[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
                    SUBCOMMITTEE HEARING ON ENSURING 
                     CONTINUITY OF CARE FOR VETERAN 
                      AMPUTEES: THE ROLE OF SMALL 
                          PROSTHETIC PRACTICES 

=======================================================================

                      COMMITTEE ON SMALL BUSINESS
               SUBCOMMITTEE ON CONTRACTING AND TECHNOLOGY
                 UNITED STATES HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 16, 2008

                               __________

                         Serial Number 110-105

                               __________

         Printed for the use of the Committee on Small Business


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                   HOUSE COMMITTEE ON SMALL BUSINESS

                NYDIA M. VELAZQUEZ, New York, Chairwoman


HEATH SHULER, North Carolina         STEVE CHABOT, Ohio, Ranking Member
CHARLES GONZALEZ, Texas              ROSCOE BARTLETT, Maryland
RICK LARSEN, Washington              SAM GRAVES, Missouri
RAUL GRIJALVA, Arizona               TODD AKIN, Missouri
MICHAEL MICHAUD, Maine               BILL SHUSTER, Pennsylvania
MELISSA BEAN, Illinois               MARILYN MUSGRAVE, Colorado
HENRY CUELLAR, Texas                 STEVE KING, Iowa
DAN LIPINSKI, Illinois               JEFF FORTENBERRY, Nebraska
GWEN MOORE, Wisconsin                LYNN WESTMORELAND, Georgia
JASON ALTMIRE, Pennsylvania          LOUIE GOHMERT, Texas
BRUCE BRALEY, Iowa                   DAVID DAVIS, Tennessee
YVETTE CLARKE, New York              MARY FALLIN, Oklahoma
BRAD ELLSWORTH, Indiana              VERN BUCHANAN, Florida
HANK JOHNSON, Georgia
JOE SESTAK, Pennsylvania
BRIAN HIGGINS, New York
MAZIE HIRONO, Hawaii

                  Michael Day, Majority Staff Director

                 Adam Minehardt, Deputy Staff Director

                      Tim Slattery, Chief Counsel

               Kevin Fitzpatrick, Minority Staff Director

                                 ______

               Subcommittee on Contracting and Technology

                      BRUCE BRALEY, IOWA, Chairman


HENRY CUELLAR, Texas                 DAVID DAVIS, Tennessee, Ranking
GWEN MOORE, Wisconsin                ROSCOE BARTLETT, Maryland
YVETTE CLARKE, New York              SAM GRAVES, Missouri
JOE SESTAK, Pennsylvania             TODD AKIN, Missouri
                                     MARY FALLIN, Oklahoma

        .........................................................

                                  (ii)

  



  






























                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page

Braley, Hon. Bruce...............................................     1
Davis, Hon. David................................................     3

                               WITNESSES

Downs, Mr. Frederick , Jr., Chief Prosthetics and Clinical 
  Logistics Officer, Department of Veterans Affairs..............     5
Bacik, Captain Mathew,USA Ret.,Montgomery Alabama................    20
Clark, Mr. Dennis, CPO, Clark and Associates Prosthetics and 
  Orthotics, Waterloo, IA........................................    22
Rogers, Mr. James, CPO, FAAOP, President, American Academy of 
  Orthotists & Prosthetists......................................    24
Guth, Mr. Thomas, CP, President, National Association for the 
  Advancement of Orthotics & Prosthetics OH......................    26
Smith, Mr. Christian T.Z., CPO, BOCOP, President, Victory 
  Orthotics and Prosthetics, Inc., Johnson City, TN..............    28

                                APPENDIX


Prepared Statements:
Braley, Hon. Bruce...............................................    42
Downs, Mr. Frederick , Jr., Chief Prosthetics and Clinical 
  Logistics Officer, Department of Veterans Affairs..............    44
Bacik, Captain Mathew,USA Ret.,Montgomery Alabama................    50
Clark, Mr. Dennis, CPO, Clark and Associates Prosthetics and 
  Orthotics, Waterloo, IA........................................    56
Rogers, Mr. James, CPO, FAAOP, President, American Academy of 
  Orthotists & Prosthetists......................................    62
Guth, Mr. Thomas, CP, President, National Association for the 
  Advancement of Orthotics & Prosthetics OH......................    77
Smith, Mr. Christian T.Z., CPO, BOCOP, President, Victory 
  Orthotics and Prosthetics, Inc., Johnson City, TN..............    83

                                 (iii)

  


                    SUBCOMMITTEE HEARING ON ENSURING
                     CONTINUITY OF CARE FOR VETERAN
                      AMPUTEES: THE ROLE OF SMALL
                          PROSTHETIC PRACTICES

                              ----------                              


                        Wednesday, July 16, 2008

                     U.S. House of Representatives,
                                Subcommittee on Contracting
                                            and Technology,
                               Committee on Small Business,
                                                    Washington, DC.
    The Subcommittee met, pursuant to call, at 10:00 a.m., in 
Room 1539, Longworth House Office Building, Hon. Bruce Braley 
[chairman of the Subcommittee] presiding.
    Present: Representatives Braley, Cuellar, Clarke, Sestak, 
Akin, and Davis.

              OPENING STATEMENT OF CHAIRMAN BRALEY

    Chairman Braley. This hearing on VA contracting with small 
prosthetic practices is now called to order.
    The human cost of the Iraq conflict has been nothing short 
of devastating. In 5 years of war, our troops have suffered 
4,000 deaths and another 29,000 injuries. As our wounded 
soldiers return from overseas, the Nation now faces a moral and 
financial challenge of providing for their medical care.
    Why should we care about the prosthetic needs of our 
Nation's veterans? In the aftermath of the devastating 
revelations about the conditions at Building 18 in Walter Reed 
Army Medical Center, an Independent Review Group headed by the 
Honorable Togo West was assembled to report on rehabilitative 
care and administrative processes at both Walter Reed and the 
National Naval Medical Center at Bethesda. The Independent 
Review Group identified traumatic amputations as one of the 
four signature injuries associated with the current conflicts 
in Afghanistan and Iraq.
    It is important to note that today's Veterans 
Administration serves not only the wounded returning from 
current conflicts, but also the additional 70 million Americans 
otherwise eligible for VA benefits. My brother, Brian Braley, 
knows this very well. He treats these patients as a 
kinesiotherapist at the VA hospital in Knoxville, Iowa. And I 
am very proud of him for making a difference in the lives of 
the patients he works with. A great number of these men and 
women will require prosthetic and sensory aid resources. In 
2007 alone, more than 1.3 soldiers sought these services. As 
amputees continue to return from the war, the number of 
patients who require prosthetic services will continue to rise.
    In order to meet this increased demand, the VA's budget for 
prosthetic and sensory aid services, PSAS, has risen 
dramatically. Increased funding for this service has been a 
bipartisan effort. Democrats and Republicans alike are 
dedicated to providing the best possible care to our wounded 
veterans. But while the VA has made great strides in offering 
treatment, many amputees continue to face obstacles.
    In addressing these challenges, we should first look to 
small health care providers who comprise the bulk of the 
prosthetics industry. Small firms make up 80 percent of this 
vital medical sector. In fact, the administration currently 
holds 600 agreements with small prosthetic practices. But 
despite the VA's efforts to ensure quality care to amputees, 
many vendors have raised concerns.
    The system, while enormously helpful to the vast majority 
of veterans, is not perfect. A series of issues regarding 
procurement have made this sector increasingly difficult to 
navigate. As a result, the well-being of our wounded soldiers 
could be improved.
    In order for small health care providers to successfully 
serve these men and women, several barriers must be addressed 
and overcome. One of the greatest challenges facing prosthetic 
businesses is the VA's obsolete contract procedure. The 
documents for this process can be outdated and hard to follow. 
In some cases, it would seem that neither the practice nor the 
paperwork has kept pace with industry development. Similarly, 
the bidding procedure for the administration's proposals can be 
disorganized and inconsistent. Consequently, many small 
businesses find themselves shut out of the system. These 
logistical roadblocks have deterred many entrepreneurs from 
participating altogether. This means more than just decreased 
revenues for small firms. It means fewer choices for wounded 
veterans.
    Further compounding the choice issue are restrictive 
contracting practices. Prosthetic providers around the country 
have noted instances in which VA hospitals have narrowed 
patient selections. This can be devastating to amputees who 
need specific devices made by a limited number of providers.
    In outsourcing to small prosthetic businesses, the VA 
allows veterans to seek more personalized care. We must ensure 
that amputees continue to have this option. It is important to 
note that these suggestions are not intended to undermine the 
vital work of the VA.
    On the contrary, this Committee recognizes the 
administration's considerable efforts in providing quality care 
to veterans. As we will hear today, its services have been a 
literal lifeline to countless veterans across the country. What 
is more, the VA has been and continues to be an important 
partner for the small business community. With this in mind, we 
must ensure that the administration and small business 
providers have the opportunity to build an even stronger 
partnership. In doing so, we will not only bolster our small 
businesses, we will also support the heroic men and women who 
have answered our Nation's call.
    These noble warriors have spilled their blood for us and 
served their country with courage. They have earned and deserve 
our support. Their well being is our moral obligation, and we 
should not shirk our financial responsibility to care for them 
as a fundamental and patriotic duty. If we fail to live up to 
that responsibility and give them the best chance to reach 
their full potential, we will pay a heavy price over their 
lifetimes in added medical expenses due to chronic disease 
processes that are aggravated by inactivity, such as morbid 
obesity, diabetes and vascular diseases that lead to heart 
attacks and strokes. To paraphrase the old Fram oil filter 
commercial, we can pay for them now or we can pay for them 
later.
    In this morning's hearing, we identify future needs of 
amputees who face care decisions in the DOD and VA medical 
systems and examine ways in which the VA and small businesses 
can work together to address those critical needs.
    I want to thank all of our witnesses in advance for taking 
time from their busy lives to travel here and share their 
testimony. I look forward to a lively, frank and informative 
exchange.
    And at this time, I have the privilege of recognizing the 
ranking member, my friend, David Davis from Tennessee, and ask 
him to share his opening statement.
    Mr. Davis.  Good morning and thank you, Chairman Braley, 
for holding this hearing on the important topic of veterans and 
prosthetic practices. I would like to thank each of our 
witnesses who have taken the time to provide a witness to this 
Subcommittee with their testimony. I would like to extend a 
special welcome to my fellow Tennesseean, Christian Zach Smith, 
a board certified prosthetist and orthotist, and I will 
introduce you later.
    The Department of Veterans Affairs operates the Nation's 
largest integrated health care system, and like most other 
Federal health care programs, the system is a direct service 
provider rather than a health insurer or payer for health care. 
VA health care services are generally available to all 
honorably discharged veterans to the United States Armed Forces 
who are enrolled in the VA's health care system. Under the VA 
prosthetic service policy, a lack of funds will never cause a 
prescription or prosthetic from being filled or delayed. This 
policy has enabled the VA to provide the highest quality 
prosthetic services and care of any government or civilian 
medical system in the world.
    A proper prescription by a VA clinician can make any 
prosthetic device in the marketplace available to the veteran. 
This means the VA's prosthetic service is required to stay 
abreast of all new technology, both in research and development 
stages and when the product is available for use after it is 
approved by the FDA. Because of this attention, the VA is often 
among the first to prescribe new prosthetic devices that come 
to the market, especially if they are high tech and high cost.
    All the 61 VA prosthetic and orthotic labs have earned 
certification by either the American Board of Certification in 
orthotics, prosthetics or pedorthics, the ABC, or the Board of 
Orthotist/Prosthetist Certification, the BOC, which are the two 
national accredited organizations. Almost all VA prosthetics 
and orthotists are board certified. Additionally, eight of 
these accredited labs have also earned certification from the 
National Commission on Orthotic and Prosthetic Education, which 
enables the labs to participate in residency programs from the 
nine prosthetic and orthotic programs in universities and 
colleges in the United States. This same standard is applied to 
all contractors to help ensure consistent quality.
    Under title 38, section 1823 of the United States Code, the 
VA is authorized to procure orthopedic and prosthetic 
appliances and related services, including research, without 
regard to any other provision of law. The VA only uses its 
expanded acquisition authority on a case-by-case basis to 
ensure veterans the highest quality of care.
    The VA has an active prosthetics small practice outreach 
program. For example, the VA's Office of Small Business and 
Disadvantaged Business Utilization has several initiatives that 
train small orthopedic and prosthetic practices to do business 
with the VA.
    Also, VA works very closely with prosthetic contractors in 
hosting conferences around the country where there is a mix of 
VA attendees and prosthetic small practices. These seminars are 
typically organized on a local and regional basis as a 
mechanism of outreach with independent practices and an 
opportunity for mutually beneficial collaboration between the 
VA and small practices. This effort has resulted in 
approximately 80 percent of contracts for these services by 
number of purchase orders and by a total cost being awarded to 
small practices.
    Chairman Braley, I look forward to working with you on this 
important issue. And again, I would like to thank each of you 
for being here with us today. And with that, I yield back my 
time.
    Chairman Braley.  Thank you, Mr. Davis. Before we introduce 
our first witness, let me explain the 5-minute rule for all of 
the witnesses who are here present to testify. We will move on 
to the testimony of witnesses, all witnesses will be allowed 5 
minutes to deliver their prepared statement and there will be a 
timing device right in front of you. The way the lights work is 
when 1 minute remains, the yellow light will come on and when 
your time is up, the red light will come on, and your entire 
written statement will be included as part of the record.
    Let me introduce our first witness. We are honored to have 
Mr. Frederick Downs as our first witness. He is currently the 
Chief Prosthetics and Clinical Logistics Officer for the 
Veterans Health Administration, Department of Veterans Affairs, 
headquartered here in Washington, D.C. Mr. Downs manages a 
nationwide $1.3 billion dollar prosthetics and sensory aids 
program that furnishes assistive aid and services to nearly 2 
million veterans with disabilities.
    Mr. Downs served in Vietnam where he was severely injured, 
losing his left arm above the elbow. He has four purple hearts 
and was inducted into the Officer Candidate School Hall of Fame 
at Fort Benning Infantry School. We are honored to have you 
here. Thank you for your service to our country, and we look 
forward to your testimony.

   STATEMENT OF FREDERICK DOWNS, JR., CHIEF PROSTHETICS AND 
CLINICAL LOGISTICS OFFICER, OFFICE OF PROSTHETICS AND CLINICAL 
           LOGISTICS, DEPARTMENT OF VETERANS AFFAIRS

    Mr. Downs.  Thank you, sir. Good morning, Mr. Chairman and 
members of the Subcommittee. Thank you for the invitation to 
discuss the Department of Veteran Affairs' relationship with 
independent prosthetic contractors in our efforts to ensure 
continuing care for our veteran amputees returning from combat. 
I would ask that my written statement be entered into the 
record.
    VA furnishes prosthetic services to enrolled veterans as 
part of the Department's medical benefits package. This 
includes sensory aids for those who meet VA's eligibility 
criteria. Our prosthetic devices include an array of items from 
appliances, parts or accessories that are necessary to replace 
or substitute for a deformed, weakened or missing anatomical 
portion of the body.
    Our Office of Prosthetics has a long tradition of using an 
extensive network of VA laboratories and contract prosthetic 
labs to provide prosthetic and orthotic devices. We operate 61 
prosthetic labs and each one of them is accredited by one of 
the two national accrediting bodies, which was mentioned. And 
we also hold our contract lab--our contract prosthetist that we 
do the contracts with, it was over 600, to the same standards. 
In fact, we held them to those standards before we adopted 
them. So it has always been a tradition that we required 
certification from our contract prosthetists for them and their 
labs.
    We contract with over 600 independent labs, as we said, and 
that provides, by the way, about 97 percent of the total limbs. 
And there is a misperception that VA fabricates most of the 
limbs, and that is not true at all. We only fabricate at the 
most 3 percent of the limbs that are provided to America's 
veterans.
    Now, to keep our people up to speed in prosthetics, we hold 
our conferences concurrent with and endorsed by the American 
Academy of Orthotists and Prosthetists during their annual 
meeting in their scientific symposium. This annual meeting is 
attended by approximately 2,000 prosthetists. Many of these are 
small business owners and VA contractors. Our goal is to 
improve communications and interaction with all members of the 
independent prosthetic community. Many small business owners in 
the field of prosthetics are members and supporters of this 
annual conference. This forum presents a unique opportunity to 
enhance the relationship between the private sector and VA. 
Small businesses, including the VA contractors, are invited to 
present their products and attend these scientific 
presentations. Businesses are provided exhibit tables or space 
that enables them to meet and interact directly with VA 
physicians, administrators, therapists, orthotists and 
prosthetists. We believe it is a model of professional and 
business interaction with government.
    Our network of providers reaches the most rural areas 
throughout the country to bring quality care to the veteran. 
Currently, those 600 contractors we have across the country 
provide access to necessary care close to their home, whether 
in a rural or urban area.
    In fiscal year 2007, as was mentioned before, we provided 
prosthetic services to 1.6 million unique veteran patients. And 
I would like to add that once we accept one of our wounded 
veterans or soldiers into our system, we have them for the rest 
of their lives. In my case, that has been 40 years and we will 
take care of those veterans until they die, with the prospects 
and as they grow older they need more prosthetics as their body 
function begin to deteriorate.
    From the beginning of the war, through current--to the end 
of the year 2007, 300,000 of the Iraqi-Afghani vets have 
returned and sought care from VA. For the nearly 800 veterans 
who were treated for major amputations within the Department of 
Defense, the prosthetics has provided services to over 200 of 
these major amputees last year and our data shows that we are 
going to double in this fiscal year as they are discharged from 
DOD care and come into VA care.
    We have implemented several initiatives to assist the OEF/
OIF service members as a transition into VA care. Our VA 
prosthetic staff, case managers and social workers have regular 
contact with the program officials responsible for the various 
benefits a veteran may be eligible to receive.
    I am running out of time here. I would like to add one 
important thing. We have just recently signed a contract with 
the Amputee Coalition of America to furnish amputee peer 
visitation programs at all of our 21 VISN integrated service 
networks. This program is designed to assist individuals and 
their families coping with a variety of injuries. It will allow 
enhanced networking among our patients with amputations to 
include sharing of information regarding access to prosthetic 
care in the VA.
    In addition, we work in concert with DOD to provide 
specialized items such as hand cycles, personal digital 
assistance and vehicle modifications which DOD is not able to 
provide. So even though these soldiers are still active duty, 
we work with Walter Reed and with Brooke Army to make sure that 
these active duty soldiers as they are recuperating are able to 
get the wheelchairs, hand bikes and whatever they need in order 
to facilitate their recuperation. And if they go home and 
convalesce and leave, even though they are still active duty, 
the local VA will provide all the prosthetic care they need. We 
will continue to do that. We are always looking forward to the 
new technologies as they are coming on the marketplace. We want 
to be first in line to make sure that our vets have that 
available to them.
    Mr. Chairman, that concludes my statement. I am pleased to 
respond to any questions you or the Committee members may have.
    [The prepared statement of Mr. Downs is included in the 
appendix]

    Chairman Braley.  Thank you, Mr. Downs. Despite the VA's 
best efforts to provide veteran amputees with the best care, 
some veterans have raised concerns about their ability to 
secure certain types of health care in the VA system. Some have 
mentioned that in certain VA facilities, veterans are told they 
are not permitted to receive care from practitioners outside 
the VA setting. To your knowledge, does the VA prohibit veteran 
amputees from seeking care from outside practitioners?
    Mr. Downs.  What they are talking about outside 
practitioners--I assume they are talking about--we have 
contractors within the VA catchment area of the facility. And 
so we ask the veteran--we give the list of the contract 
prosthetists--and these are the small companies around the 
facility. And here is a list of these contractors. So you can 
go to any one of these that you choose. Now, those prosthetists 
who do not have a contract, the veteran is allowed to go there 
if they wish because it has a lot to do with the chemistry 
between you as the amputee and the prosthetist. So they are 
allowed to go there if they want, but we, of course, have this 
contract process and we encourage them to use the contractors.
    Chairman Braley.  Now, we know that in some parts of our 
country, particularly the more rural areas, access to those 
services can be a challenge. Are you able to tell us today what 
might be the greatest type of mileage range that a veteran 
returning home would face in locating a certified O&P provider 
that would be able to meet their needs in certain parts of the 
country?
    Mr. Downs.  Oh, out in the West, sometimes a couple hundred 
miles, they have to--one of our--it has to be a certified 
prosthetist. That is how we ensure quality. But if that 
veteran--whatever the prosthetist closest to that veteran--we 
are very flexible in how we work with the veteran in trying to 
achieve their needs. So we have a system set up. That is how we 
control this complex, multi-faceted operation. Taking care of 
1.5 million disabled vets and trying to make sure that all of 
them are pleased with their care is a challenge. So what we 
will do if one of those veterans who is 200 miles away, if 
there is a prosthetist close to them that is certified, who is 
not on the contract and he wants to go to that prosthetist, 
then we will work on an arrangement with the prosthetist. We 
will ask that prosthetist to accept the contract price in that 
geographical area, and invariably all of them do. It is a fair 
price. And then the arrangements are made.
    We are a large organization, sir. And certainly we have 
bumps along the road. We have new employees who don't 
understand the rules, the policies. There are always issues 
that we have to deal with. So we try to keep on top of them. 
And one of the things we do is make sure we are available. We 
have a system set up so that the veteran--if the veteran is not 
getting satisfaction at that facility, there is any number of 
places they can go to. First of all, of course to their 
Congressman. Also they can contact their veteran service 
organization. They can call us. We have a Web site. We 
developed that after having a forum meeting with the Iraqi/
Afghani vets. A number of them were complaining about the very 
things you are talking about. And we are saying we have an 
actual policy to cover all of this, why isn't the word getting 
out there. It is a constant frustration communicating and 
getting the word to everyone. So we had this forum and these 
folks came together. And they said what you need is an Internet 
site so that we can start talking to you. So we developed an 
Internet site--and I have got the numbers here some place. We 
are up close to 300,000 hits on it, so that people can now 
contact us directly that way. Our numbers are published, my 
phone number, along with my staff. Our phone numbers are 
published. We have VISN prosthetic reps. Their numbers are 
published. So we attempt everything we can to get communication 
out to people. And it is a constant battle, I have to tell you.
    Chairman Braley.  One of the problems that was identified 
when we had multiple hearings in oversight and reform on the 
independent review group's report and the Wounded Warriors bill 
that we passed out of the House was that there seemed to be a 
great number of case managers in the VA system who were 
advocating through the system itself on behalf of patient, but 
there seemed to be a lack of patient advocates whose sole 
responsibility was to help patients navigate sometimes the maze 
of regulations and requirements and be there as a source to 
patients.
    Are you aware of anything going on with O&P patients to 
address that problem?
    Mr. Downs.  Well, they are like any other patients. They 
have access to those case managers at the medical centers. Let 
us say they went down to the prosthetic service, they went to 
the amputee clinic team and they didn't think they got the 
right service. They can go to the director of the medical 
center for one. They can go to the patient advocate and voice 
their concern. So there is a prosthetist in place there for 
that individual to voice his concerns.
    Chairman Braley.  I am sure that you are aware that 
Congressman Filner, who is the Chair of the Committee on 
Veterans' Affairs, recently introduced the Injured and Amputee 
Veterans Bill of Rights. And this legislation would require 
displays in VA amputee clinics, documents informing veterans of 
their right to quality O&P care. It would also express the 
rights of veterans to see the practitioner of their choice.
    Do you see that this proposal would be useful to veteran 
amputees who are confused about their rights in the system?
    Mr. Downs.  That would help. It certainly would. Anything. 
VA has a Patient Bill of Rights that is posted in all our VA 
facilities. That covers all aspects of their medical care. But 
if it is felt that an extra posting in our labs would help, 
then fine. Because we have a passion to make sure that these 
men and women coming back get the best of care and that the VA 
is open to them, and so we keep putting the word out 
constantly. We have monthly conference calls with our 
orthotists and prosthetists. We have an e-mail group with our 
prosthetists and orthotists. And as I said, they attend the 
academy meetings once a year. We do everything we can to make 
sure that they are aware of what is our policy from Washington. 
They need to hear that all the time and we tell them that all 
the time. We tell them--and we tell the clerks, we tell 
everyone that we can in the prosthetic area. These individuals 
coming in here are dealing with lots of issues, losing an arm, 
spinal cord injury, you are blind, your life is ended you 
think, you have got to get yourself back together. So what they 
need is a friend. So when they come to prosthetics, certainly 
we preach to them you don't just say no if you have to say no, 
we don't want you to say no, figure out how to say yes. And for 
a combat injured, there is no doubt it is a yes. And then you 
make sure that you take care of this person. And that means--
and we have tried to institute this, too. If you have got to 
take that person by the hand--and we have a number of people 
that do that. Take him by the hand, he doesn't need anything in 
prosthetics, nobody has taken care of that, take him down the 
hall yourself to rehab or wherever he needs to go. It is that 
constant word all the time from Washington that they know what 
the message is, and we try to make sure that that message is 
clear to them.
    But again, it is always a challenge. We are dealing with 
200,000 employees in VHA and about over 1,000 of them work in 
prosthetics and you have everyone in range from GS-5s up to the 
GS-14s, the whole range of issues they are dealing with because 
we are taking care of--with 1,000 employees, we are providing 
appliances to 1.5 million disabled veterans and wheelchairs and 
legs and aids for the blind. And each one of those specific 
disability areas takes expertise. And you have to be flexible, 
too, because--for instance, this TBI, traumatic brain injury, 
that we are dealing a lot with now with these young troopers 
coming back, we are discovering new prosthetics that we need to 
provide to them. Because a prosthetic really at the VA is 
anything that goes to support a bodily function. So what they 
determined when we had some meetings is that with a traumatic 
brain injury patient, if you take a personal device, a personal 
digital device like a BlackBerry, only don't call them that, 
and put a different program into it so that it will read 
software. And so for a blind or little-vision person, it will 
give an individual instructions of how to navigate. So even 
though we didn't use PDAs before, we now have the prosthetic 
device now. So we provide those.
    We have to be alert to all kinds of new technologies that 
can be used in different ways to serve the disabled that we 
really hadn't thought about before, and we have disabled people 
on our staff nationwide in wheelchairs, low vision. And so my 
own people out there keep us informed of new technology. It is 
a dynamic process.
    Chairman Braley.  If you were listening during my opening 
statement, I brought up the interrelationship between providing 
optimal care for O&P patients to deal with their long-term 
health care needs, and I wonder if you are aware of any 
longitudinal studies of the O&P patients in the VA system and 
how they respond over their lifetime to getting the maximum 
return on their O&P investment and what other types of health 
care implications it has for them?
    Mr. Downs.  Well, they have--there is not any longitudinal 
studies now, but there are--recently there was a meeting out in 
Seattle with our VA folks and researchers to put together a 
system--how can we do a longitudinal study. There has never 
been really a good way up to this point of saying which limb is 
better, is a computer leg better or of the different types of 
ankle, which one is the best, which type is the best knee. And 
it really comes down--which socket is the best socket. It comes 
down to basically how does it feel. If it feels good and 
comfortable, then it is a good prosthetic device. And we have 
often--we have not had the data systems yet, sir, to track 
that. And now we are getting to the place we have data systems 
to track it. Then we have to have the researchers develop 
programs to look at those longitudinal studies. Is the body 
powered arm superior to the myoelectric arm? Do you need a 
myoelectric arm for social occasions and use the body powered 
arm for doing your day-to-day work? And of course we provide as 
many different arms and legs to the individuals as they want. 
They want a running leg, they want a walking leg, they want a 
swimming leg. All of these are available to them. And that is a 
misperception that the VA doesn't do this. We actually provide 
all of this. In fact, we have always been in the vanguard of 
it.
    As a medical health care system, a national medical health 
care system, where we do have problems, it is--people point it 
out very quickly. And that is good because we are responsive 
and we need to be able to go out and find out what exactly is 
that problem out there, what is occurring. So we do have this 
feedback system to keep us up on the technology, make sure we 
know what is going on out there.
    And one of the things that frustrates my staff and I all 
the time is we deal with the problems every day. All the vast 
majority of the disabled veterans out there who are happy with 
the service, we never hear from them and that is great. But we 
hear the problems day after day. So we certainly try to stay on 
top of those, sir.
    Chairman Braley.  Thank you, Mr. Davis.
    Mr. Davis.  Thank you, Mr. Chairman. Thank you, Mr. Downs, 
for your service. God bless you. You are a true American hero, 
and I appreciate that. Last year I lost my cousin Fred who was 
in a wheelchair from Vietnam. And thank you for the service you 
gave to Fred and those things will never be forgotten. I do 
appreciate your service.
    You mentioned in your response to the chairman that a 
veteran can go outside the contract and choose a provider. Is 
there any negative consequences to the veteran if they do that?
    Mr. Downs.  No. No. And where the problem comes from, sir, 
is that at the local level, people get into routines and say, 
here is our list of contractors and perhaps they don't explain 
fully to the person, if you are not happy with any of those 
contractors, if there is a prosthetist you would rather go to--
maybe that conversation doesn't take place as often as it 
should. So that is where the confusion comes in sometimes, too. 
But one of the keys to our success in our prosthetic program is 
that--and it was developed in World War II because of--the 
amputees coming back were just getting low bid limbs and that 
was it. They were very angry, they went to Congress, laws were 
passed and the Prosthetic Service in the VA was formed. And the 
idea was to increase the quality of the limbs, make sure we are 
on top of things. So that tradition remains true today. And one 
of the reasons I was appointed 28 years ago to the position of 
prosthetics--I have been around a long time, but I love this 
job--as a Vietnam vet I was bound and determined that future 
veterans would not go through what I went through and my peers 
went through and your cousin went through. So we are in the 
system now and we are bound and determined we are going to make 
it as good as it can be.
    Mr. Davis.  So there is no negative financial consequences 
if they go outside?
    Mr. Downs.  No.
    Mr. Davis.  The only requirement you have is the provider 
is actually certified to provide the product?
    Mr. Downs.  Yes. There is no negative. And if a prosthetist 
says to the individual, well, you have got to pay extra money, 
you have to co-pay, that is absolutely wrong. And if we find 
out about it, you can't get any contracts from the VA because 
we pay for everything. These soldiers coming out of DOD, when 
they--they are used to the Walter Reed and the Brooke 
environment, so they want to stay with the military. But when 
they find out that TRICARE requires a co-pay and this and that 
and even for the combat veterans, well, then they start 
shifting to the VA because we provide a holistic picture of--
because we take care of everything for you. And they learn 
that. And that is the reason they are shifting to the VA in the 
numbers that they are, because of our philosophy and how we 
deal with the disability.
    Mr. Davis.  You mentioned in your testimony working with 
Walter Reed and other active duty military. Can you tell me how 
you work together?
    Mr. Downs.  Yes, we have--for instance, after this hearing 
I will be going out to Walter Reed for a town hall meeting they 
are having so I can speak to the amputees and the other 
disabled about what we have in prosthetics and the VA. I myself 
have been going to Walter Reed for years before the war and 
certainly now during the war just to avail myself on a personal 
level, pure--I am an amputee and I am succeeding, and therefore 
you can do the same thing. And that is very important 
psychologically, because when you see someone who is doing 
something and you are laying in the bed--I remember my first 
example of that, I was in bed at Qui Nhon and I had been 
wounded about 5 days, my arm was gone and I thought my world 
had ended. And this major, she brought by a picture of a double 
arm amputee and he was fly fishing and he was driving. And it 
clicks in your mind, well, if he can do that, I can do that. 
Well, it is the same kind of philosophy of me and other peer 
visitors. Lots of peer visitors go out there to do that. So, 
yes, we go to Walter Reed on that level.
    On the VA level, I work out there with the clinicians so 
they know we are here. We work our way through problems. That 
is how we begin to realize that they weren't able to buy the 
high-tech wheelchairs and sports wheelchairs. So we worked out 
a deal where we just provide those. And even though 
appropriated funds for us weren't supposed to depend on active 
duty and vice versa, we went to the Secretary of the VA, at 
that time Mr. Principi, and he said sure, go ahead, we will 
take care of that. So we worked out those arrangements.
    Now, we officially--we also have a--we are rotating our 
prosthetists, orthos and therapists through Brooke and Walter 
Reed so they can spend a week there to see what it is like with 
the active duty. So when they go back to the VA, they have got 
a better sense for it. We have, of course, case managers and 
social workers at each one of those facilities. And those case 
managers at the VA level are to be--they get the hand-off from 
the Brooke and Army--or from Brooke and Walter Reed and I think 
now San Diego is in this, Balboa. So we have a lot of activity 
going on.
    My deputy, Jane Randolph, will be going down to the 
military treatment facility at Brooke in a week or two. And 
that is where they bring their clinical folks together. And we 
will have some VA people there so that we will receive training 
on what is going on and what is current right now.
    So, yes, there is a lot of activity. You know what happened 
to us at the beginning of the war is we are in our routines. 
And so these young soldiers were coming into the medical center 
and we thought if we had everything--into the Walter Reed, for 
instance. What happened was that they then go home on 
convalescent leave and they go to the VA medical center and 
they would say no, you are not a veteran yet so you can't come 
to the VA system. Well, of course, that was a political 
relations nightmare for us because the soldiers said I can't 
get treated in the VA, they won't treat me. That was one of the 
problems we had. Because you can't explain to a young soldier 
the difference between DOD appropriations and VA 
appropriations. They don't understand that. But that is how we 
operated, because that is the way the law was. So that caused 
us problems.
    The other problem was for some reason the perception was 
the VA did not provide high quality, high tech prosthesis. And 
in this day and age, these kids out there, they would type in 
bad stuff into the Internet at the speed of light all around 
the world and all of a sudden we weren't doing this. And it 
took us--it has taken us years to--you know, we are trying to 
prove our point that yes, we do. So we learned a lot of 
lessons. And we have made a lot of corrections since then in 
the forum meetings with the folks who were criticizing us so 
they could see what we are really doing, the Internet site that 
we have set up, and pushed emphasis on making sure that we 
reach out to these amputees.
    So what our folks are supposed to do now is that when a 
soldier goes--is discharged, the VASecretary sent out 500 and 
some thousand letters to those individuals to make them aware 
the VA is there, we provide services to you. Our prosthetics 
people are supposed to contact each one of the amputees or 
individually who uses prosthetic devices to let them know that 
we are here for you, when you need us come here. So we have a 
lot of those lessons learned that we are implementing now, too.
    Mr. Davis.  How does the VA ensure a timely transfer of 
medical records between active duty military and the VA?
    Mr. Downs.  That is a question I am not really 
knowledgeable enough to answer. They are working hard on it, I 
can tell you that. Because the problem is that the DOD medical 
records are different than the VA and they don't transfer 
electronically. That is an issue. And I think the report 
probably pointed that out. So I know we have teams working on 
that very hard and diligent with DOD. But I am not 
knowledgeable in that area.
    Mr. Davis.  Let's take it from the next level then, from 
the VA to the prosthetist, to the provider. What type of 
communication do you have between the local hometown community 
provider of a product?
    Mr. Downs.  Well, there are a couple of things that go on. 
First is the local prosthetic rep, prosthetic chief is supposed 
to have contact with the prosthetic services shops in his area 
or her area and they have had for years and years. And they in 
the contract--so when they get ready to do a new contract, they 
send out a request for proposal to the folks who are already on 
contract but it is also published in FedBizOPPS and other 
publications. So that those prosthetists can compete for the 
contract in that VA area. And that relationship, the 
prosthetist is often a part of the amputee clinic team. So that 
relationship goes back and forth, whether they meet on a 
weekly, basis, biweekly, whatever their workload is. So that is 
the relationship that exists at that level.
    At our level is that we meet with the academy and the AOPA 
leadership on a regular basis. Often they will contact me if 
there is a problem someplace. So our relationship there I think 
is very good, very solid. I hope they confirm that so that--we 
are open to whatever they have to say to us, because that 
relationship is key. One of the things that I had to build back 
up when I took over is all those relationships had gone bad. 
And to me, we are not successful unless--in the VA unless we 
have a relationship with the people who provide these goods and 
appliances. And so we need to have that communication flow. You 
can't do this in a vacuum. And to me I have never considered 
civilian industry as the enemy, so to speak. It is our partner. 
And I really believe that because another philosophy of mine is 
you buy American and you buy small business. And that is 
something that I admitted in prosthetics in the beginning, and 
when I took over the logistics 3 years ago that was the 
philosophy. And we established small business liaisons at each 
of the VISN levels. And we are supposed to have them at the 
facility level.
    We are building on that relationship. We just attended the 
big small business meeting out in Las Vegas and gave a 
presentation out there last week or the week before last. So it 
is a continual process of keeping people informed, 
communicating. And whenever--we think we are trying to cover 
all the bases. We are trying to come up with new ideas all the 
time. But again, being available to the national 
representatives of the associations, the prosthetic--we make 
presentations at AOPA so that we are there, they can come and 
ask us questions. And, of course, all of our information is 
published so that they can call us and send us letters, which 
they do. And we answer a tremendous amount of volume of mail 
and telephone calls. I meet with--I meet or my staff meet with 
vendors, not only in the prosthetic world, but vendors of all 
types because as the Chief Officer of Prosthetics and Clinical 
Logistics, that covers the whole gamut of everything we do in 
the health industry, med surg equipment, the nonexpendable 
equipment.
    So we have found that if we allow people to come in and 
talk to us instead of trying to brush them off, then we have a 
much better relationship because they need information, we need 
to give it to them. The government is a very complex 
organization. The contracting to me--you know, contracting to 
me is like in the government. We have all these rules and 
regulations, 200 pages of FAR. And it makes it dad gum hard to 
get a contract with anybody. If you are in private industry, 
you look at the government and think how the heck do they do 
business. Well, it is difficult but we follow all the rules and 
regulations to try to get there.
    Mr. Davis.  I will yield back.
    Chairman Braley.  The gentleman from Pennsylvania is 
recognized for 5 minutes.
    Mr. Sestak.  Thank you, Mr. Chairman. Thanks for your 
service, sir. Two things I think are most important, I would 
gather, and you mentioned at least one of them and even the 
second. The first one is how to get information to all the 
veterans, not just in your area, but everywhere else. The 
second one is the standard of care, that it is consistent in 
the quality that everyone gets. And so it is a bit 
disconcerting to hear the Tammy Duckworth testimony on the 
Senate side where she made it very clear that the care being 
provided in Walter Reed and other places was of a higher 
quality than the VA to her exposure not just as an amputee, but 
for the organization she heads in her State.
    My question from--the first of my questions are, you have 
several standards of quality. I mean, we have over 600 good 
contractors out there. But how do we ensure this standard? I do 
mentioned several of them, the ABC and the BOC. But the ABC is 
felt to be a higher and more quality of care. Why do we have 
two standards then? Then you have another standard called the--
as I remember, the National Commission on Prosthetic and 
Orthotic Education. If you want to work with universities and 
you are starting to go out that way yourself with this 
agreement you have just had and then you have your own 
guidelines.
    Do you think we need to step back here and have one 
standard quality of care unique to the veteran that we can all 
kind of accept?
    Mr. Downs.  Well, sir, let me answer that for you. The 
American Board of Certification is the oldest certified body 
that I know of in America. And so--
    Mr. Sestak.  Just because the chairman will cut me off 
shortly because I am a freshman.
    Mr. Downs.  Sorry.
    Mr. Sestak.  Should we have one standard is really my 
question. There is four right now you are kind of using.
    Mr. Downs.  No, not really. There are only two 
certification bodies for prosthetists and orthotists, and that 
is ABC and BOC. And BOC is the newest one. I think it came in--
we accepted them as a certifying body. And I forget when it 
was, the late 1980s or early 1990s. And in the world of 
accreditation, they meet those requirements to be an 
accrediting body.
    So our general counsel tells us that we have to accept them 
because ABC or BOC, they are both verified by accrediting 
bodies. And those are the two--
    Mr. Sestak.  If I could, sir--I understand that. But why 
don't you use some system like your VA/DOD clinical practice 
guideline for rehabilitation for lower limb amputation? I have 
gone through it and it is fairly vague in some areas. But why 
not--I know somebody is telling us we have to use it. But is it 
the best when we have two different sets of criteria out there?
    Mr. Downs.  ABC is the best.
    Mr. Sestak.  Should everybody be required to go ABC, then, 
because it is the best.
    Mr. Downs.  I have to say this. ABC and BOC are the best. 
In fact they are the only certifying bodies for us in the area 
of prosthetists and orthotists. They have education programs, 
requirements and continuing education programs. So those are 
the best. There is no problem there. Going back to Tammy and 
her disillusion with the VA--
    Mr. Sestak.  If you don't mind. I could come back in the 
second round.
    Mr. Downs.  Go ahead.
    Mr. Sestak.  I was just struck by her testimony, and then 
diving into the different accreditations if I could, how do we 
ensure that all these small companies ensure that our--what is 
the standard we go by to ensure every small company will give 
the same type of access to all the technologies that prevail 
out there? And you mentioned a number of them. You know, one 
you mentioned early on was the microprocessor controlled knee. 
How do we ensure that every one of those has access to the 
technology? Do we and how do we do it?
    Mr. Downs.  Well, this is part of the certification 
prosthetist. So, for instance, a company may be certified by 
ABC or BOC. So that means they have met certain education 
requirements and length of time and training and experience. If 
a new technology comes out like the C-Leg. So that manufacturer 
says here is the criteria that you must be trained on as a 
prosthetist before you are going to be allowed to fit this. 
Because the company doesn't want the--
    Mr. Sestak.  Why do you waive companies from being 
accredited and give contracts to them? You have under your 
Veterans Administration Solicitation 260-AA, you actually say, 
hey, we will accept proposals from those offers who have not 
been able to complete their accreditation in the ABC and BOC. I 
am happy to give you a copy of it. So my question is, why are 
we actually solicited--my concern keeps going back to what is 
the standard for consistency, particularly when we are offering 
contracts out there without the accreditation being done by 
these companies?
    Mr. Downs.  Sir, the guarantee of quality is a 
certification process. I am not familiar with that instrument 
you are reading there.
    Mr. Sestak.  I should end. I am over my time. My background 
in the military has always made me concerned when there is two 
sets of standards or more. And my concern really comes--I am 
seeing now there is a little leakage here where we are letting 
some of these companies maybe be accredited before they are. 
But I want to make sure the care for the veteran is number one 
and consistent across the Nation.
    Thank you.
    Mr. Downs.  The only reference I can make to that without 
seeing a document is that the--by the time the contract is 
signed, they must be certified. They must meet certification of 
ABC or BOC because it is our policy that you must be certified.
    Mr. Sestak.  It says in the contract award that 6 months 
after the award they could become certified.
    Mr. Downs.  Okay. Well, maybe somebody has changed the 
contract without us knowing it at a particular facility. 
Because I can guarantee you that is not something we would 
accept. And in the medical area, there are often more than one 
certification--more than one certifying body on the 
accreditation process. It would be easier for me if everything 
was simple like that, I guarantee you. I will say that. It 
would be easier for all of us in the government if there was 
just one set of criteria on something like that.
    Mr. Sestak.  I can't agree more. I didn't understand all 
these--
    Chairman Braley.  The gentlewoman from New York is 
recognized for 5 minutes.
    Ms. Clarke.  Thank you very much, Chairman Braley and 
Ranking Member Davis, for holding this important hearing today. 
Mr. Chairman, let me just briefly state that I felt compelled 
to attend this hearing today, and I am glad I did. I want to 
feel assured that quality health care is provided to our 
injured soldiers who fought in Afghanistan and Iraq.
    Many of these veterans are young Americans, who are at the 
advent of their adult life and they have lower incomes and 
whose injuries necessitate special health care, attention and 
response. I am concerned that these very valued individuals 
have complete and full access to the prosthetics they need to 
fulfill their God given potential. We must ensure that the VA's 
health care system is operating at such a level that if a 
veteran is seeking assistance, they will in fact get the best 
available care.
    Having said that, I am honored and actually I honor you, 
Mr. Downs, for your ongoing service today and your presence at 
today's hearing. I would like to know if you can tell us the 
percentage of prosthetic care that is provided by VA personnel 
versus the percentage provided by contracted service providers.
    Mr. Downs.  Do you want me to answer that now, ma'am?
    Ms. Clarke.  Yes.
    Mr. Downs.  Artificial limbs, about 97 percent of those are 
provided by our contractors. About 3 to 1 percent of the limbs 
are--less than 3 percent are fabricated by our VA labs of lower 
extremities and 1 percent of the upper extremities are 
fabricated by our VA labs, and all the rest of the business 
goes to private industry.
    Ms. Clarke.  Let me ask. What kind of outreach, including 
initiatives, and conferences does the VA Office of Small 
Disadvantaged Business Utilization use to build and maintain 
relationships with independent prosthetic contractors? Since 
most of the business is really outside of your purview. For 
instance, are you using the Internet and computer technology to 
establish quality control and information sharing regarding the 
latest in prosthetic technology?
    Mr. Downs.  Well, the OSDBU, which is the Office of Small 
and Disadvantaged Businesses, we work very closely with them to 
make sure that we are included in any programs they put out 
across the Nation and what their responsibility is, not only in 
prosthetics but across the board, that the VA's attention is on 
doing business with small business. So we work closely with 
them and they, of course, attend many conferences with small 
businesses and are always promoting that.
    Ms. Clarke.  Just put a pin in that statement. Does the VA 
provide oversight? Is there a liaison so that you are clear on 
them meeting their goals in terms of that and what type of 
quality they are supporting in terms of businesses that are out 
there?
    Mr. Downs.  Yes, ma'am. OSDBU's job actually is to oversee 
what we do. The office of OSDBU, they answer directly to the 
Secretary. And so Scott Denison, who is in charge of that, why 
his job is to make sure we are doing our job. So he does 
performance measures on us which are presented to the Secretary 
every month, how are we doing in VHA, how is VBA doing, how is 
the cemetery service doing. And all those socioeconomic goals 
are broken down and they were raised for all of this year. And 
as you know, a law was just passed.
    So our first place that we have to go to in VHA is to the 
small disabled veteran owned businesses. They are our first 
avenue that we have to look at in any business that we do now.
    Ms. Clarke.  Do you feel assured that there is a quality 
control, there is enough communication vehicles to make sure 
that the standard of care, and I am just sort of referring back 
to something that Congressman Sestak said, the quality of care 
is available and equally distributed to all veterans who seek 
it?
    Mr. Downs.  Yes, ma'am. In the area of prosthetics, the 
reason that the ABC or BOC certification is so crucial is 
because that is the standard of care. Those are the--that is 
how we guarantee quality. Being certified, of course, doesn't 
mean that you are naturally the best. Certified means you have 
met the criteria that you should be at a certain level and so 
that is the only measurement we have actually, is that 
certification--and that is the same way that we do with our 
other medical areas too--is that whether you are a cardiologist 
or a physical therapist you have got to be accredited in your 
field before you can work for the VA and provide that care. And 
that is one of the ways that we determine quality. And there 
are other areas of quality, too, which are not so easily 
measured in the area of prosthetic/orthotics. Certification is 
one process, but then again is the individual receiving 
training in that device that they are wearing, that they are 
being provided.
    So that is another aspect of it, that each of the amputee 
clinic teams is supposed to make sure--part of their criteria, 
has that person been trained on how to use that new limb, that 
new type of limb, are they being introduced to the new 
technology. So those are all constant signals that we send out 
to people. But the certification is something that guarantees 
us at least equal access of the quality--the potential for 
quality.
    Ms. Clarke.  Thank you very much, sir. My time has run out. 
Thank you, Mr. Chairman.
    Chairman Braley.  Mr. Downs, because of the importance of 
your testimony, we are going to open up to a brief second round 
limited to 2 minutes per person. So I would ask you to keep 
your remarks focused so that we can move quickly through this.
    But one of the concerns that has bee raised by independent 
O&P providers is that the terminology and the processes used by 
the VA have sometimes not kept up with current thinking in the 
O&P community. Specifically there has been criticisms that some 
of the RFPs that are used are error laden and contain outdated 
terminology.
    Can you tell us what the VA is doing to address those 
concerns and make sure that the internal departmental framework 
matches up to what is going on in the industry?
    Mr. Downs.  RFP.
    Chairman Braley.  Requests for proposals.
    Mr. Downs.  I didn't realize that that was a problem, and I 
will immediately address it.
    Chairman Braley.  And maybe some of our other panelists can 
address that in their remarks and follow up with you.
    The other question I had for you is we know when someone 
loses a limb outside the VA system and they are either being 
cared for by Medicare or sometimes by private pay, one of the 
things that is often critical in helping plan for the long-term 
care needs of those patients is either a prosthetic needs 
analysis or that may be incorporated into a broader life care 
plan. This gets back to my concern I raised earlier about the 
total impact of a prosthetic device and the need for that type 
of long-term care.
    Many of the young men and women who are coming back from 
Iraq and Afghanistan are in that 20-year age range. They are 
going to have a 55-year life expectancy. So is the VA doing 
anything to do metric planning for the long-term care needs so 
that we in Congress can be better equipped to talk about what 
it is going to cost over the life expectancy of these returning 
veterans as we are doing our long-term financial planning here 
in Congress?
    Mr. Downs.  Our metric in that area is our budget planning 
and the numbers of disabled that we serve. And in that respect, 
yes, we project out in the coming years, the age of the 
veterans, the type of devices and the increase in the cost and 
the potential of new technology. We factor it into our budget. 
So that is how we forecast the metric to take care of that.
    Chairman Braley.  Thank you.
    Mr. Davis.
    Mr. Davis.  How does the VA ensure that veterans are 
receiving consistent care across the country from prosthetic 
providers?
    Mr. Downs.  Well, we have our feedback mechanism on that, 
of course, is from the veterans themselves. But the amputee 
clinic teams, they are the ones who evaluate the limb after it 
is fabricated, the individual--the patient is supposed to come 
back into the amputee clinic team and show the amputee clinic 
team his limb or her limb and the team asks him a number of 
questions, are you satisfied with it, does it fit, et cetera, 
et cetera, and only then will the VA pay for it. That is the 
process. So that is the quality assurance there.
    Mr. Davis.  One last question. How does the acquisition 
process differ from the national contracts versus local 
contracts? Is there a difference?
    Mr. Downs.  No. Well, yes and no. National contracts, we 
establish the contract and the pricing structure. And then that 
is how--that is what every one of the individual facilities 
then must pay to use that contract. At the local facility when 
they do a contract, it is negotiated locally so they are in 
charge of what that structure would be, the pricing structure, 
and it is different at each place. We don't have a national 
contract for artificial limbs or orthotics.
    Mr. Davis.  Thank you. I yield back.
    Chairman Braley.  The gentlewoman from New York, do you 
have any further questions?
    Ms. Clarke.  Thank you, Mr. Chairman. Mr. Downs, how does 
the VA analyze or track prosthetic devices utilization and how 
does it schedule repair and replacement of prosthetic 
components and technologies?
    Mr. Downs.  That is a difficult thing for us to do. We know 
how many new devices and what type and we have our repair 
costs. So we know what we pay for repairs each year. But we 
haven't--we track through our compliance with the contract, the 
types of limbs that are provided, and so what we look for there 
are trends. Do we see an increase in the number of C-Legs, for 
instance, and--but we don't really have a way of analyzing it 
beyond that.
    The uniqueness about an artificial limb is that the patient 
has got to be happy with it. And one of the questions we always 
have is, well, we issue it to them, do they wear it or do they 
stack it away. So one of the ways we check on that is do they 
come back. Because if they are coming back, they are regular 
users. If we provide it to them once and they don't come back--
    Ms. Clarke.  Do you think it would be valuable to sort of 
set up a separate sort of database that is dedicated 
specifically to this data and then having that available to 
distill and really, you know, follow up on it?
    Mr. Downs.  Absolutely.
    Ms. Clarke.  And if a veteran has the option of using a VA 
laboratory or a contractor, what are the advantages and 
disadvantages with each choice?
    Mr. Downs.  There is none really. It has to do with the 
personal preference. Sometimes if you like the prosthetist--it 
depends on how you are treated. Did the people in the VA lab 
treat you nice, did they fabricate a quality limb and you are 
comfortable with it, you are going to go back. If you are not 
comfortable with it, you are not going to go back. That is 
clear cut. You can't make an individual go to a prosthetist 
that is not doing a good job for them. And the strange thing 
about it is, is that I may think this prosthetist is good, but 
another amputee thinks that prosthetist is terrible. So that 
chemistry stuff comes in there, too. But there are no negative 
consequences there.
    Ms. Clarke.  Thank you very much. Thank you, Mr. Chair. I 
yield back.
    Chairman Braley.  Mr. Downs, thank you for taking time from 
your very busy schedule and joining us today. We really 
appreciate your testimony and look forward to continuing to 
work with you on these very important issues that affect our 
Nation's veterans.
    At this time, I would like to call our second panel up and 
ask them to be seated so that we can begin with their 
statements.  Before we begin with the second panel, I want to 
apologize to you for the constricted environment you find 
yourself in at the table. This is not our normal hearing room 
for the committee and it is currently under renovation over at 
Rayburn. So we would not have these columns here if we could 
create the ideal hearing room. But thank you for your 
indulgence.
    I will introduce each individual witness and allow them to 
give their statement before moving on to the next one. And, Mr. 
Davis, you will be introducing Mr. Smith; is that correct?
    Mr. Davis.  Thank you.
    Chairman Braley.  Our first witness on Panel II is Captain 
Matthew Bacik, who is a 2002 graduate of the United States 
Military Academy. He served two tours in Iraq and one in 
Afghanistan. Captain Bacik has served in the 82nd Airborne 
Division, and I have to tell you that my colleague and friend 
from Pennsylvania, Patrick Murphy, will be delighted to hear 
that you joined us here today. And the elite Special Operations 
Third Ranger Battalion. He received three Purple Hearts and a 
Bronze Star over the course of 14 total months deployed. He 
medically retired from the Army in 2006 after losing his right 
leg below the knee, the result of an IED attack near Baghdad.
    Captain Bacik currently coordinates the Wounded Warrior 
Project--thank you for that--where he performs outreach 
services for OIF/OEF soldiers and veterans in Alabama.
    Welcome.

        STATEMENT OF CAPTAIN MATTHEW BACIK, RETIRED ARMY

    Captain Bacik.  Mr. Chairman, Congressmen, thank you for 
giving me the opportunity to be here today. It is an honor. I 
would like to share with you just my experience in 
transitioning from the battlefield to the civilian world.
    I was deployed three different times, Iraq in 2003 with the 
82nd Airborne Division, Third Ranger Battalion in Afghanistan 
and Iraq in 2005, and received a total of three Purple Hearts, 
all from improvised explosive devices. My third injury 
destroyed most of my right foot, and I underwent a total of 13 
reconstructive surgeries before my leg was amputated on the 
right side below the knee.
    Shortly after the amputation, I chose to pursue a medical 
retirement. My experience is somewhat unique. I did not have an 
amputation at Walter Reed and have always relied on private 
providers for my prosthetic care. The VA system has been very 
beneficial to me for three specific reasons: One, the VA has 
paid for and approved the absolute best equipment that I could 
ask for; two, communication between myself and Mr. Fred Downs' 
office through their open forums; and, three, I have 
established a very strong relationship with a provider who is a 
member of my local community.
    I would like to focus on the relationship that I have 
established with Glenn Crumpton of Alabama Artificial Limb and 
Orthopedic services in Montgomery, Alabama. Glenn is a 
certified provider; however, he does not hold a contract with 
the VA. His family has been providing prosthetic arms and legs 
for veterans from every conflict since World War II until the 
present. And just as important, before the wars in Iraq and 
Afghanistan, Glenn had experience making legs for all different 
types of amputees, both active and not so active folks.
    Glenn's patients wanted to run, bike, swim, skydive and ski 
in the best available equipment and Glenn's shop has a wealth 
of trade knowledge in crafting these custom fit prosthetics 
that enable folks to do those very challenging physical 
activities. He has an unparalleled conviction to learn and grow 
with his patients and carries the heavy burden. If the leg he 
manufactures isn't right, the patient's life isn't right.
    Last month, I met Glenn twice at 6:30 a.m. before work to 
work on my new running leg. Just last week, I broke my every 
day--my main foot. Glenn and I checked our respective schedules 
and by chance we were both in Birmingham, Alabama on separate 
business. Glenn had a foot shipped to the hotel that he was 
staying at and when our respective engagements were completed, 
I met Glenn in his hotel and I had a new foot put on and I was 
100 miles from my home and 100 miles from Glenn's shop.
    Most of our work together has been on weekends, evenings 
and in early mornings, and he provides that same level of care 
to all his patients. The interesting thing, how did I find 
Glenn? It was just good luck. He doesn't hold a contract with 
the VA and had I not been resourceful enough and, you know, 
capable enough after returning from the war and retiring from 
the Army to go out and seek this gentleman, I might not have 
ever linked up with him. And if you consider the stresses of 
such a traumatic life changing injury, I was very fortunate to 
be able to research on my own and vet the different providers 
that were available to me and come up with who I thought would 
be the best fit. The VA in my area uses a national company 
and--not a national contract holding company, a company that is 
very large, having offices across the Nation. And they hold the 
contract for the prosthetic care out of the Montgomery 
facility. A lot of times with such a large private provider, 
there is a lot of lateral transfers and there is a lot of up 
and down transfers of personnel and you are not able to 
establish that same relationship with a gentleman or a lady who 
is going to live in your community and be, you know, by your 
side for that next 55 some years of your life expectancy.
    The benefits of the relationship Glenn and I have 
established can easily be transferred to other veterans if they 
know he is there and know his capability. In the VA clinics, 
Glenn has been allowed to attend with his current patients, but 
if a new patient comes into the clinic, the firm holding the 
contract automatically receives the work unless the veteran has 
somehow linked up with Glenn prior to the clinic, at which 
point Glenn can bring him to the clinic as his patient, his 
representative.
    For me, VA at the national level has been very instrumental 
in helping me learn about what my options were, what was 
available to me and how to navigate the prosthetic system as a 
disabled vet. Mr. Downs' forums have been an invaluable part of 
keeping good communication flow between not myself but many 
other different veterans. Many of the civilian nonprofit 
organizations that try to supplement and point vets in the 
right direction also attend those forums.
    And on a final note I would just like to say again that the 
VA has paid for any type of equipment that I have asked for and 
that I have needed, and they have done an excellent job of 
following up on and checking on my progress to make sure that I 
am using the equipment that I have been provided. And I would 
just like to close with that.
    [The prepared statement of Captain Bacik is included in the 
appendix.]

    Chairman Braley.  Thank you, Captain, and thank you for 
your service to our country.
    Our next witness is somebody that I know very well. He is 
not just a friend, he is a neighbor of mine in Waterloo, Iowa. 
Dennis Clark serves at the President of Clark & Associates 
Prosthetics and Orthotics, headquartered in Waterloo. The 
company was originally started in Waterloo by Mr. Clark's 
father Dale. Dennis purchased the company in 1987. There are 
now four locations in Waterloo, Marshalltown, Dubuque and Mason 
City.
    Mr. Clark has served as past President of the American 
Orthotic and Prosthetic Association and the American Board for 
Certification in Orthotics and Prosthetics. And if I may be 
allowed to indulge just a second, my father went ashore on Iwo 
Jima the day both flags were raised and he had a very high 
standard for heroes. There are many people in this room today 
who meet that standard. But I just want to say that Dennis in 
my mind is one of the people who deserves our honor and 
respect. When he saw the need for returning veterans coming 
back with prosthetic needs, he made the trip to Walter Reed for 
20 months on his own dime, staying here in Washington, D.C. On 
his own dime to provide the care that our Nation's veterans 
deserve.
    And I have a picture of him here holding a heater out at 
Walter Reed working on a socket. And, Dennis, you are the type 
of inspiration that we wish we could clone and send across the 
country of Americans who saw a need and responded and at great 
personal sacrifice. I am very proud to have you here today, 
very proud to call you my friend, and we look forward to your 
testimony.

 STATEMENT OF DENNIS CLARK, CPO, PRESIDENT, CLARK & ASSOCIATES 
                   PROSTHETICS AND ORTHOTICS

    Mr. Clark.  I thank you very much. Chairman Braley and 
Ranking Member Davis, I would like to thank you and the members 
of the subcommittee for creating this forum and for your 
participation in discussing this very significant issue, 
ensuring continuity of care for veteran amputees: The role of 
small prosthetic practices. And I am honored to be here to 
testify.
    My name is Dennis Clark. I am a certified orthotist-
prosthetist and owner and president of Clark & Associates 
Prosthetics and Orthotics, Inc., a small business located in 
Iowa with offices in Waterloo, Dubuque, Marshalltown and Mason 
City. My family's involvement in caring for wounded veterans 
began during World War II. My father, Dale Clark, also a 
certified prosthetist, worked for a company named Ray Trautman 
& Son in Minneapolis, Minnesota. He worked for the company for 
over 20 years, eventually buying out the Waterloo, Iowa 
location and incorporating Dale Clark Prosthetics in Waterloo 
in 1968. It is no small coincidence that I began working for my 
father in the summer of 1968, eventually purchasing the company 
from him in 1987.
    As Chairman Braley indicated, in September of 2003, I was 
contacted by a representative from Walter Reed Army Medical 
Center and asked if my clinical staff and I would be willing to 
spend the remaining months of 2003 helping provide lower 
extremity prosthetic care to soldiers returning to Walter Reed 
from Iraq and Afghanistan. We proudly accepted this opportunity 
to serve and in fact continued providing care at both Walter 
Reed and occasionally at Bethesda Naval until the end of May, 
2005. During that time we were honored to provide prosthetic 
care for over 300 soldiers.
    Since our departure from Walter Reed, Clark & Associates 
has continued to provide prosthetic care for a small number of 
service connected veterans from the current conflict as well as 
a number of other nonservice connected veterans and as well as 
service connected veterans from other military actions.
    My primary concern here today is making sure that these 
soldiers continue to have access for quality care and current 
technology. To this end, it is important that the VA maintain 
its position on qualifying practitioners by requiring American 
Board for Certification in orthotics and prosthetics, ABC 
certification, as a minimum requirement for persons providing 
care to our Nation's veterans, as well as requiring facility 
accreditation also by ABC, being part of the standard for 
companies providing orthotic and prosthetic care to veterans.
    Since this is the first war fought in what I would call the 
Information Age, more media coverage and public focus has been 
placed on prostheses and prosthetic rehabilitation than at any 
time in the history of prosthetics. This fact, coupled with the 
reality that advances in prosthetic industry are arguably 
bolstered by the effects of war, suggests we will see more new 
technology in the next decade than in all of the previous 
decades.
    Technology for technology's sake was not part of our 
thought process or protocols at Walter Reed. We steadfastly 
attempted to match technology with the associated function and 
use of the prostheses in order to meet the patient and the care 
team's goals and objectives.
    In the past, new technology in terms of techniques, 
materials and components mostly came from within the 
profession. However, today scientists and researchers from 
various digital and microprocessor oriented backgrounds are 
making significant new contributions in advancing prosthetic 
outcomes. This trend will continue into the future. That is why 
it is so important that training and comprehensive training and 
knowledge is required to use these new technologies within a 
patient's prosthetic management will further highlight the need 
to qualify and measure the performance of not only the 
prostheses, but prosthetic providers.
    In addition to my role at Clark & Associates, I am also 
President of POINT Health Centers of America. POINT is the only 
United States prosthetic and orthotic network consisting of 100 
percent ABC accredited facilities. Each of these 146 member 
companies are independently owned small businesses. These 
companies are acutely affected by any VA prosthetics and 
orthotic procurement decisions. Accordingly, effective 
communication relative to VA contractor regulations and other 
administrative requirements is vital to these small businesses.
    In closing, it is critical that we remember the discussion 
we are having here today will affect this current group of 
wounded warriors for the next 40 to 50 years as most of them 
are in their early to mid-20s. The groundwork for the 
investment we make in their care today should be as important 
as the sacrifices they made for our freedom. We have not yet 
seen the depth and breadth of the contributions of this 
differently abled group of Americans has made. But having 
worked with hundreds of them, I firmly believe in time this 
group of volunteer soldiers will one day be known as the next 
greatest generation.
    Thank you.
    [The prepared statement of Mr. Clark is included in the 
appendix.]

    Chairman Braley.  Thank you. Our next witness is Mr. James 
Rogers, who currently serves as the President of the American 
academy of Orthotists & Prosthetists. In 1994, Mr. Rogers 
founded Orthotic and Prosthetic Associates in Chattanooga, 
Tennessee. It is the largest provider of O&P services in the 
tri-state area with eight offices in multiple clinical 
specialties. The American Academy of Orthotists & Prosthetists 
was founded in November of 1970 to further the scientific and 
educational attainment of professional practitioners in the 
disciplines of orthotics and prosthetics.
    Welcome, Mr. Rogers.

  STATEMENT OF JAMES ROGERS, CPO, FAAOP, PRESIDENT, AMERICAN 
              ACADEMY OF ORTHOTISTS & PROSTHETISTS

    Mr. Rogers.  Thank you, Chairman Braley, Ranking Member 
Davis. I would like to thank the members of the subcommittee 
for allowing us to testify today. The American Academy of 
Orthotists & Prosthetists, the Academy, is the national 
membership organization that represents the interest of the 
orthotic and prosthetic professionals.
    It is a privilege to be a part of a profession whose work 
helps people who need orthotic and prosthetic services resume 
full and productive lives and to be able to continue to support 
themselves and their families. We have a proud history in our 
profession of working to serve veterans and working with the 
VA. We do this both through contracts between small businesses 
and the VA and also by having many of our members actually work 
within the VA system.
    Over 60 percent of our membership actually own a small 
business or work for one. They work in all sorts of settings, 
including large cities, suburban communities and the most rural 
areas of our Nation.
    The services we provide for veterans and the Veterans 
Administration is some of the most important work that we do as 
professionals and as Americans. One way to thank veterans for 
their service is to ensure that the VA and the many small 
businesses who are contracted by the VA provide the needed 
orthotic and prosthetic services and that they will be 
available to meet the needs of the veterans for the rest of 
their lives.
    We need to remember that the VA not only serves veterans 
who return--a veteran who returns from war with a service 
related injury, but they will also serve the needs of patients 
in the future through the normal aging process and the 
possibility of acquiring a disability or an injury later on as 
they develop. With modern technology, we can return a veteran 
who has an amputation or another severe orthopedic injury to 
full functionality and give them the ability to continue to 
support themselves and their families and to participate as 
fully in society as they wish to.
    But why is the involvement of small business so crucial to 
the success of our rehabilitation efforts with veterans? To 
answer this question, you have to understand the history of our 
profession. Before the First World War, prosthetic and orthotic 
businesses were not allied health professionals. They were by 
and large craftsman from a variety of different professions who 
were introduced to the disabled community through personal 
contact and circumstance. After the conclusion of World War II, 
the large influx of amputees and young men without careers 
created an enormous need for these services and an opportunity 
to advance the technology.
    With funding from the Federal Government and specifically 
the VA, prosthetic and orthotic education and training programs 
were begun at a number of select universities. Many of those 
trained were veterans themselves. The majority of the current 
3,500 O&P facilities in the United States remain small 
businesses and many are even family owned. It is not unusual at 
the Academy's annual meeting in scientific symposium to see 
more than one generation take continuing education courses 
together.
    An example of this cooperation between the VA and small 
prosthetic businesses is a veteran I will call Jack. He is a 
young man from rural America where family, farming, hunting and 
fishing define one's existence. He lost his dominant right arm 
in an RPG attack while serving as a gunner on a Bradley in 
Iraq. He was stabilized in country and arrived at Walter Reed 
within days of his injury. While as Walter Reed, Jack was there 
for 3 months alone without his wife and his three young 
children. When I met Jack, after his transition from the DOD to 
the VA system, he had already received four prostheses, three 
at Walter Reed, one through the VA contracted provider set up. 
None of these prostheses were suitable for the activities he 
would resume back home. He was frustrated, he was angry, and he 
was referred to me as a problem case.
    He recognized that the care and service he received was 
quick and of the highest technological value, but that wasn't 
what he wanted nor what he needed. He needed a prosthetist that 
would allow him to work as a conservation officer in a variety 
of weather conditions and make a prosthesis after listening to 
his needs that would suit those needs. He needed a prosthesis 
that would allow him to shoot a bow, hold and fire a shotgun or 
a rifle, enable him to fish with his children and take a creel 
study in a local lake.
    What he received was the very best technology we have 
available in myoelectric and cosmetic prostheses. What he 
lacked was a local prosthetist who understood his day-to-day 
existence and appreciated what was important to him and how 
that translated into a specific design. After I made the rugged 
weatherproofed prosthesis that he required, he has invited me 
back several times to Kansas to hunt and fish and spend time 
with his family, and it remains one of the most rewarding 
experiences I have and it is an example that highlights the 
relationship of the VA and small businesses and the necessity 
for that.
    We need to continue this contracting process and the 
intimate relationships that it fosters. We, the Academy and our 
professionals, appreciate the good working relationship we have 
with the VA and Fred Downs and his staff, and it is our goal to 
continue to work to develop a closer relationship in the area 
of research and particularly to look at best practices in the 
O&P field.
    I would like to again thank the committee for holding this 
hearing and allowing me to speak.
    [The statement of Mr. Rogers is attached in the appendix.]
    Chairman Braley.  Thank you. Our next witness is Mr. Tom 
Guth, who is the President of the National Association for the 
Advancement of Orthotics and Prosthetics. Mr. Guth is also the 
owner of RGP Prosthetic Research Center, the largest prosthetic 
manufacturer on the West Coast. Founded in 1987, the National 
Association for the Advancement of Orthotics and Prosthetics is 
a nonprofit trade association dedicated to educating the public 
and promoting public policy in the interest of O&P patients.
    Welcome.

 STATEMENT OF THOMAS GUTH, CP, PRESIDENT, NATIONAL ASSOCIATION 
        FOR THE ADVANCEMENT OF OTHOTICS AND PROSTHETICS

    Mr. Guth.  Thank you. Thank you, Chairman Braley, Ranking 
Member Davis and members of the subcommittee. Thank you for 
this opportunity to testify on the role of small prosthetic 
businesses and their important work with veteran amputees who 
rely on quality prosthetic care or artificial limbs to return 
to full function.
    I am Tom Guth, and I am a certified prosthetist for RGP 
Prosthetic Research Center. I am here as a small business 
owner. RGP Prosthetic Research Center in San Diego was started 
by my father in 1947, and today RGP is one of the premier 
prosthetic clinics in the country. I have dedicated my career 
to developing new ways to increase the quality of life and 
comfort of amputees who use artificial limbs, many whom are 
injured and amputee veterans who wish to continue an active 
lifestyle.
    I am here today representing the National Association for 
The Advancement of Orthotics and Prosthetics. NAAOP is a 
nonprofit trade association dedicated to educating the public 
and promoting public policy that is in the interest of 
orthotics and prosthetic patients and providers who serve them. 
I am testifying today to bring forth the view of small business 
professionals serving O&P patients, particularly those who work 
with our Nation's veterans through the VA.
    RGP has served veteran amputees as a component of our 
prosthetic practice for over 6 decades and we are proud of our 
service to the VA. However, the current system is not always 
without challenges to both the veteran in gaining access to 
appropriate prosthetic care and the private practitioner in 
serving that patient.
    Take, for example, my patient of nearly 40 years, who I 
will refer to as Tom to protect his confidentiality. I first 
designed and fabricated a prosthetic limb for Tom after his 
return from Vietnam where a land mine had taken off one of his 
legs above the knee. For nearly 40 years, I have worked with 
the local VA prosthetic chief and Tom to provide high quality 
prosthetic care. Recently after 8 years of walking on the same 
prosthetic limb, Tom came to my office with a VA prescription 
for a new prosthesis with the same design as his existing limb. 
But technology had changed dramatically over the past 8 years, 
and I recommended that Tom receive a microprocess prosthetic 
knee unit that would allow him to walk more consistently and 
safely. Tom wanted to try the new knee, but the local VA staff 
denied Tom access to the microprocess unit, stating that he did 
not need the more recent technology and generally giving him 
the run around. Tom then became ill and is fighting to return 
to his health. His request for the microprocess knee has not 
been approved to this day, although he could have benefited 
from it for months now.
    So it is important to realize that the positive 
pronouncements and the favorable signals from the national VA 
office that the program covers whatever the amputee veteran 
needs are sometimes lost in translation at the regional and 
local levels.
    As service members return from Iraq and Afghanistan with 
amputations and neuromuscular skeletal injuries, many will need 
prostheses and orthoses. The VA contracts with the utilized 
private business to provide prosthetic care to approximately 97 
percent of the O&P patients. However, as it stands, anecdotal 
evidence suggests that there are significant inconsistencies 
and access to quality O&P care throughout the country. It also 
appears that in some areas of the country, such as San Diego, 
the VA is actively working to increase the amount of O&P care 
provided in house by a VA hired O&P staff and decrease veterans 
access to the private O&P practices and professionals who have 
served the VA patients well for decades.
    Overall, with the collaboration of small business, the VA 
has provided quality orthotic and prosthetic care to the 
veterans over the years, whether or not their underlying 
impairment was service connected. But there are many areas 
where inconsistencies across the country are apparent and 
require improvement.
    The adoption of the VA several years ago over regional 
decision making through the VISNs, the regional service 
network, has highlighted these inconsistencies. It is 
imperative that the VA establish standards that all veterans 
understand and can rely on with regards to their prosthetic and 
orthotic needs.
    This is why NAAOP supports H.R. 5730, the Injured and 
Amputee Bill of Rights. H.R. 5730 proposes the establishment of 
a bill of rights for the recipients of VA health care who 
require orthotic and prosthetic services. This bill of rights 
will help ensure that all veterans across the country have 
consistent access to the highest quality of care, timely 
service, and the most effective and technology advanced 
treatment available. NAAOP believes that the adoption of a bill 
of rights will establish a consistent set of standards that 
will form the basis of expectations of all veterans who require 
orthotic and prosthetic care.
    The bill proposes that every VA facility throughout the 
country be required to promptly display the bill of rights. In 
this manner, the veteran across the country will be able to 
read and understand what they can expect from the VA health 
care system. And if a veteran is not having their orthotic and 
prosthetic needs met, they will be able to avail themselves of 
their rights.
    To improve the current bill, we propose that a copy of the 
bill of rights be required to be provided in paper form to 
every veteran attending the amputee or rehabilitation clinic 
and that each patient sign off on the clinical file to indicate 
that they have received and read the document.
    In addition, we propose that Congress direct the VA to 
establish a toll free dedicated telephone number to report 
instances of noncompliance with these rights as an ombudsman 
could help resolve this agreement.
    NAAOP thanks this committee for examining how small 
prosthetic businesses work with the Department of Veterans 
Affairs to provide for the needs of veterans with injuries and 
disabilities requiring orthotic and prosthetic care. I thank 
you for this opportunity to testify before the committee.
    [The prepared statement of Mr. Guth is included in the 
appendix.]

    Chairman Braley.  I thank you. Mr. Davis.
    Mr. Davis.  Thank you, Mr. Chairman. I would like to 
introduce a fellow Tennesseean, Christian T.Z. Zach Smith. 
Zach, welcome. Zach is President and Co-Owner of Victory 
Orthotics & Prosthetics, Incorporated. Victory has three 
offices and 19 full-time employees.
    Zach graduated from the former Median School for Allied 
Health located in Pittsburgh, Pennsylvania. He is board 
certified in both orthotist and prosthetics and licensed to 
practice in the State of Tennessee.
    Zach was inspired to enter the orthotic and prosthetic 
field by his dad. His father incurred a below the knee 
amputation in 1991 and has enjoyed a full and active life 
since. He enjoys working in his profession because it allows 
him daily to experience the reward of helping amputees to live 
a fulfilling life by enabling them to walk, run, work and 
contribute to society.
    Zach, welcome.

 STATEMENT OF CHRISTIAN T.Z. ZACH SMITH, COP, BOCOP, PRESIDENT 
      AND CO-OWNER, VICTORY ORTHOTICS & PROSTHETICS, INC.

    Mr. Smith.  Thank you. Thank you, Congressman Davis and 
Chairman and the committee, for your time and dedication to our 
deserving veterans.
    As Congressman Davis stated, I have experienced the VA 
process personally with my father's amputation and 
professionally as a contracted provider, and my father's 
positive prosthetic experience is the reason I am in this 
profession.
    As a prosthetist, I am involved in several clinics. The 
clinical model I participate in at Mountain Home in Johnson 
City is the most efficient and patient oriented clinic that I 
have the privilege of participating in. The primary reason for 
the success of this clinic is the team approach to care. In 
attendance is a physician of rehab, physical therapist, a 
kinesiologist, the VA's prosthetic rep, and the contracted 
orthotist and prosthetist. The role of each member is as 
follows.
    The physician is present to explore the full medical 
history and current medical condition of the veteran. In 
addition, she determines if the veteran's current health 
condition can sustain the use of the proposed prosthesis or 
orthosis.
    The physical therapist and kinesiologist are present to 
review and present the physical therapy history and current 
treatment modalities. They also discuss future therapy needs of 
the prescribed orthosis or prosthesis.
    The contracted orthotist and prosthetist discuss as a team 
the most appropriate prosthesis or orthosis to best treat the 
patient.
    The prosthetic rep is present to facilitate the paperwork 
and coordinate all aspects of his or her care, including the 
prosthesis, physical therapy and possibly an additional 
assisted device. Once the veteran has chosen a contract 
provider and the provider delivers the prosthesis, the veteran 
returns to the VA clinic for final delivery.
    This process is very efficient from the initial evaluation 
to the delivery, and the VA is also involved in following the 
patient to confirm the efficacy of the prescribed orthosis and 
follow-up treatment. Despite the strength of this model, I 
believe we can improve in the following ways.
    I recommend the following: A preamputation consultation. 
This benefits not only the patient but the family involved by 
informing them of post-op pain management, post-op fall 
precautions, post-op care and follow-up and explore the options 
of an immediate post-op prosthesis. In addition, the amputation 
consultation may involve the surgeon to discuss the amputation 
level and possible procedures. This ensures efficacy of the 
future prosthesis and may involve the patients on his or her 
prosthetic options. Immediate post-op prosthesis is great for 
early ambulation, optimal healing position, residual 
protection, edema control and a physiological benefit for the 
patient and the family.
    Improved communication between the DOD and the facilities 
is necessary. I have been informed of difficulty in obtaining 
prior medical history when the veteran is transferred from the 
DOD facility to the VA system.
    In addition, I would recommend improved provider selection 
accommodations. Selection of a vendor based on geographical 
location is unfair. He or she should be allowed to review the 
education, the certifications and the experience of the 
prospective facility and prosthetist. In keeping with this, 
facilities should provide assurance of this information. I 
believe we need to develop a standard of care and a method of 
sharing technology.
    I have explained this process because from my knowledge, 
not every VA clinic is set up in this particular configuration. 
As an example, I would like to read a short story of a veteran 
I had the privilege of taking care of. An example of my 
positive experience as a VA contractor and small businessman is 
apparent in my experiences caring for a veteran with an above 
knee prosthesis in 2007. For the sake of privacy, I will refer 
to him as John.
    John had been an amputee since 1971. He incurred a 
traumatic amputation which left him with a very short above 
knee residual limb, 4 inches in fact. The trauma of losing a 
limb and the difficulty he experienced with ill-fitting 
prostheses over the years had him contemplating suicide in 
several instances.
    However, he came to grips with his situation and has used 
the prosthesis ever since. When we first evaluated him, his 
residual limb was bloody, extremely painful and he had severe 
low back pain. He commonly had to refrain from activities that 
required a lot of physical exertion. However, given the fact 
that he owned a farm required him to participate in strenuous 
activities, the days following those activities forced him to 
remove the limb for several days until his residual limb had 
healed. He repeated this painful cycle over and over again for 
the last 37 years.
    Our desire to provide the highest technology and best 
possible care led us to attend an educational event that taught 
a method of socket design that far exceeds anything we had 
previously used, the negative pressure system. In short, we 
fabricated and fit John with the NPS style socket that has 
forever changed his life. He wears the limb each and every day. 
His residual limb is now healthy and pain free. And most 
importantly, he has returned to work on his farm, providing for 
his family and improved his sense of self-worth tremendously.
    Competition driven patient care. Independent contract 
providers exist in a very competitive market outside the VA 
system. We are required by our credentialing organizations to 
maintain continuing education levels. This market is not based 
on price, but on service and clinical competence. When price is 
a determining factor, the low bidder wins and service is no 
longer a consideration in patient care and commitments to 
continuing education sometimes falter. In fact, service may be 
cut to make the process profitable for the provider.
    In the private sector, fees are relatively fixed and 
clinicians are forced to stay current with technology and 
technique. The level of service provided determines the 
success, failure of the provider. This type of competition 
exists in the clinic that I attend and ensures a high level of 
service and guarantees that veterans will receive quality care 
with the highest appropriate technology.
    In summation, I am proud be to a contract provider in the 
VA system. This is a great system and in my region it works 
very well. However, the vets we treat have risked their lives 
and sacrificed their limbs. They deserve the highest level of 
care and expertise we can offer.
    Battlefield medical advancements have saved many lives that 
would have been lost in previous conflicts. The results are 
more severely wounded soldiers and more complex amputees to 
care for. These wounded soldiers deserve every advantage to 
restore them to productive sons, daughters, fathers, mothers 
and whatever else they desire to be. We owe it to them to 
create and maintain a system of contracting that serves them 
all.
    Thank you.
    [The prepared statement of Mr. Smith is included in the 
appendix.]

    Chairman Braley.  Thank you, Mr. Smith.
    Mr. Guth, I want to start with you and the story you were 
telling about the patient you were caring for about the micro-
process knee. Do you remember that?
    You know, I have had the opportunity over in the Rayburn 
Building to see some amazing advancements in upper extremity 
technology with neuro motor driven prosthetic devices. And this 
gets back to one of the points I made in my opening statement. 
You seem to be not very satisfied with the overall relationship 
that the VA has with small businesses and expressed concerns 
about the inconsistencies and how they are treated by their 
local VA.
    How would this Injured and Amputee Veterans Bill of Rights 
address some of that different treatment and help veterans get 
the type of care selection that you feel they deserve?
    Mr. Guth.  Well, what happens is that the Bill of Rights is 
actually the rights that the VA already has in place for these 
amputees and orthotic patients. The problem is that the VA is 
not going out of its way to educate its patients on exactly 
their rights. They tend to just not let them know that they 
have the right to go outside the contract, to go to any 
provider they want to go to. They don't tell them that they 
have the right to have a micro-processed knee or the latest 
technology. They don't tell them that they have a right to have 
a leg for the shower or the swim, you know.
    So I think what is happening is between the national office 
saying the guy can have five legs and they can all be micro-
process if they want to. And down to the VISNs, it doesn't 
communicate that way. I think the VISNs are being more 
controlled by the bean counters than the policy at the VA.
    So they are fearful to give these kind of products that 
cost a lot of money to these veterans, and also some of the new 
contracts that they put out--now, my company was contracted for 
the last 60 years with the VA. We just lost the contract. And 
some of the new contractors have never worked with VA patients, 
have never had a VA contract, do not have some of the 
qualifications required to put on micro-process knees or 
propiol feet or the new i-Hand that you are talking about.
    So they are limited. The VA is not going to order those 
parts if the contractor that they are dealing with doesn't even 
have the license to do it. But some of them do. You know, it is 
not all of them. But it is just that I think that the VISNs are 
just not giving the patient their rights. If the patient knows 
his rights, he will be able to, you know, get done what he 
needs done.
    Chairman Braley.  Thank you. Captain, I first had contact 
with Mr. Clark's business when one of my clients, a young man 
about your age, had a below the knee amputation in an unguarded 
auger accident. And he was very concerned as a young man about 
his future and what types of mobility he would have as he 
progressed if his life. I was just hoping you might be able to 
share with us what a typical, young veteran with a below the 
knee amputation or an above the knee amputation goes through as 
you are trying to deal with planning for the rest of your life, 
coping with the rehabilitation process and how vital the VA 
benefits are as you are going about that.
    Captain Bacik.  Yes, there is a couple of different phases 
that the soldier, you know--that the veteran would go through. 
And the first is when you are transitioning from DOD to VA and 
a lot of that depends on where you are transitioning to, what 
vision that you are heading to. Once you are in the VA system 
and you start to figure out, okay, what am I going to do with 
my life and that leg, getting that leg straight, getting that 
leg right is definitely your first priority. And I think that, 
you know, the nonprofits have a role to play and maybe we 
should have thought about maybe representing that role a little 
bit, too, at this table. But a lot of these problems that 
happen in certain parts of the country have already happened 
where I am at and we have already addressed them, and the way 
we are sharing lessons across the table is through these 
nonprofit organizations that are kind of there to, you know, 
just share lessons back and forth, meet with folks like this, 
talk to other veterans and I think that is where we could maybe 
make it better for people in different parts of the country.
    And as you move out, I think they--Mr. Downs said maybe 800 
amputees. So maybe we should expect to see about 40 amputees 
per State and if there is three main clinics, it is like 15 or 
13 amputees in each State. Some of them are still going to be 
on active duty, some are still at Walter Reed, some of them are 
not at the point in their health care yet where they are going 
in to see a prosthetist. So when you break it down to the 
community level, you may only have, you know, two or three 
amputees that have walked through a clinic that sees 2,000 OIF/
OEF veterans. And without--it is important to educate the 
patients, but we also need to be educating the folks that we 
are entrusting to kind of guide the patients through their 
care. And if you are going to see 2,000 vets, you know, if I 
was a case manager, I would be worried first about PTSD because 
you are going to have a larger portion of that pile, have 
issues with that than you are going to have amputees. And 
getting the information to these folks about what programs are 
available for amputees is where I think the--you know, maybe 
the issue is.
    As far as the capabilities--as you go up your leg, as long 
as you have your knee, you are fine, you can do anything, the 
sky is the limit. As you start to go up a little bit higher, 
life gets more challenging.
    Chairman Braley.  One of the concerns that was raised in 
the Independent Review Group study was that--it was something 
that you talked about earlier in your opening remarks, and that 
is the impact of travel on someone who is in need of orthotic 
and prosthetic services. And they talked in the report about 
those veterans who are on TRICARE Prime who had a reimbursement 
allowance for mileage as part of that. But patients who were 
under TRICARE Standard had no similar reimbursement.
    Is that something you hear veterans talking about as it 
relates to getting not only high quality care but also access 
to care, especially in a time of high gas prices?
    Captain Bacik.  Definitely, you know, people are concerned 
about that. And from the veterans standpoint, our time as a 
member of the civilian workforce is valuable to us. And you 
know there is a cost associated with spending 8 hours at the VA 
trying to accomplish something and, you know, making the 
correct phone calls, sending the correct e-mails while you are 
trying to manage a professional career and also, you know, be a 
father or a mother and, you know, have some kind of--have 
something to do on the side of that, just go play a game of 
golf or something. You know, that is all--our time is very 
valuable to us. And I think that having--you know, for me, 
having my private provider, he interfaces with the VA and does 
most of that war gaming on behalf of me because he has 
established that relationship at the local level. Very 
beneficial. He knows--you know, he is motivated because if he 
doesn't--if he doesn't get a leg made for me, he doesn't bring 
food home to his family. So he is motivated to make it happen, 
knows who to talk to, knows how to navigate the system.
    As far as the traveling requirements, you know, my 
prosthetist lives about a half hour away from me and he has a 
satellite office in the same town I actually live in. So I will 
see him there or he will travel to see me, whatever he needs to 
do.
    Chairman Braley.  Thank you. Mr. Clark, as a leader in the 
O&P community, you have had the opportunity to talk with a lot 
of practitioners about the VA procurement process and its 
challenges. From your background and experience, can you share 
with us what issue raises the most concern with O&P 
professionals about their interaction with the VA system?
    Mr. Clark.  Yes. The concern that comes up most often is 
the technology issue and the contracting, the other two. It is 
technology, access to technology for patients where that 
technology is appropriate, not unlike the case that Mr. Guth 
talked about. That technology seems to make good sense is 
appropriate for that patient and there are occasionally 
constraints put in there. I believe that is getting better. But 
constraints can be put in there and hurdles can be made that 
are sometimes usurious to get beyond.
    The other thing is just the contracting process. It is 
getting more complex, even how you are informed that there is 
the RFP out there. Getting that information is tougher to find. 
You almost have to be a watchdog or hire a watchdog to find 
that out for you in some of the VISNs. So those are the two big 
issues that are out there. I would like to say, you know, that 
seeing Ms. Russell as part of--a deputy for Fred Downs is 
great. She comes from Walter Reed. We worked with her at Walter 
Reed. She, like all the other people within the VA system, has 
such an incredible passion to make sure these things get taken 
care of.
    So I think things are hopefully going in the right 
direction. This study obviously highlights many things.
    Chairman Braley.  What recommendations are you familiar 
with maybe coming from either professional associations, a 
certification board on how to deal with that communication 
problem within the VISN so that there is--you should be able to 
get 24-hour a day, one-stop shopping, check in, find out what 
is available, be involved in the procurement process, why isn't 
that happening?
    Mr. Clark.  I think the Web site that has been created is 
going to be a great help and I think that kind of 24/7 access 
to information is going to be a great help. It takes time to 
disseminate that information. The VA is the largest health care 
system I think in the world. So it takes time to disseminate 
all of this information out to everyone. And everyone has their 
own little fiefdoms possibly within the business and the way 
they like to do things. Once we determine and are able to 
stabilize everyone with the same core values and the same core 
beliefs and the same core strategies, then we can go out and 
they can tactically do what they need to do within their VISNs.
    It is going to be education both to the patient and to the 
people managing the VA centers and continued education like 
these town hall meetings, like the information that is on the 
Web site, like the information that gets sent out to those 
people that are managing this care.
    Chairman Braley.  Thank you.Mr. Davis.
    Mr. Davis.  Thank you again. You have provided some 
wonderful testimony and I appreciate each one of you. Captain 
Bacik, if you would, tell me a little bit about why you think 
Glenn chose not to contract with the VA.
    Captain Bacik.  Well, Glenn certainly tried to contract 
with the VA. And in the past he was a contractor on their 
books. And Dennis might know more details to the story. But at 
a certain point, I think when they transitioned to an 
electronic bid system for renewing the contract Glenn was not 
privy to the new system for establishing or renewing that 
contracting relationship. So he was taken off their contracting 
rule.
    Mr. Davis.  So he provides good health care, you the 
patient appreciates the care you are receiving and because of a 
computer glitch he was not able to contract? Is that what I 
hear?
    Captain Bacik.  Yes, sir. And of course that situation as I 
understand, and it might be more than a computer glitch, but 
basically it is a paperwork issue where his contract was not 
renewed. And he is very active in the State. It is not like--
you know, he sits on--he was the immediate past President of 
the State Certification Board. So he is a well-known provider 
locally.
    Mr. Davis.  Mr. Clark, you look like you want to add to 
that, and I would love for you to.
    Mr. Clark.  Again, I don't know--as Mr. Bacik said, I don't 
have 100 percent of the input. But I believe what happens is a 
similar story, and again I am relating it secondhand, as to 
what happened in Houston. The RFP was placed out there on a 
government Web site and I received an e-mail from someone one 
day telling me that no one in Houston replied. I find that a 
little bit hard to believe. No one in Houston replied because 
nobody knew it was out there. You had to reach out to that 
government Web site.
    My guess is that Glenn didn't go to the Web site at the 
right time to find out that he needed to submit the RFP by a 
certain date in the way that it needed to be submitted. And 
because of that, he was eliminated as a contract provider by 
not responding the way he needed to in a timely fashion, even 
though he was not made aware of that fact.
    I am speculating that that is the issue because the story, 
as Mr. Bacik relays it, is so familiar to what I heard from 
some folks in Houston. We actually hired someone in our company 
to watch those e-mails and let us know when that--when the RFP 
would come out so that we wouldn't miss that deadline.
    Mr. Davis.  And the smaller the business, the harder it is 
to have someone monitoring government Web sites?
    Mr. Clark.  Without question.
    Mr. Davis.  Especially when you are in front of a small 
business committee. Has someone relayed these problems to Mr. 
Downs? Because this morning he sounds like he really wants to 
work with the provider community. Has anyone related this 
problem?
    Captain Bacik.  Glenn has been in contact with our VISN 
director. We are VISN 7 in Atlanta. It is headquartered there. 
And I know he has spoken with him often about it.
    Mr. Davis.  Sounds like this is something Chairman Braley 
and I may be able to work together on and try to find a 
solution.
    Moving on down the line, Mr. Rogers, you spoke of a Jack. 
You said he had had four prostheses. Why did he have so many?
    Mr. Rogers.  Well, I think what happened was that--
according to Jack--is thatthere was such an emphasis paid on 
providing him quick care and high technology in a very busy 
environment at Walter Reed that it was very difficult for him 
to make the adjustments as an amputee that he needed to make. 
And he didn't have a lot of help doing it. And the next thing 
he knew he was being shipped back to Kansas and had prostheses 
that he was asked to sign for that really didn't relate to 
anything that he was hoping to do when he got back. And he made 
a fairly quick transition through the VA system, at least from 
what I understand is normally the case, and had a single 
provider available to him who really didn't serve his needs 
well.
    I think by everybody's estimation he wasn't cared for well 
by that particular provider in the VA system. Because he was 
referred to me through the Wounded Warriors at Fort Reilly and 
he had already transitioned into the VA system. The way he was 
able to do that is that he maintained his employment on the 
base. So they asked me as a noncontracting VA provider in the 
area if I would see him. And I think the emphasis--the lesson 
to be learned from this example is that the care of a local 
prosthetic and orthotic professional where an amputee knows 
that they are not going to see somebody for a brief period of 
time and then there is going to be a huge distance between them 
where that relationship is going to end, the local relationship 
fosters development in communication and there is an interest 
taken on the part of the prosthetist in that individual. And 
the individual knows that. And that is the model that has 
existed for a 100 years in the United States and provides the 
civilian population with excellent prosthetic care, and that 
model needs to be promulgated throughout the VA system.
    Mr. Davis.  I hear you saying Jack didn't get the care that 
he deserved and was due. A follow-up to that, do you think it 
was a good use of taxpayer dollars if he actually received--and 
we can be open and frank here. That is what--we are trying to 
learn. Is it good use of taxpayer dollars to buy four 
prostheses that ultimately end up costing taxpayer dollars and 
then you end up with the fifth limb doing the job?
    Mr. Rogers.  Of course not. But I also think--as quickly as 
I say that, I don't think that example is reflective of the 
balance of care that is received through Walter Reed or 
Bethesda. And I think in this particular instance it could have 
been timing or the influx of people. It could have been Jack's 
personality and some of the adjustment disorders that he was 
going through with this, being without his family and so on.
    It is not as easy to say, gee, he just was not served well 
and that is the norm of care there and it was not a good 
expenditure of taxpayer dollars. I think what it really 
illustrates is the importance of that communication because I 
know of many veterans that I have seen in Kansas who got 
excellent care and appropriate technology and felt like the 
care they received coming through Walter Reed was exceptional. 
So although I don't think it is a good use of taxpayer dollars 
in this instance, I don't think that is reflective of the care 
that occurs at Walter Reed.
    Mr. Davis.  So Jack was outside the norm?
    Mr. Rogers.  I think so, yes.
    Mr. Davis.  In your opinion. Okay.
    Mr. Guth, you talked about Tom. Why do you think his new 
micro-processor was denied?
    Mr. Guth.  Well, he actually--he went to the clinic without 
telling me. So I wasn't there as a patient advocate for him. 
And that is when they prescribed him and told him that the 
micro-processor knees were kind of experimental, they broke 
down constantly, he probably wouldn't enjoy it, go back to what 
you have here. You did well for 35, 40 years, you don't need 
anything different.
    So he came in to me with the prescription. And I said, 
well, did you--and he said I asked them for a micro-process 
knee and they told me no. So I said, well, I don't think they 
have that right. But why don't--so he went back the next day 
not in a clinic and talked to the prosthetic chief and the 
prosthetic chief told him that you get this leg first and then 
you can go ahead and have your micro-process knee made. But 
first you get your spare leg and then--but you won't have to go 
through clinic to get this new micro-process knee, you have 
already been through clinic.
    So he came running into me and he said, yes, you have to 
build me this one first but then I get my micro-process knee. I 
said, great, let me get on the phone to the VA and make sure 
that we are all on the same page. I got on the phone with the 
VA and they said no way, this man is not getting a micro-
process knee without coming back through clinic. And then he 
went back 2 more days requesting the same thing and was turned 
down. And finally his health got bad and he had to go back home 
and he couldn't pursue it any further.
    Mr. Davis.  Was it your understanding from earlier 
testimony today that they can pick and choose their best 
equipment for their needs?
    Mr. Guth.  Well, if you listen to Fred, they say they can 
have anything they want, including five micro-process knees if 
that is what they need. But that is not what is happening. 
Okay? I have two patients at the VA that actually have two 
micro-process knees, and the reason for that is because they 
deserve a functional spare. And once you have walked on a 
micro-process knee, I don't care if you have walked on this 
other knee for 40 years, you get used to that micro-process 
knee, you believe in it, you don't think about your prosthesis 
so much, you go back to your old leg and you fall. So the only 
functional spare for one of these micro-process knees is 
another micro-process knee. Both of these patients that got the 
two knees--and the only reason that--I am sure they are the 
only ones in all of VISN 22 that have two micro-process knees--
is because they were World War II amps. One has been on anger 
management paid for by the VA since the war and the other one 
called his Congressman and told him off. And that is how they 
got the second knee. And the VA said, of course, you can have 
one.
    Mr. Davis.  Thank you.
    Mr. Smith, you talked about John. Why do you think it took 
37 years to provide him with the correct limb?
    Mr. Smith.  Well, that is hard to decisively say. But in my 
opinion, he transferred to Mountain Home from a previous 
facility that wasn't run the exact way that the Mountain Home 
clinic is run. I think we are overlooking a simple solution to 
a lot of the problems that are coming forth today. And that is 
that in the clinic I participate in, there is a system of 
checks and balances. You know, it is not that somebody randomly 
chooses what is best for that patient. It is a team effort, 
everybody puts their head together to determine what is best 
for the patient. The patient goes to the chosen facility, he 
comes back and the follow-up care not only determines the need 
for physical therapy but it determines whether or not the 
device prescribed to him worked. And I think that that is an 
injustice to the taxpayers and the patients and everybody 
involved to not have a system of checks and balances.
    You know, I am not going to be as politically correct as 
Jim to say that I don't think it is the best use of taxpayer 
dollars to throw these limbs at these amputees right off the 
bat. There are several reasons for that. First and foremost, 
they don't know what to expect. These amputees just went 
through a traumatic experience. They don't know if they need a 
micro-processor to go to the job that they don't have yet. They 
don't know what the job is. In addition to that, every 
prosthetist sitting at this table knows that amputees, the 
dimensions of their limb changes over time. You know, you start 
off with a limb that has been through trauma, it has edema and 
swelling, the muscles have atrophied from nonuse. And to just 
fit someone randomly with four limbs is in my opinion 
ludicrous.
    In addition to that, I will take the time to say that I 
disagree with contracting with exclusive providers. You know, 
in the model that I described there is multiple orthotists and 
prosthetists present. I believe that this is in the best 
interest of the taxpayers, the patients and the VISN. And the 
reason for that is that again there is a system of checks and 
balances. It is not one prosthetist doing the work and then 
having no one to say, yes, that is a good prosthesis or it 
isn't.
    The fact that ABC or BOC certification is a minimal 
requirement doesn't mean that the prosthetist is good at what 
he does. We all know in different professions that there are 
people that are really good at what they do and others that 
aren't. So I think it would be in the best interest of 
everybody if this clinic model was used as a standard and that 
the providers who want to be in the VA system should be allowed 
to do that, provided they meet the requirements of 
certification. To have one provider is unfair. Competition is 
what our country was based on; a competitive market. And I 
don't think it is correct for the VA to disenfranchise that 
model. Competition makes better practitioners. That is just the 
way it is, whether in the private sector or the VA sector.
    So in this case, as far as John, I don't think that there 
was enough follow-up care for this individual. He was a very 
difficult patient to fit. In the prior prosthetist's defense, 
it wasn't easy to fit him. Luckily I do continuing education 
constantly and I am always looking out for better technology 
and better techniques. And that is why in my testimony, I said 
I thought it was a good idea to have some type of a joint 
educational event that is specifically for VA vendors, 
providers and the VA personnel involved in that process.
    Mr. Davis.  You have outlined success there at the Mountain 
Home VA Medical Center. How broadly is that used across the 
country? Is it limited to just Johnson City, Tennessee or do 
you see it in other VAs?
    Mr. Smith.  From my understanding, it is not used 
everywhere. Some of the participants in the clinic that I 
attend have been in different VA facilities and I have heard 
just from them that that wasn't the way that it was conducted 
in the facilities they had previously worked at. So for me to 
say across the board it is a standard or not a standard, I 
really couldn't say, but I have heard personal testimony to say 
that this model is not used in every clinic.
    Mr. Davis.  Can I get some of the other panelists to tell 
me, do you think that would be helpful if that was a standard?
    Captain Bacik.  I have used--I have been in that clinic 
model in two different systems, the Tampa VA and the Montgomery 
VA. And the way it works is the patient will walk into the room 
and there will be a board of leg makers that are--that have 
that contract and then the doctor will be there. The doctor 
will say, okay, this is what this patient needs, and then you 
go around the room and the providers say this is what I think 
we can do based on your capabilities and what has worked well 
for you in the past. And in Tampa, it worked great. And I think 
that is probably the textbook answer.
    In the Montgomery facility, since Glenn didn't have the 
contract, if he doesn't bring you to that clinic as, hey, this 
is my patient, I am bringing you to the clinic, if you show up 
to the clinic on your own, only the person with the contract 
can reach out and say, hey, based on your capabilities and what 
you have done in the past and what you are wearing now, I think 
this would work well for you. In our clinic, you know, we have 
got--there is two providers and one of them has that voice and 
the other--you know, if the doctor says, hey, Glenn I think you 
should take care of this new patient, then Glenn is in the mix. 
If not, you know, he just kind of observes.
    Mr. Guth.  Excuse me. The doctor is not allowed to say 
that, not a VA doctor. He is not allowed to refer to your 
practitioner, period.
    Mr. Davis.  That is good to know. And if you will bear with 
me, I am going to do one more question. And this will just be 
for anyone or everyone. How can the current VA model for 
orthotics and prosthetics be enhanced?
    Mr. Guth.  I think you have to set national standards and 
make sure that all 22--he said there is only 21 VISNs, I 
thought Fred Downs said. Our VISN is 22. That may be why we are 
out there on the edge,  we are outside the network. But you 
need to have a national program and each one of those VISNs 
have to be educated on exactly how to run it. You know, we have 
a prosthetic clinic like they are talking about, and for 60 
years it worked out wonderfully but they took all the providers 
who did all the work and got rid of all of them and put in all 
new providers who hadn't seen any of these patients before, and 
none of us, the old providers, are allowed to attend those 
clinics unless our patient requests us to be there and we show 
up with our patient. We are only allowed into that clinic for 
that patient, and then we are kicked out.
    Now, I think that that is a terrible way to do it. And then 
they are also not told that if you don't like these providers, 
you can go anywhere you want as long as the person is 
certified. And you can go to any State and go anywhere. We are 
not going to pay your transportation, but you have the right to 
go to any prosthetist that is certified in this country. And, 
in fact, I fit four or five patients that do not come from the 
VA in California. They come from--one of them comes from 
Tennessee because he wasn't getting service at his Tennessee 
clinic, and so he came out to see me and we forced the VA in 
San Diego to do what was right. And one of those was a micro-
process knee. So--
    Mr. Davis.  Thank you. And I yield back.
    Chairman Braley.  Mr. Rogers, I want to follow up on your 
Jack story. One of the things you talked about was despite the 
fact that veterans have access to the best technology in 
theory, sometimes the VA fails to design prosthetics that 
specifically meet a veteran's job or lifestyle. I think this 
gets back to what I was talking about earlier, which is whether 
there is a lack of institutional forward planning sometimes 
that tries to look at what a veteran's future is going to look 
like and continues to track them as those needs change as they 
may be laid off from a job, going to a different type of job 
environment or their recreational needs change. In your 
opinion, what steps should the VA take to avoid that situation 
and what should be the role of the local prosthetist?
    Mr. Rogers.  I think before I answer your question a 
distinction needs to be made. He received the majority of his 
prostheses, three of the four, from the DOD, not from the VA. 
So, you know, my experience with the VA process is such that I 
think the local prosthetist does that by and large. You know, 
in the civilian model, that relationship that is formed ensures 
that that happens. When an amputee's circumstances change or 
their needs change or their prosthesis is no longer serving 
them well, that is their function, that is their ability to get 
around day to day, things that we take for granted. They are 
going to come back to you if they have a relationship with you, 
and that is how you are going to know that.
    I don't know that it is the VA's responsibility to monitor 
that in any way or if that is even possible. I do think, 
though, that the VA can provide a mechanism for communication. 
I think that the Patient's Bill of Rights is an excellent idea, 
if that can be disseminated so that amputees know that they can 
go outside of the contracted provider. I don't know that you 
want to wholesale revamp the contracted provider process, but 
making sure that noncontractor providers like myself are 
available to amputees and that the amputees know what their 
rights are and what they can do would go a long way to solving 
some of the problems that you hear and that you have heard at 
this committee.
    Chairman Braley.  Mr. Guth, one of the concerns you 
addressed was the increasing use at some VA centers of in-house 
staff to provide O&P services. What specific concerns does that 
raise to you in terms of the quality of care, the ability to 
monitor developments in technology and new advancements in O&P 
products and services?
    Mr. Guth.  Well, up to about 5 years ago, the VA employed 
no certified practitioners whatsoever. We were vendors, all the 
work was done outside. They didn't have any certified people on 
board. The last 5 or 6 years, they have worked very hard, I 
think they now have, what, 60 practitioners and last time, 
about 6 months ago, I heard they had 40. The VA in San Diego is 
now hiring another prosthetist, orthotist to help take on the 
load, which if they are only doing 3 percent of the work they 
don't need another prosthetist or orthotist to take on the 
load.
    When I was able just 2 weeks ago, I went to my clinic to 
show my patient off that had a new micro-processed ankle and 
they were all very impressed. But as I was being rushed out of 
the clinic, one of my old patients, who I had made a leg for 25 
years ago and he was still wearing it--and the reason I can 
tell that is because on the front we used to put our name and 
their Social Security number and their name. That was a VA 
requirement. They were carrying in four brand new legs. He is a 
BK, below the knee, four brand new legs made by the VA and he 
is wearing my leg that is 25 years old. Well, obviously he has 
rejected these four brand new legs and they still haven't 
solved the problem. Now, there is an example of lack--waste of 
taxpayers' money.
    One of the problems when the VA does hire a prosthetist out 
of our industry, they are paid the lowest of anybody in the 
industry, below our standards. So they are not exactly hiring 
the cream of the crop but they are certified. And a lot of them 
are BOC, which is what we were just--even Fred said that is a 
little below ABC.
    Chairman Braley.  Mr. Clark, I don't think there is any 
doubt that the certification requirement has improved the 
overall quality of the service veterans receive when they have 
an amputation. But you have also expressed hope that we move 
toward facility accreditation as part of the standard for 
providers as well.
    So given the fact that provider certification has 
successfully increased the level of service received by 
veterans, why do you believe that facility accreditation is 
necessary?
    Mr. Clark.  Facility accreditation deals with much more 
than the governance procedures that are out there. We have to 
be able to communicate well, have excellent note taking, have 
communication back with the prescribing physicians, with other 
health care professionals. There has to be a process. If there 
is problem, what is your in-house process for dealing with a 
patient not being satisfied with the care or any conflict 
management that you might have internally. That facility 
accreditation goes way beyond just the physical specifications 
of the building; is it handicapped accessible, is it all this 
and that. It causes the provider not only to be good at the 
stuff working in their business, but good at the on their 
business stuff too. So they are working toward quality note 
taking, staying current and all those types of things with 
respect to running their business and running a quality 
organization.
    That is just another standard that we can put out there to 
make sure that the people that are providing care to these 
deserving veterans not only are good at what they do, but their 
organizations are run well so these conflicts can be managed.
    I am seriously hoping at some point also that some of this 
stuff that Tom and Zach and Jim have been talking about, once 
we start doing performance measurements, not only for the 
components of prostheses but for the functional levels of the 
people who receive prostheses, some kind of performance 
measurement--that takes some of this burden of who should 
provide this care and how can we select and how can we 
determine how this is done.
    Using some form of evidence based care I think is the next 
step in prosthetics--no pun intended--the next step in 
prosthetics and orthotics, and I think an absolutely critical 
one that we take, especially in light of this large number of 
young active group of men and women who are going to be needing 
these services for generations to come.
    Chairman Braley.  Thank you, Mr. Davis. Do you have any 
further questions?
    Mr. Davis.  No.
    Chairman Braley.  I just want to thank all of our witnesses 
for this very informative conversation. I just want to close 
with one of the concluding remarks from the Independent Review 
Group report.
    In the conclusion section where they wrote, generally the 
Nation must recognize that there is a moral, human and 
budgetary cost of war. When we engage in armed conflict, we 
must recognize those costs and be prepared to execute on those 
obligations. I can think of no area where that obligation is 
greater and our Nation has a higher calling than to take care 
of the needs of our wounded veterans. And I hope that as we 
move forward from this hearing, we can work together to address 
these concerns and provide them with the optimal care for the 
best possible outcome in their lives.
    And I just also have one more housekeeping matter to take 
care of. All members are advised that they have 5 days to 
submit statements and supporting materials for the record. I 
ask unanimous consent. Without objection, so ordered.
    This hearing is now adjourned. Thank you very much.
    [Whereupon, at 12:20 p.m., the Subcommittee was adjourned.]

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