[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
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
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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
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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
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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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