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Senate Hearing on Reforming the Indian Health
Care Sysem. Testimony of General Paul K. Carlton, Jr.
(Retired), MD, FACS Before the US Senate Committee on
Indian Affairs.
June 11, 2009
Before the U.S. Senate Committee on
Indian Affairs
“Factory Built Medical
Considerations for the Indian Health Service”
June 11, 2009
Written Testimony of
Paul K. Carlton, Jr., M.D., FACS
LtGen, USAF, retired
Director, Office of Homeland Security
The Texas A&M Health Science Center
___________________________________________________________________________
I am Dr. Paul K. Carlton, Jr., currently
a professor of surgery at The Texas A&M Health Science
Center, TAMHSC, and the retired Air Force Surgeon General.
As part of the Texas A&M land grant mission, the
TAMHSC seeks to provide solutions to the many challenges
we face in healthcare delivery, particularly in rural,
frontier, and emerging regions. This includes training
providers willing to serve these areas, promoting the
use of innovative technologies to increase access to
healthcare, and application of the breadth of science
across the Texas A&M University System to improve
the public health. This focus on solutions led to a
joint conference hosted by the Texas A&M Health
Science Center and the Texas A&M College of Architecture
in the fall of 2007. This conference presented a pioneer
effort on how to use the component building method in
medical applications. Out of this conference came many
new and innovated ideas for the reconstruction of Iraq,
applications for Air Force facilities and applications
for the Indian Health Services. These medical construction
innovations comprise the rest of this testimony.
The building industry in our country
has been undergoing a revolution in efficiency using
new methods and new thinking with pre-fabrication of
larger portions of buildings, done in climate controlled
factories. The Modular Building Industry has been leading
this charge by progressively improving their quality,
their efficiency, and their timeliness. They currently
have over 100 manufacturing facilities scattered across
our country.
They recently started moving into the
healthcare field with both in-patient and out-patient
facilities. The largest user of out-patient, pre-fabricated
facilities has been in the dialysis field. By moving
these facilities closer to their population served,
they are able to give better service, closer to home.
The in-patient pre-fabrication world opened
with a full up hospital in Bensalem, Bucks County, PA.,
in 2007. This was a combination of factory built and
site built. The factory portion of this building is
what allows the efficiencies and quality improvement
that have been noted. A consistently superior quality
has been delivered by these factories because of the
excellent working conditions that are not influenced
by weather or availability of professional workers.
These are done in a factory by a staff that does tasks
repetitively, increasing their individual productivity
as well as avoiding the weather delays. The facilities
were even certified as meeting all standards before
leaving the factory by the State of Pennsylvania. The
transportation issues are worked through by designing
exactly what the transportation system will allow in
terms of moving these larger portions of buildings.
A provider of these types of facilities,
U3 Innovations of San Antonio, along with Modern Renovators
and Aspen Street Architects built the Air Force their
first truly component, pre-fabricated section clinic
in the last six months at Creech AFB, Nevada. All of
these businesses participated in the fall semester project
with the College of Architecture and Health Science
Center at Texas A&M in 2007. This clinic was to
fulfill a need that had languished for over two years,
with no bids coming close to the allocated amount of
money. Using pre-fabricated sections, this clinic was
built in four and a half months and on budget for $1.5M.
Our group from the fall project held a grand opening
for all of our colleagues to see what high quality this
building represented. It has an all-steel frame, concrete
floors, and an exterior that blends with its surroundings
nicely. It was built in six components in Loretto, TN.,
and transported by truck to the site. The beauty of
this approach is that it was built to cost and we will
add a nicer parking lot and nicer roof as money becomes
available. Pending those, we have a fully functional
facility to meet the needs of this isolated Air Force
Base so vital to the current wartime mission.
Our critical access hospitals (and
many urban hospitals) have now reached their life expectancy,
having been built about 50 years ago under the enlightened
funding initiatives of the Hill-Burton act. These under
25 bed facilities, vital to the nation’s healthcare
system in rural American, need to be replaced and we
cannot afford to do so. A critical access hospital construction
project in Tehachapi, California, was recently estimated
at $67M, to be completed in three to four years. The
similar sized pre-fabricated hospital, using all components,
had been contractor proposed at $25M. It was cancelled
because pre-fabricated construction was considered unacceptable.
Standards are standards and both would have met all
standards. Unfortunately, the change was more than Tehachapi
was ready to accept. Change is hard for all of us but
fiscal reality has to be considered at some point.
One innovative physician
executive from Nashville, Dr. Jerry Tannenbaum, has
designed such a critical access hospital and is ready
to write contracts on such facilities for $14.5M. That
design includes 12 beds, two large operating rooms,
a post anesthesia recovery unit, a complete imaging
suite, a full laboratory, a 12 bed patient wing, Emergency
Department, and administrative section. This would be
33,000 sq ft, all pre-fabricated, and up in nine months
from contract signing with a fixed guaranteed price.
Comparing that to the $67M that Tehachapi estimated
for their hospital and you have to say “what is
the difference?” Can we afford to resist change
at that difference in price?
I am currently involved in the rebuilding
process of medical activities in Iraq. We are proposing
all pre-fabricated section type construction for them,
using the work force in America, to rapidly solve many
of the pressing issues they face in medicine and in
housing. We have also proposed using mobile surgical
vans, that meet all standards of care, to turn any clinic
into a full up hospital whenever and wherever it is
needed. The Iraqis currently have one of these units
in country and love its flexibility and ease of use.
How does all of this then apply to
the Indian Health Service? I believe that what we have
learned could easily be applied by providing better
service to the Indian Nation at a more affordable cost:
1. In–patient facilities:
If we used the critical access model proposed by Dr.
Tannenbaum, the physician from Nashville, at $14.5M
each, you could provide twice the number of hospitals
for the same cost. A similar component
model by the Rural Health Consortium in California,
comprised of 13 critical access hospitals, has similar
numbers. If you used either of these models, tailored
it to the exact size needed in any location, using
pre-fabricated sections, you could cut down on the
$2.4B construction backlog that currently exists for
the Indian Health Service. Better service at a lower
cost is hard combination to beat.
2. Out-patient facilities: If we use the Creech AFB
model for clinics for the Indian Health Service, we
could be building modern state of the art out-patient
facilities for fractions of the cost of what we are
paying now. The issue of timeliness is also a critical
portion here- these are done in a factory, with fixed
pricing, and they meet delivery dates because weather
is not a factor.
3. Mobile Medical Care- You could also use the mobile
surgical vans, as the Iraqis do. These vans are used
in our country for operating room renovations routinely
and meet all standards of care including Joint Commission
on the Accreditation of Healthcare Organizations (JCAHO),
Medicare certification and state licensure. They would
allow us to turn any clinic into a full up hospital
for the number of days per month that it would be
effectively used at our more remote Indian Health
Service locations. This would allow each reservation
to have surgical or other specialty services offered
to them as the need dictated. The real payback for
using such a concept is that by providing better service
for the Indian Nation, we would be fulfilling a training
requirement for the Public Health Service. We call
this the “Thursday Hospital” concept,
moving the surgical vans from place to place as demand
exists. These vans, which are totally self-contained,
could then be the foundation of a national response
system for any medical large scale disaster. Since
they meet all standards of care, they can be used
daily for non-emergency healthcare. The Indian Health
Service, comprised of Public Health Service people,
would have been using them daily, so no equipment
training would be required to respond to national
emergencies. You would use them like you use a portable
CT scanner or MRI machine, simply have a docking station
built onto the clinic or hospital so the patient never
has to move outside. To have the potential of superb
mobile facilities, no training tail involved for the
professional staff, and used every day is exciting
to contemplate! There would then be little fixed cost
for preparedness for equipment for our nation in times
of a medical emergency. From a national preparedness
perspective, this is a very cost effective alternative
to consider.
The Indian Health Service has a great
mission, to take care of the health needs of our Native
Americans. You have a great group of people to do this
with, the Indian Health Service medical professionals.
Perhaps these new methods for providing high quality
facilities could enhance the delivery of healthcare
to this deserving group of people- at an affordable
cost. I encourage you to look closely at all I have
discussed. Go see the facilities I have described in
Bucks County, Pa; at Creech AFB, NV; and in St. Johnsbury,
VT. Look closely at how to allocate the tax payer dollars
involved. I believe that you will find this revolution
in the building industry applicable to the Indian Health
Service and other federal building projects.
Thank you for this opportunity to share these thoughts
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