Clinic into a
global health entity . Fox News contributor and Iraq W ar veteran Pete Hegseth is
another name being mentioned . T he 37 year old conservative considered
controversial pick within the veterans community having come up against a
S ecretary Shulkin who was against the privatization of the VA health system .

M eanwhile , some good news a recently released RAND Corporation st udy has
shown the VA outperforms many other hospitals and health agencies in terms of
outcomes . T he study commissioned by the U.S. Department of Veterans Affairs the
R AND study found the VA performed significantly better than non - VA hospitals on a
number of measures such as mortality and effectiveness of treatment . H owever ,
they did more poorly on readmissions .

F or some soldiers insomnia can be an issue . A study of a 150 active duty soldiers at
Fort Hood were able to improve their condition with talk th erapy methods given over
a short period of time . T he soldiers were given a number of 60 minute sessions that
taught them relaxation techniques and s leep hygiene . S hort term therapy
intervention seem to work , t he soldiers who completed the so - called CBTI therapy
interventions reported better sleep overall . F ewer bouts of wakefulness and there
was an added benefit , those soldiers also fared better on mental health tests such as
mental fatigue and mental wellness . A n estimated 20% of enlisted soldiers are
wrestling with insomnia issues . T he study's lead author suggesting this training
should be provided on a much broader scale to address the health issue which can
also be a red flag for other mental health concerns among the nation's military . I ’m
Mariann e O’Hare with these health care headlines.

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Mark Masselli: We ’ re speaking t oday with Vice Admiral Raquel Bono director of the
Defense Health Agency the DH A. T he DH A directs the 10 joint shared services
including TRICARE the military health plan . Admiral Bono began field duty as a
surgeon in 1990 during Operation Desert Storm , and has since earned numerous
distinctions including the Defense Superior Service Medal and the Legion of Merit
th
Medal. Admiral Bono served as the 11 C hief of the Navy Me dical Corps . She
earned her medical degree from Texas Tech University completing her general
surgery residency at the Naval Medical Center . Admiral Bono welcome to
C onversations at Health Care.

Raquel Bono: T hank you .

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Raquel Bono

Mark Masselli: Y eah , you're at t he helm of one of the largest and perhaps most
complex health systems in the world the Defense Health Agency covers millions of
active enlisted and deployed members of all of the branches of the armed forces
around the world as well as the health care need s of their families . I’m wondering if
you could share with our listeners the greater challenges that you face a t DHA to
service such an enormous health care delivery system .

Raquel Bono: W e are actually a microcosm of the larger health care environment .
M any of the challenges that you're seeing in the National Health Care are very
similar to some of the challenges that we see in military health system. We are like
the seventh largest health care system one of the largest federated health care
systems. What you’ve got there are 9.4 million beneficiaries who need to receive
care in a variety of settings whether that’s across the United States or overseas in
international areas where we have some of the members of our military forward
deployed. Certain ly the thing that people most readily associate with the military
health system is when we’re around the combat field taking care of those that maybe
in harm’s way. Just that alone gives you kind of an understanding of the scope and
the types of patients th at we might be serving. Even in those very unique settings
that challenges and the opportunities and the desire that we have for our
beneficiaries is very similar to what we’re trying to accomplish in the health care for
our nation.

Margaret Flinter: We ll Admiral Bono your agency has to ensure that members of the
military have access to really sophisticated and quality care in the war theater.
Share with our listeners little more about what are these unique challenges of
delivering health care in a host ile and unpredictable environment?

Raquel Bono: Absolutely what we do when we have people who are actually
forward deployed, and in some cases an international settings where they also are
allowed to bring some of their family members. This would be pla ces like Italy and
Germany, and we do very extensive partnering with not only our partners with
international SOS but also partnering with the local health care that they have in the
area. In many of these overseas areas the health care that is available there is very
comparable to western medicine. When we get to the more austere environments
where we’re forward deployed and we’re in a contingency setting or a combat
setting, you’re absolutely right, we’re working in a much more austere environment
where we adhere to the principles of suscitation and treatment that are common
across any of the emergency areas in the United States and in the emergency
departments. It does require us to have all certain level of innovation and several
things have come out of this last conflict where we have looked at the use of
tourniquets and how effectively we now use them in a situation where you have
significant hemorrhage. You may also see the military partnered with the American
College of Surgeons to stop bleed camp aign .

Margaret Flinter: Right, I've been reading about that.

Raquel Bono: Yes and so this is very exciting b ecause for a while the re tourniquets
had fallen out of favor, but because of the successful experience t hat we've had on
the battlefield we were able to come back and everybody's been able to re look now

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Raquel Bono

at the use of tourniquets recognizing that they can be used in a very effective and
s afe way . I think that's an example of where and a very austere and hostile
environment we've kind of re - innovat ed the use of the tourniquet a nd been able to
inform how that would make a very positive impact on civilians emergency care .

Mark Masselli: Admiral you are appointed to your current post under President
Obama and it was with a clear mission in mind to ov ersee the transformation of the
defense health agency become more streamlined and hopefully elegant as we like to
say , and the DHA is in a period of profound change management including the
deployment of a new electronic health records system . F or all tho se who listen who
know that is a challenge in any organization across your system . I can't imagine how
you sleep at night , but tell us about the new EHR system you're adopting and the
operational changes required for its implementation at DHA .

Raquel Bon o: I think that this is an important advancement for the military health
system. W e realize d that there are more elegant solutions that are out there in the
commercial sector. The defense health agency is looking to o ptimized those
connection that we ha ve with the industry to say what are some of the solutions that
you’re using and is that s omething that we can deploy within our military health
system. This is a commercial off - the - shelf program , and we want ed to bring that in
for a variety of reasons, b ecause we recognize that with technology moving as
quickly as it’s moving that we need ed to be able to have access to the leading edge
that industry offers. Going with the commercial off - the - shelf product was an
extremely part for us from the military hea lth system. That is a significant change
management effort. I think for the military health system with makes this something
that is a driven change is that we all share the same goal, making sure that we’re
taking care of our patients no matter if they army, air force and navy, w hether they're
here in Garrison or whether they're deployed to the battlefield. With our new
electronic health record it allows us to maintain access to our patient’s data no
matter where they may be transferred because one of t he unique things about our
patient population our military is that every couple of years we moved different duty
station. Having this electronic health record system that can be access no matter
where our patients are is a strong enabler to making sure th at we’re providing that
continuity of care and we’re getting that most transparency of our patient data.

Margaret Flinter: Well, Admiral Bono you’ve got some very speciali zed health care
workforce needs preparing your frontline trauma physicians and surg eons and
nurses for care delivery in the conflict zone s and also the care that goes on
afterwards for those who've been wounded in battle . W e've learned a lot about the
Veteran Affairs health professional education and training system but I don’t think we
are well versed in the work that you are doing. Tell us about the infrastructure that
supports the education and training of your clinical workforce.

Raquel Bono: You’re right there’s a broad spectrum that we need to be paying
attention to, and in havi ng the medically ready force and a ready medical force there
are different drivers for how we go about doing that. Let me talk a little bit about the
medically ready force, those are the folks that provide the health care that d eploy
with our operational t roops to make sure that they are well cared for and that they
have the medical support once needed in these different contingency environments.

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Raquel Bono

Those that are what we think of as more combat oriented things like surgery,
anesthesia, emergency medicine tha t have a lot of trauma r elated capability . B eing
able to make sure that we provide the right kind of training that we have the
providers who are ready to go at a moment's notice is an imperative . We have a
very strong reliance on our medical enlisted who often times do the immediate and
the initial resuscitation for anybody who’s injured.

For a medical enlisted, we have something called the Medical Education Training
Campus in San Antonio Med C wh ere for all the medical enlisted across a rmy , a ir
f orce , n avy we're able to train them to a standardized level of how you do these type
of trauma resuscitation . That’s something I think you see reflected in the survivability
rate that we had in the last 15 years. Our medics and our med techs are the first
respo nders and because o f that standardized training they have, we were able to
h ave a very high rate of survivability up in the 90s, 90 plus percent. For our
surgeons, anesthesiologist for the specialty care we not only provide those
opportunities within our military treatment facilities. We also p artner with civilian
institution with trauma centers , and a great example of that is some of the response
that we've been able to participate in with our civilian partners the Pacific Northwest
with the railroad th at went off. Some of our providers and medic and were able to
help the local trauma in Las Vegas with the terrible episode there.

Some of our military surgeons p articipated with the civilian in taking care of those
victims . Then another examples in San Antonio where we have the only level one
trauma center for the Department of Defense partnering with the u niversity h ospital
enable them to be able to be part of the response to those subtle [inaudible
00:13:48 ] mass casualty .

Mark Masselli: We're speaki ng today with Vice Admiral Raquel Bono Director of the
Defense Health Agency the DHA providing medical services to the army, navy, and
the air force . Admiral you know we wanted to e ducate more people about the great
work that happens at DHA . I think most of our listeners are probably more well -
versed in the Veterans Health A dministration . Wanted to know what the integration
was, has the handoff go so that our audience might understand this continuum of
care.

Raquel Bono: We know that the most vulnerabl e time in anybody’s health care
experience is when there is a handoff of some kind , even if it's something as simple
as going from the emergency department to another part of the hospital. For us in
the military system where we take care of our active dut y who are in uniform and
their family members we recognize that our partnership with the VA and this helps
with the transition for all of our members as they go from the care that they receive in
the DOD to the care that they receive in the veterans hospit als. What we try to do
then is optimize our partnering with the VA and how we’re going about doing that is
with the electronic health record. We know that there’s a lot of information sharing
that needs to occur as a patient transitions or care from one sector to another. We
want to be able to have as much transparency and interoperability of that data
transfer with the VA. VA is also very interested in using the same electronic health
record that we are deploying and we’re working very closely with the VA to
understand how that maybe optimized, it’s a very exciting opportunity here.

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Raquel Bono

I think the other things that we're looking at is how well can we partner with each
other in certain locations where we have a strong military presence and we also
have a s trong VA presence, are there ways that we can be doing more resource
sharing to include facilities, personnel, nurses, doctors, surgeons and then other
services. We're actively looking for those types of opportunities and I think you’re
also seeing this i n a civilian health care market is that there is more and more
partnering and collaboration going on because the ability of any one system to
provide all services is getting more and more challenging to do. The best way to do
that is to find ways to partn er and I think that makes partnering with the VA a natural
fit.

Margaret Flinter: You know Dr Bono I think another area that must be a front of mind
very shared concern with you and the leaders in Veteran Affairs is the invisible
trauma done such an amaz ing job of saving lives on the battlefield and helping
people recover. Trauma and post - traumatic stress disorder is such a concern for
everybody. Highlight if you could some of the promising research that has emerged
and how is that research now helping soldiers deal with PTSD or are we making
some progress on that front?

Raquel Bono: Margaret I think we absolutely are, but I think that all of us collectively
have come to appreciate how complex this actually is, and because it's so complex
the solution set is not a one size fits all. There has to be a high degree of
individualized treatment and a high degree of appreciation for how each individual is
affected by trauma. The best approach is taking a multi disciplinary approach and a
multi modality appr oach making sure that in all that treatment that the support
network, the family of the individual is included as part of that. I can’t stress how
much we've realized that makes such an impact that we design our systems to make
sure that we have that mult imodality approach. We also realize that the network
needs to be a part of that to include that in some cases the family and that network
also need some assistance and support with any behavioral health repercussion.
We have tremendous support from a lot of people in industry and in private
organizations who are very helpful in making sure that we keep our military members
and their families at the forefront of this.

st
Mark Masselli: Admiral you’ve been very focused on how we build a better 21
century h ealth care system. You have to do with not only within the various
branches of the military but also across many of our NATO allies who partnered with
the Defense Health Agency to provide care around the globe. Wondering if you
could share with our liste ners what have you learn that might be helpful for us to
emulate in the broader health care system in America?

Raquel Bono: It is so true we've partnered with our international partners and allies
and because we often time serve together in the battlefie ld or in a contingency
operation we’re often times taking care of each other’s members. Being able to have
that interoperability either in our equipment, our devices, our processes in our health
record only serves to enhance and support that ability to ca re for people in a very
rapid way but also make sure that we’re keeping the transitions as tight and as
informed as possible. Not only do we continue to work with them or not and

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Raquel Bono

participate in training evolutions where we have this military training we a lways make
sure that we’re doing some type of medical training as well with our partners. What
I’ve done here on the Defense Health Agency is actually invited representatives from
Germany, Canada and the UK to sit here in the Defense Health Agency and to be a
part of our conversation so that we have access to some of the things that they’re
thinking and they actually can participate in helping to shape and inform our thinking
of where we’d like to go with our next effort.

Margaret Flinter: We’ve been spe aking today with Vice Admiral Raquel Bono the
D irector of the Defense Health Agency . You can learn more about t heir work by
going to H ealth .MIL/DHA or you can find follow Dr. Bono on Twitter @DHA Director.
Vice Admiral t hank you so much for your dedicati on , for your service to the country
and for joining us on C onversations on Health Care today.

Raquel Bono: Thank you it’s been my pleasure and I really appreciate you interest.

[Music]

Mark Masselli: At Conversations on Health C are, we want our audie nce to be truly in
the know when it comes to the facts about health care reform and policy . Lori
Robertson is an award - winning journalist and Managing Editor of FactCheck.org, a
non - partisan, nonprofit consumer advocate for voters that aim to reduce the l evel of
deception in US politics. Lori what have you got for us this week?]

Lori Robertson: M any readers have asked us whether people have developed
cancer because they received the polio vaccine . T here are no known cases and it's
very unlikely . I n th e 1950s and 1060s p eople did receive polio vaccines that were
contaminated with a virus that causes cancer in rodent , but research suggests this
virus doesn't cause cancer in humans . A bout one in 200 people who contract the
polio virus develop polio which involves loss of movement in the limbs . In 1954 the
year before the polio vaccine became widely available US saw more than 18,000
reported cases of paralytic polio . By 1964 th at number had dropped to 106. While
the US is virtually polio free the diseas e still is present in other parts of the world so
the CDC still recommends that children get the vaccine . T he vaccines develop
Jonas Salk grew the polio virus in a culture of monkey kidney cells and then used a
chemical called formalin to kill the virus r endering it unable to cause polio . L ike other
vaccines this dead virus in 1960 scientists discovered that some of the monkey
kidney cells used to make the polio vaccine were contaminated with Simian Virus 40.
F or monkeys this virus is harmless but in hig h doses SV40 can cause cancer in
rodents .

S tarting in 1961 authorities required new lots of polio vaccine to be free of S V40 still
many vaccines produced prior to this year were n’t recalled . E ven among the
contaminated vaccines the formalin used to kill the polio virus killed all or most of the
S V40 a s well . Studies have consistently shown that people who received the polio
vaccine in the 1950s and 1960s h ad no increased risk of cancer but that doesn't rule
out the possibility that some select individual s could have developed cancer . While
some vaccines were contaminated several decades ago it's very unlikely they
caused anyone to develop cancer , and that's my tactic for this week I'm Lori

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Raquel Bono

Robertson Managing Editor of F act C heck .org.

Margaret Flinter: F actCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you ’d like checked, email us at
CHCradio.com we ’ ll h ave FactCheck.org’s, Lori Robertson check it out for you, here
on Conversations on Healthcare.

[Music]
Margaret Flinter: Each week conversations highlights a bright idea about how to
make w ellness a part of our communities and everyday lives . S eptember is suicide
prevention month and it's of particular interest to the Veterans Administration . A n
estimated 22 veterans p er day are taking their own lives in what's being described as
a post - war suicide crisis . T he VA has launched a campaign aimed at all Am ericans
who know veterans who may be struggling to be aware that they can make a
difference just by reaching out it's called The Power of One campaign . T he idea that
one person reaching out to one veteran in a caring manner can make a difference .

Female: T he power of one small action , one conversation or one phone call can
make a difference in the life of a veteran going through a difficult time . F or free 24/7
confidential support call the Veterans Crisis Line or the Military Crisis Line.

Margaret Flin ter: Ac cording to Dr . Caitlin Thompson Deputy Director of VA Suicide
Prevention Program it takes only a moment and just one small act can start them
down the path to getting the support they need . T he VA has launched a suicide
prevention hotline it's now collaborating with community g roups across the country to
prepare them to better address the needs of these veterans , many of whom don't
know how to ask for the help they need . V eterans , service members and anyone
concerned about them can call the Vetera ns Crisis Line 1800 - 273 - 8255 they can
chat online at Veterans Crisis Line .net/chat or send a text to 838255. All Veterans
Crisis Line resources are optimized for mobile devices . A dedicated program aimed
at reaching out to veterans across the country emp owering community groups and
individuals to find ways of offering support to getting veterans the help they need
before it's too late , now that's a bright idea.

[Music]

Margaret Flinter: This is Conversations on Health Care I’m Margaret Flinter.

Mark M asselli: I’m Mark Masselli, peace and health.

Conversations on Health C are broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health
Center.

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