[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
HEARING ON OPTIMIZING CARE FOR VETERANS WITH PROSTHETICS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, MAY 16, 2012
__________
Serial No. 112-61
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
ANN MARIE BUERKLE, New York, Chairman
CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
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of converting between various electronic formats may introduce
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C O N T E N T S
__________
May 16, 2012
Page
Hearing On Optimizing Care For Veterans With Prosthetics......... 1
OPENING STATEMENTS
Chairwoman Ann Marie Buerkle..................................... 1
Prepared Statement of Chairwoman Buerkle..................... 56
Hon. Michael H. Michaud, Ranking Democratic Member............... 2
Prepared Statement of Hon. Michael M. Michaud................ 57
WITNESSES
John Register, U.S. Army Veteran, Limb Prosthesis User, Board
Member of the National Association for the Advancement of
Orthotics & Prosthetics (NAAOP)................................ 4
Prepared Statement of Mr. Register........................... 57
Jim Mayer, Veteran............................................... 7
Prepared Statement of Mr. Mayer.............................. 61
Michael Oros, Board Member, American Orthotic & Prosthetic
Association.................................................... 15
Prepared Statement of Mr. Oros............................... 63
Joy Ilem, Deputy National Legislative Director, Disabled American
Veterans....................................................... 17
Prepared Statement of Mrs. Ilem.............................. 68
Jonathan Pruden, Alumni Manager, Southeast Wounded Warrior
Project........................................................ 19
Prepared Statement of Captain Pruden......................... 74
Alethea Predeoux, Associate Director of Health Legislation,
Paralyzed Veterans of America.................................. 20
Prepared Statement of Ms. Predeoux........................... 78
Linda A. Halliday, Assistant Inspector General for Audits and
Evaluations, Office of the Inspector General, U.S. Department
of Veterans Affairs............................................ 31
Prepared Statement of Ms. Halliday........................... 81
Accompanied by:
Nicholas Dahl, Director of the Bedford Office of Audits and
Evaluation, Office of Inspector General, U.S.
Department of Veterans Affairs
Kent Wrathall, Director of the Atlanta Office of Audits and
Evaluation, Office of Inspector General, U.S.
Department of Veterans Affairs
John D. Daigh, Jr., M.D., Assistant Inspector General for
Healthcare Inspections, Office of Inspector General, U.S.
Department of Veterans Affairs................................. 33
Accompanied by:
Robert Yang, M.D., Physician, Office of Healthcare
Inspections, Office of Inspector General, U.S.
Department of Veterans Affairs
Lucille Beck, Ph.D., Acting Chief Consultant, Prosthetics and
Sensory Aids Service, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 40
Prepared Statement of Dr. Beck............................... 87
Accompanied by:
Joe Webster, M.D., National Director for the Amputation
System of Care, Veterans Health Administration, U.S.
Department of Veterans Affairs
Joe Miller, Ph.D., National Program Director for Orthotic
and Prosthetic Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
Norbert Doyle, M.B.A., Chief Procurement and Logistics
Officer, Veterans Health Administration, U.S.
Department of Veterans Affairs
STATEMENTS FOR THE RECORD
Christina M. Roof................................................ 91
QUESTIONS FOR THE RECORD
Letter & Questions From: Hon. Michael H. Michaud, Ranking
Democratic Member, Subcommittee on Health - To: Ms. Lucille
Beck, Ph.D., Acting Chief Consultant, Prosthetics and Sensory
Aids Service, Veterans Health Administration, U.S. Department
of Veterans Affairs............................................ 98
Response From Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 99
HEARING ON OPTIMIZING CARE FOR VETERANS WITH PROSTHETICS
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WEDNESDAY, MAY 16, 2012
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to call, at 9:59 a.m., in
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle
[Chairman of the Subcommittee] presiding.
Present: Representatives Buerkle, Stearns, Bilirakis Roe,
Runyan, Michaud, and Reyes.
OPENING STATEMENT OF HON ANN MARIE BUERKLE,
CHAIRWOMAN
Ms. Buerkle. Good morning. The Subcommittee will now come
to order.
Good morning and welcome to today's Subcommittee on Health
hearing, Optimizing Care for Veterans With Prosthetics.
Our Nation's commitment to restoring the capabilities of
disabled veterans struggling with devastating combat wounds
resulting in the loss of limb began with the Civil War.
Restoring these veterans to wholeness was a core impetus behind
the creation of the Department of Veterans Affairs and then and
it continues to play a vital role in the department's mission
now.
Prosthetic technology and VA care have come a long way from
the Civil War era wooden peg legs and simple hooks.
Following World War II, in 1945, veterans dissatisfied with
the quality of prosthetic care stormed the Capitol in protest.
Congress responded by providing the VA with increased
flexibility for prosthetic operations and launching Federal
research into the development of new mobility and assistive
devices.
With these reforms, VA led the way in prosthetic care and
research, guided by dedicated professionals both inside and
outside the department who worked tirelessly to provide
veterans with the quality care they earned and they so much
deserve.
As a result, the model of VA care for today's veterans
includes leading edge artificial limbs and improved services to
help them regain mobility and achieve maximum independence.
Still the magnitude of the heart-breaking injuries
sustained by servicemembers and veterans returning home from
military service in Iraq and Afghanistan find the VA struggling
to keep pace with the rising demands of younger and more active
veterans with amputations.
Prosthetic care is unlike any other care provided by the
department. Prosthetic devices, particularly prosthetic limbs,
quite literally become a part of their owner, requiring the
integration of body, mind, and machine.
The goal is not just to teach amputees to walk or use an
artificial arm or hand but to provide multi-disciplinary
continuing care to maintain long-term and lifetime functioning
and quality of life, which is why I am troubled by the
department's proposed changes to prosthetic procurement
policies and procedures.
The forthcoming reforms will, among other things, take
prosthetic purchasing authority from prosthetic providers and
transfer them to the contracting officers. This is alarming to
me. As we will hear soon, it is also alarming to many of
today's witnesses.
I would like to read a quote from Captain Jonathan Pruden,
a wounded warrior himself, who states in his testimony that:
``we see no prospect that this planned change in prosthetics
procurement holds any promise for improving services to the
warrior. Instead it almost certainly threatens greater delay in
VA's ability to provide severely wounded warriors' needed
prosthetic devices and heightens the risk that a fiscal
judgment will override a clinical one.''
I think that the Members of this Committee agree, along
with many of you in the audience this morning, that we cannot
allow this to happen and this morning we will look to the
department for assurance that it will not happen.
It is nothing short of inspiring to see how far modern
technology and most importantly the spirit, courage, and
resolve of our veterans themselves has come in restoring
mobility, dignity, and hope to our Nation's heroes. They are
our heroes and this Nation owes them this debt of gratitude to
make sure our veterans have exactly what they need to survive,
to thrive, and to have a high quality of life.
It is vital that we set VA prosthetic care on a course that
matches the courage and bravery of the men and women who serve
our Nation in uniform.
Again, I thank all of you for joining us this morning.
I now recognize our Ranking Member, Mr. Michaud, for any
remarks he might have.
[The prepared statement of Chairwoman Ann Marie Buerkle
appears in the Appendix]
OPENING STATEMENT OF HON. MICHAEL H. MICHAUD,
RANKING DEMOCRATIC MEMBER
Mr. Michaud. Thank you very much, Madam Chair.
And I would like to thank everyone for attending this very
important hearing we are having today.
The purpose of today's hearing is to look closely at VA's
prosthetic and sensory aids services and to examine the, number
one, demand for prosthetic services; number two, equality of
care and access issues; three, the impact of ongoing
procurement reforms; and, four, if current acquisition and
management policies are sufficient.
As the three Office of Inspector General reports have
shown, there are numerous concerns including the frequency of
overpayment in nearly a quarter of the transactions totaling
over $2.2 million in fiscal year 2010, the absence of
negotiations, price guidance, and other controls and the
limited information to assess if current prosthetic limb
fabrication and acquisition practices are effective.
I have said it on this Committee before, but what seems to
be a case that there is little accountability in management
and, once again, procurement and procedures and policies were
not in place or not followed in managing nearly $2 billion
worth of prosthetics and sensory aids.
The VA in the last year's budget submission claims that
$355 million in savings in fiscal year 2012 and 2013 due to
acquisitions improvements, but if the VA cannot follow its own
policies and procedures, how much faith can we have in the
claim of acquisition savings?
I hope the VA can help us understand today what
accountability we should expect and to make certain that the VA
does not continue to overpay for prosthetics in the future,
that taxpayers and veterans receive the best value for their
devices and for management to ensure that the prosthetics and
sensory aids services is fully meeting veterans' needs.
Finally, it has come to my attention that VA has proposed
changes in the procurement of prosthetics and that there is a
high degree of concern among some of our witnesses today as to
the effectiveness of these changes.
I look forward to hearing from the VA on these issues as
well, and I would like to thank all of the panelists for coming
today and want to thank those of our panelists who are veterans
for your service for this great Nation of ours.
I am committed to working with all of you to ensure that
our wounded veterans, those who have served honorably and made
such great sacrifices are able to go about their lives more
comfortably with these devices and with the best support and
services from the VA possible.
So I want to thank you once again for coming today.
I want to thank you very much, Madam Chair, for having this
very important hearing. I yield back.
[The prepared statement of Hon. Michael H. Michaud, appears
in the Appendix]
Ms. Buerkle. Thank you, Mr. Michaud.
I would like to now invite our first panel to the table.
Joining us this morning are John Register and Jim Mayer.
Mr. Register is a veteran of Operations Desert Shield and
Desert Storm and a world-class athlete, winning nine gold
medals in the army's armed services competition.
In 1994, John suffered an injury that led to the amputation
of his left leg. Undaunted and with the aid of a prosthetic,
John went on to win a silver medal in the 2000 Paralympic games
where he set the American long jump record with a distance of
5.41 meters.
He now works with the United States Olympic Committee where
he manages the Paralympic Academy Youth Outreach Program and
the Paralympic Military Program.
We also have the privilege of being joined by Mr. Jim
Mayer. Mr. Mayer served as an infantryman in the United States
Army during the Vietnam War. He is a combat-disabled veteran
and a bilateral below the knee amputee.
After serving so honorably in combat, Mr. Mayer has devoted
his life and career to assisting his fellow veterans, working
for 27 years with VA and 12 with our veteran service
organizations.
Perhaps most notably, he has also spent 21 years as an
amputee peer visitor and mentor at VA and the Walter Reed Army
Medical Center and now at the Walter Reed National Military
Medical Center, where he is affectionately known as the
``milkshake man''.
Gentlemen, thank you both so much for your service to our
Nation and for your continued service to your fellow veterans
through your many worthy endeavors today. Both of you are truly
inspiring to all of us and it is really an honor to have you
here with us today. I very much look forward to hearing your
testimony.
Mr. Register, you may proceed.
STATEMENTS OF JOHN REGISTER, VETERAN; JIM MAYER, VETERAN
STATEMENT OF JOHN REGISTER
Mr. Register. Thank you very much and, Ranking Member
Michaud, thank you, and Members of the Subcommittee.
And I know the milkshake man. I have to go to Walter Reed
this afternoon, so that is outstanding.
Thank you for this opportunity to testify on the ability of
the Department of Veterans Affairs to deliver state-of-the-art
care to veterans with amputations.
And today I am testifying on behalf of myself and an
organization for which I serve on the Board of Directors, that
organization being the National Association of Advancement of
Orthotics and Prosthetics, the NAAOP, a national association
that promotes public policy and interest of orthotic and
prosthetic patients and the providers who serve them.
I served, as you stated earlier, in Desert Shield, Desert
Storm, and my injury actually happened May 17th, 1994. So my
18th anniversary is actually tomorrow.
I was just over at the Pentagon where a friend actually
found photos of the actual accident. So I just have them in my
bag, so I am kind of just stressing out a little bit right now
seeing those photos again.
But it is remarkable about the prosthetic care does come
afterwards and that is what I am going to talk about a little
bit today.
I did go back after my injury and went to the Paralympic
games in 2000, winning the silver medal in the Paralympic
games.
I currently now live in Colorado Springs and I began my
initial care at the amputee clinic in Denver VA hospital and
referred to a local prosthetist in Colorado Springs for my
primary prosthetic care.
And I sought out this process because of two reasons. They
were close to my home, first of all, and, secondly, they
understood the high level of activity that I am accustomed to.
This was done in no way to disparage the care that I
received at the Denver VA. In fact, when I first was an
amputee, I came to Walter Reed and also the VA hospital right
here in the Capitol region and had outstanding care.
In my experience, I have always been treated with dignity
and respect at the three VA hospitals that I have been
fortunate to work with. And finding a local prosthetist is
pretty typical in the VA prosthetic care.
And just a few years ago, approximately 97 percent of
prosthetic limbs were provided by private prosthetic
practitioners under contract with the VA. And I understand this
percentage has decreased in the past few years as the VA has
invested their internal capacity to their capacity to fit and
fabricate limb prostheses.
I had a close working relationship with my local
prosthetist over the years and would like to continue seeing
him. And the prosthetist is certified and accredited by one of
two accrediting agencies the VA recognizes and requires.
My local prosthetist's office in town is seven minutes from
my house. He has signed a VA contract to provide that care. And
the ongoing care I receive at my contract prosthetist was high
quality and very convenient, creating little disruption for my
current job, my family, and my lifestyle.
I developed a need for a new prosthetic as it was coming
out and I began to be interested in this new technology. And
the VA hospital in Denver, when I went to go see them for the
consult, said that I would have to come there in order to get
this limb fitted.
And I did not realize I had a choice in the matter and
believing the new technology would meet my prosthetic needs and
increase my quality of life, I agreed and began the fitting
process at the Denver VA, driving 70 miles each way to receive
that prosthetic care. And I could have just as easily have gone
down seven minutes from my home to get that care done.
And it was also later that I realized after like my fourth
or fifth visit that I could be reimbursed for gas mileage. So
that is something I did not know that I wanted to get out to
the other vets and I began tweeting that out as well on my
social network to my VA vets.
I traveled to Denver numerous times in the fitting process
before I finally received my new limb which I am wearing today
and I am really thankful for.
Every time I need adjustments or a servicing of the
prosthetic, I must take the better part of day off of work,
drive a significant amount of distance, and obtain my VA care
at the Denver VA.
Again, great care there. I am not disparaging that. It is
just a bit of an inconvenience. I have no complaints about the
prosthetic care that I received. So I consider myself to be
very fortunate where I am not vulnerable and uneducated about
the process. But I worry about those veterans who are not in a
position to advocate for themselves, simply accept what they
are told about the prosthetic care and the options.
Veterans, I think, just need to know some of the rights
that they have. They should have a choice in the prosthetic
practitioner and choice of technological options and a choice
to seek a second option when it is desired by a patient.
Passage of such legislation like H.R. 805, the Injured
Amputee Veterans Bill of Rights, I think, is critical.
And I reviewed three reports recently issued by the Office
of the Inspector General and have some general observations to
just offer this Committee.
The first is of the $1.8 billion spent by VA on prosthetics
in fiscal year 2010, only $54 million or three percent was
spent on prosthetic limbs. And this is a relatively small
portion of dollars spent by the VA on a broad category of
prosthetics.
Secondly, the VA has a major investment in its internal
limb prosthetics capacity in 2009 with the development of the
amputee system of care, ASOC program that should be commended
for its commitment and focus on this important population.
The report also notes high satisfaction of those with lower
limb prosthetics but less satisfaction with upper extremity.
And we agree with the OIG that the VA should improve on this
care of the population and request of the VA to publish the
report on upper limb research associated with the VA/DoD
research conference held two years ago.
The NAAOP takes issue with the OIG's calculation of the
difference in what it asserts as a cost to the VA to provide
prosthesis on average to veterans and its in-house capacity and
the Veterans Health Administration. The report stated that
$12,000 on average for a prosthesis while the average cost of a
prosthetic limb fabricated at VHA's prosthetic lab was
approximately $2,900. This is highly a little suspect
calculation of VA's true cost in providing prosthetic care and
we just want to know what kind of the costs are associated with
those that went into that report.
As the VA enhances its internal prosthetic capacity, it is
important to recognize the legitimate role of private
prosthetists who have provided prosthetic care to veterans for
decades with the VA.
Allowing veterans to access private prosthetics in their
own hometown communities preserve quality by allowing their
choice in provider. The relationship between the prosthetist
and patient can mean all the difference in the world,
especially, you know, with myself going on to higher level
competition and wanting to have a higher quality of life.
The last two points is I think it is important that the VA
maintains access to local private prosthetics under the
contract with the VA to conveniently service veterans. And this
is why the NAAOP strongly agrees with the recommendation in the
health care inspection report that VA addresses veterans'
concerns with the VA approval process for fee-based and VA
contract for prosthetic services to meet the needs of veterans
with amputations.
So we ask the Committee to seriously consider in a
subsequent legislation hearing passage of a legislation pending
before this Committee that seeks to address this very issue,
H.R. 805, an Injured and Amputee Veterans Bill of Rights.
So on behalf of NAAOP, I want to thank you, Madam
Chairwoman, and the Subcommittee for examining this critical
issue. And I also thank you for this opportunity to testify
before you and I welcome your questions after my friend.
[The prepared statement of John Register appears in the
Appendix]
Ms. Buerkle. Thank you very much, Mr. Register.
Mr. Mayer, you may proceed.
STATEMENT OF JIM MAYER
Mr. Mayer. Chairwoman Buerkle, Ranking Member Michaud,
thanks for the chance to talk to the Subcommittee today and
thank you for those kind words in your introduction. I really
appreciate that, ma'am.
I received, like John, I received a lot of prosthetic care.
I received it from the VA, from Brooke Army Medical Center,
from Walter Reed, and the private sector.
And your reference to my peer mentoring and peer visiting
amputees at Walter Reed over the years, I have gotten to know
current warriors and their families, their concerns. And in
short, I think I understand the catastrophic injuries they have
overcome through military health care and rehabilitation. I
understand it from being at their bedside and I also understand
from being in that hospital bed myself.
As of May 1st, there is 1,459 warriors with amputations.
The care for those warriors is at the very core of the VA's
mission. Yet, it is clear that VA's prosthetics today is at a
crossroads. VA to me has the chance to regain its leadership
role that you referred to in the excellence in this field of
prosthetics provision and amputee care.
But the current direction and recent decisions involving
prosthetic care suggests that the Veterans Health
Administration, VHA, is about to further compromise its ability
to serve these veterans.
In 2004, eight years ago, Secretary Principi testified
before this Committee that VA in his opinion had lost its edge
in prosthetics and it was not doing enough to ensure that VA
had developed world-class prosthetic care and rehabilitation
programs.
His primary solution at that time was to build a, quote,
center of excellence in amputee research and rehabilitation.
Secretary Principi's words of eight years ago still ring true
today, but the number of warriors with amputations has since
increased by over 900 percent.
In 2006, Congress revisited this issue and proposed
legislation to create in VA five such centers. The leadership
from the VHA opposed the bill and the legislation died.
In my humble opinion, as a result of some of that history,
the VA lost its long-held leadership position in prosthetics
and was eclipsed by DoD. Since 2006, DoD has not established
just one but three amputee centers of excellence which are
holistic in care.
The warriors there receive world-class care and when they
are no longer on active duty, they are going to have to turn to
the VA. In my opinion, the VA has to ensure that the expertise
that is necessary to continue the level of clinical care that
the warriors have become accustomed to in the military and the
VA's administrative processes guarantee timely care.
I want to reference your remarks, Madam Chairwoman, about
transfer of warranted prosthetic purchases within the
prosthetic services in the VA to acquisition, to supply. I
totally agree.
I think the potential wait times because of lack of
knowledge on the supply side about prosthetics, if this were a
bulk purchase item, I probably would not be worried about it.
But I know John and I know that when prosthetics are delayed,
it is not a wait time. It is an inability to function in my
life or to thrive in life.
I want to couple that with I understand that VA is moving
towards decentralizing the funding for prosthetic purchases.
This is an issue that was solved over 20 years ago by
centralizing or fencing off those funds so local VA medical
facility directors could not use that money for other purposes.
Twenty years ago, veterans were delayed to the next fiscal
quarter or the next fiscal year because the monies were used
for other purposes.
I would like to summarize by saying what I think needs to
happen with VA right now. I think it is time for them to
suspend their decision on VHA transfer of the prosthetic
purchases to supply, also to kind of drop any discussions about
decentralizing funding.
At the same time, it is time for a full-scale program
evaluation led by a little more impartial body such as VA's
Office of Policy and Planning and put stakeholder cohorts on
that effort, and I kind of list those in my written statement,
and have that effort report directly to the oversight of
Secretary Shinseki.
To me, he has shown he has the ability to take tough issues
and decide what is right for the veterans.
Thanks for the chance to be here.
[The prepared statement of Jim Mayer appears in the
Appendix]
Ms. Buerkle. Thank you both very much.
I will now yield myself five minutes for questions.
I will start with you, Mr. Register. When you received your
injury, you received care from the DoD as well as from the VA.
Mr. Register. I did.
Ms. Buerkle. You mentioned that in your opening statement.
Can you compare and contrast those services? How would you say
one was versus the other, either positively or negatively?
Mr. Register. Yes, I will. And I think that I want to
clarify when I went to the Department of Defense at Walter
Reed, this was before all of the new kind of bells and whistles
they have over there now with the amputee care because it is
extraordinary what the servicemembers have.
And so I would liken them. They were pretty much the same.
They were almost on, I think, an equal basis. So I had a
prosthetic limb that was made there and also over at the VA
that was right here in the D.C. area and I had no issues going
between either one or the other.
I think when it came time for understanding a little higher
level of activity, I found both lacking in that knowledge base,
so I began seeking it out as trying to become a world-class
athlete again and looking at what was going on not just in the
United States but around the world and what other people were
walking or actually running on. That is what I started looking
at. Who needs to begin to align this thing so I can actually
run at my optimum time.
And that I found outside of both the DoD and the VA system.
In fact, some of that was--that expertise is so critical that I
went all the way to California from Virginia to find one
prosthetist who actually knew how to get me aligned right and
correctly. If I did not get that person, I would not be a
silver medalist today and that is just a point in fact.
I think for my ongoing care right now, again, it is more
the inconvenience than it is for what I have seen. But I do
see, you know, having been down to Brooke Army Medical Center,
out to San Diego, California, and here at Walter Reed that the
care is exquisite. And these individuals that are coming
through are not--they are looking to get back into the fight.
They are looking to go back with their units.
And so that is the same level of high activity that I found
lacking before that they are now receiving to go back and do
those things. Amputees are now back in the fight and they are
going on to higher employment. They are going on to being with
their families.
And that is what I see as the difference.
Ms. Buerkle. Thank you.
Mr. Mayer, in your opening remarks, you talked about the
fact that VA has lost its leadership position in prosthetics. I
would like to know if you can maybe identify or help me to
understand when and how VA lost its premier status and the
military took that over.
Mr. Mayer. I will try. I had the pleasure of being the
first staff Committee manager for the very first VA Prosthetics
Advisory Committee in the early 1990s when Secretary Derwinski
ran the VA. I did not have a vote. I just took the notes and
organized the agenda.
The burning issues today are already being reconsidered by
VHA. My quarrel is not with the PSAS employees and their
ability. They are professionals. They do a good job.
My quarrel is at the more senior ranks of VHA management
and it really does not matter who is there culturally, and I
understand the motivation. Culturally they look for, because of
budget reasons, they look for flexibility at the local
management level at the medical facility.
Prosthetics monies and procedures are a very interesting
large target. That is how I would summarize it.
Ms. Buerkle. Thank you.
Mr. Register, in your testimony, you talk about differing
needs depending on amputation--whether the amputation is an
upper body or lower extremity.
Can you kind of talk about that with us and the differing
needs as you see them?
Mr. Register. I think with miotics and upper limb
extremities, the use of getting the hand function back, I
think, is one that is pretty critical. And as you look at how
that has come and developed over time, it is really amazing the
intricacies that the upper bodies have with getting that limb
function back.
With lower extremities, it is a matter, I think, of just
gait and walking and functionality of the limb. You know, it is
kind of comical what is inside of the world of amputees, below
the knee amputees, when I am down at Brooke Army Medical
Center, for example, is below knee amputees and above knee
amputees kind of have a rift going against each other where the
above knee amputees always call the below knee amputees little
paper cuts because they have their knee, right?
So I think it is a matter of functionality and just walking
again and getting back upright with that whereas with arms, you
know, we write with our arms and they are more mechanical as
far as what we are doing. They are more tangible, I think, with
that.
And so I think that is a difference between the upper
extremity and lower extremity.
Ms. Buerkle. Thank you both very much.
I now will yield to the Ranking Member for his questions.
Mr. Michaud. Thank you very much, Madam Chair.
I once again want to thank both of you for your service to
this great Nation and for coming here today as well.
Mr. Mayer, you recommended that for the strategic plan that
VHA can participate in it, but the operational controls should
be centralized in the secretary's office.
Could you explain a little more why that should be?
Mr. Mayer. It is just an opinion based on historical
experience. Like I said, VHA and PSAS have a long history of
dedicated professionalism. But when it comes down to these
issues, you know, I am just here to tell you John is right.
This generation of warriors are athletes.
My day, we wanted to learn how to walk. Walking do not get
it for these guys and gals. They run. They climb mountains.
They go in the Paralympics. I mean, I got out of breath just
watching them.
I am just here to tell you if you think the complaints were
big 20 years ago, wait a couple months. Let these policies go
in effect. And you know who is going to get the complaints. It
is going to be Members of Congress and veteran service
organizations.
That is why I kind of go, okay, no, not to VHA senior
management, let them participate, but Secretary Shinseki has
shown pretty activist style when it comes to large issues.
Cool.
Mr. Michaud. You also mentioned the Department of Defense
definitely has superiority over the VA as it relates to this
issue.
Why do you think that is, the fact that it does not have to
go up to the Secretary of Department of Defense? It appears
that is down at the lower level. Why is that?
Mr. Mayer. Well, I think it is a question of leadership
recognizing the clientele and their needs and the fact that
John said a number of them want to get back in the fight.
So they have got to be trained. They have got to be
conditioned and they have got to go through a board process to
actually certify that they can return to duty. So it is a
question of need.
Congress provides the funding. Congress still provides the
funding. It is known out there as GWOT funding. It is the war
funding.
My only concern about that is given the budget situation, I
do not know how much longer that funding is going to let these
centers operate at the level they do.
But I think the real key is what I called holistic. And I
do not want to go into the details of trying to name. It is not
just the surgical expertise and the clinic expertise. It is the
merger right together of physical therapy, outpatient therapy,
adaptive sports, challenges.
And to me, one of the best kept secrets in the military is
the outpatient nurse amputee manager. For years at Walter Reed,
I watched this individual, Steve Springer, quietly fix
problems, keep the track on recovery, be the advocate, and
never in a way that calls attention to his role but really
calls attention to the warriors.
So I think that is what makes it work. And I think
collocating research with the clinical part instead of being
stand alone is another big accomplishment.
Mr. Michaud. Great. Thank you.
Mr. Register, how long did it take you to get the new
technology that permits microprocessing control of the
prosthetic knee through the VA?
Mr. Register. Well, I have done it twice now. And the first
time I was here in the Virginia area when I first got what we
call the C-Leg. And that is kind of the first microprocessing
technology that actually worked pretty well.
And that process took about a month to maybe a month and a
half, maybe six weeks. And the current process of going back
and forth, it took about three months to get that prosthesis.
In fact, the situation was, I was going up, and I try and
show by example, so I attended the National Veteran Wheelchair
Games which will be in Richmond this year. And I had a
wheelchair made for playing wheelchair basketball. So my chair
had come in and I went back up to the VA to get it from the
Denver area, traveled almost 70 miles. And I knew I had to go
there to get it.
And on the way, I just kind of sent a note. And I was in
the lobby area waiting for my appointment. And I saw an e-mail
from my prosthetist saying you know what, your leg is here, it
is in. I said great. It is all cannibalization. Let's just put
it on. I can walk out of here with it.
And he said, no, we want to come back again and we have to
fabricate it and make sure that everything is good to go. So I
could have actually left that day with three pieces of my
equipment, my wheelchair, my sports chair, and then my
artificial leg and walked right out of there.
But because the VA wanted to ensure that the fabrication of
my socket was done to marry that with the new X2 that I have
was just--it was kind of just funny and ludicrous to me that I
could not just go on in the shelf, put it on with my Allen
wrench, and just walk out the door with it.
Mr. Michaud. Great. Thank you.
Thank you, Madam Chair.
Ms. Buerkle. Thank you, Mr. Michaud.
I now recognize the gentleman from Tennessee, Mr. Roe, Dr.
Roe.
Mr. Roe. Thank you.
And, again, both of you all, thank you for your service to
our country.
And I also want to congratulate the staff that wrote this
memo today for the most acronyms that I have ever seen. I
counted at least a dozen. And I thought the PLO was people's,
you know, whatever. But, anyway, it is a different organization
here.
John, why do you think or do you think that there is, or
either one of you all can grab this, a drop-off? And I have
been to Walter Reed in Bethesda on multiple occasions and it is
unbelievable to see the amputees up and about and the care they
are getting.
Is there a drop-off when they go to the VA, when these
warriors are handed off?
And you are absolutely right. There is a different
expectation than in Mr. Mayer and our's generation, so there is
a complete different view of the young people now.
Is there a drop-off? Do you see that?
And certainly not in your case because you are incredibly
motivated, not in your case.
Mr. Register. Is that to me?
Mr. Roe. Yeah.
Mr. Register. I can answer. Thank you for the question.
And I think what Mr. Mayer was saying is spot on. And there
is. I see a little bit of a drop that happens from DoD to the
VA, but I think it is a much larger issue than just the
amputees. I think there is a systematic care that has to
happen, a continuum of care that goes forward.
What I am seeing now with the drop, I think it has to do,
my personal opinion, is that there is a center of excellence
when these young men and women are coming back to the DoD
hospitals and they are coming back as units.
When we see a KIA, a killed in action, I am looking at the
paper. I know that there are going to be six or seven other
young men and women that are coming back and are going to hit
those DoD hospitals that survived that. And so those are the
ones that I am focused in on.
And when I see them come back, they are extremely motivated
to get back because they do not want, as the soldier's creed
is, they do not want to leave a fallen comrade. They do not
want to leave their buddies on the battlefield and they feel
that they have lost that ability to fight. Once they get
support and those mechanisms and tools to rehabilitate, they
are ready to be active again.
And I think that on the VA side, the population has always
been different and that has not been--you know, the activity
level has not been as high for getting back into like a war
fighting situation. So I think that is the drop.
What I do see on the VA side right now is that with the new
sports center that they are--the sports programs, they are
really pushing out into the communities now increasing the
activity level of the veteran patient.
And so those that are coming to the VA hospitals are being
linked in with community-based programs across the United
States. And that is at its infancy right now. So the model is
being changed and I think that is going to change the dynamic
for the VA.
Mr. Roe. I think part of it, too, may be generational. As
you are older, your expectation may be just to ambulate. If I
can ambulate well, that is a success. A 23-year-old, that is
not a reasonable outcome. Your reasonable outcome is to return
to the mountain climbing, snow skiing, whatever I did before,
backpacking, whatever it may be.
And I totally agree with you on the upper and lower
extremity. I think that is a really tough one.
We just graduated a year ago a young medical student who is
now a physician and who lost his right arm with a Black Hawk
helicopter crash and then came back, did his pre-med, went to
medical school, graduated.
And it is tougher for him. He is going into emergency
medicine, but because of the dexterity you need with your
hands, he can walk, ambulate fine, but it is difficult for him
to do a lot of things.
And I think that is probably the satisfaction difference
that you see. If you get back to jumping, running like you are,
you feel pretty good about that, whether you have a prosthesis
or not.
And I think the other thing, you brought up a great point,
it is very individual who you relate to. I know as a physician
myself, when you have that relationship with your patient, you
have great confidence in your fellow you work with or the
person you worked with there in Colorado Springs. And they know
you. They know your leg. They know exactly about you.
And I want to just say for myself, but I think I can speak
for most of the Committee, I do not care what it costs for you
to get the care you need, for a wounded warrior to get the
prosthesis that they need in a timely fashion.
Mr. Mayer said it very well. It is inconvenient. It affects
how you live. You take one day off or three days that you
cannot do something, you cannot take care of your family,
cannot go to your work, whatever, because of your prosthesis,
is not acceptable.
In our budget, 1,500 and something was the last number I
saw of wounded warriors who have lost one or more extremities.
We cannot--as a Committee and as a country--do enough for those
warriors. And those needs are going to go on.
And Mr. Mayer can tell you, Mr. Register, that you will
change as you get older. Your leg changes. Things just change.
And gravity has a great effect on us.
Mr. Register. I am finding that out.
Mr. Roe. You are finding that out. And so we have a
commitment, I think, to those wounded warriors not for this
great care now but for a lifetime of great care. And I think I
can speak for the entire Committee on that. I think we all feel
that way.
Again, I want to make sure that the care does not drop from
the time you leave DoD because I have seen that facility out
there multiple times. It is phenomenal to when they get to the
VA.
And I am out of time, I realize, but later if you get a
chance, I want you to get on that answer about why you think
the VA's prosthesis is $2,900 and you are out in the private
sector, it is $12,000. I agree with your analysis. I read your
testimony.
I yield back.
Ms. Buerkle. Thank you.
I now recognize the gentleman from New Jersey, Mr. Runyan.
Mr. Runyan. Thank you, Madam Chair.
And, gentlemen, again, thank you both for your service to
this country.
Just talking, Mr. Register, just talking about whether it
is contractor or fee for based and the VA, equally satisfied
with both?
Mr. Register. Restate the question. I am sorry.
Mr. Runyan. Whether you are with, you know, with a private
doctor or with the VA, the treatment equal?
Mr. Register. Yes, I have no--from what I have experienced
at the three VAs that I have gone to, there was one that was
out in--I did a clinic in California. There was also one in
Virginia as well as the one in Denver. I received great care.
Mr. Runyan. Because it kind of comes back to a lot of
things we discuss here in this Committee, and obviously I think
Mr. Mayer, you know, obviously stated that we have a 900
percent increase in the need, you know, for prosthetic
treatments.
And moving forward and knowing there is a need out there,
one thing we talk about here all the time is access to that
care. And when we move forward from this, obviously yourself
wanting to get back into the athletic mode.
When you look at the holistic approach of all this, you
know, and avoiding onset of things like diabetes and stuff by
staying active and not compromising your health because you do
not have the access to care, you know, whether you want to make
the 70-mile trip to Denver or not. There is something to be
said about, you know, seven minutes away versus 70 miles away.
And I think it really becomes an issue because I see in my
district all the time, you know, veterans all the time say,
well, I am not going to spend my whole day traveling to go get
treatment until I really need it.
And I think that is something we really have to look at
because as you just said also, you do not see the--you agree
that the treatment on both the private side and the VA side are
equal, but if they are the same way, I do not think we--and you
brought it up, you did not see you were entitled to
reimbursement for travel at the end of the day also being
another cost to the VA system where we could get that same cost
to another veteran to help them along, you know.
And I just think I do not have a lot of questions. I just
wanted to make that because there is an access to care issue
here. And I think as we have increased, as Mr. Mayer said, with
the 900 percent increase, it is a huge, huge issue.
And I just wanted to throw that out there. I really did not
have any other questions.
So I yield back, Chairwoman.
Mr. Register. Madam Chair, may I respond?
Mr. Runyan. Sure.
Mr. Register. That is a great observation. I think what I
wanted to say is what Mr. Mayer was talking about earlier and
what you just said, sir, is that a lot of these veterans are
finding that system of care and they are not moving away or
they are moving back to where they found that quality.
So, for example, down in Brooke Army Medical Center, they
may get their care. They are off and walking. They are doing
what--they are going back to regular life. But they are not
finding the care where they have moved to, so they wind up
coming back to San Antonio because they have that system of
care. They do not want to get away from it.
And it is not just about getting back into athletics, you
know. That just happened to be what I did. It is getting back
into school. It is getting back with your families again. It is
walking your daughter down the aisle. It is taking your son
fishing.
It is all those things that they had before that they want
to get back to with the high level of care. And having that in
a centralized location where they do not have to travel so far
to do it is just--I think it is paramount for that individual.
Mr. Runyan. Thank you.
Yield back.
Ms. Buerkle. Thank you very much.
If anyone else has any further questions.
[No response.]
Ms. Buerkle. With that, we want to say thank you to both of
you for giving us the opportunity to thank you in person for
your service and your sacrifice to this Nation both then and
now as you continue on with your work. Thank you very much. You
are both dismissed. Thank you.
I would like to invite the second panel to the witness
table.
Good morning and thank you all for being here this morning.
With us today is Michael Oros, Board Member for the
American Orthotic & Prosthetic Association; Joy Ilem, Deputy
National Legislative Director for the Disabled American
Veterans, Captain Jonathan Pruden, retired, Southeast Alumni
Manager for the Wounded Warrior Project; and Alethea Predeoux,
Associate Director of Health Legislation for the Paralyzed
Veterans of America.
Thank you all for being here. In particular, we would like
to recognize Ms. Ilem and Mr. Pruden for their honorable
service to our country. Thank you both very much.
Ms. Ilem is a service-connected disabled veteran who served
as a combat medic in the United States Army. Captain Pruden is
a veteran of the United States Army. He was severely injured
when a roadside bomb struck a Humvee he was driving while
serving in Iraq in 2003 and subsequently he lost his right leg.
Thank you both for your honorable service and your very
important advocacy efforts on behalf of all disabled veterans.
I am eager to begin our discussion, so we will begin. Mr.
Oros, if you would like to proceed with your opening statement.
STATEMENTS OF MICHAEL OROS, BOARD MEMBER, AMERICAN ORTHOTIC &
PROSTHETIC ASSOCIATION; JOY ILEM, DEPUTY NATIONAL DIRECTOR,
DISABLED AMERICAN VETERANS; JONATHAN PRUDEN, ALUMNI MANAGER,
SOUTHEAST WOUNDED WARRIOR PROJECT; ALETHEA PREDEOUX, ASSOCIATE
DIRECTOR OF HEALTH LEGISLATION, PARALYZED VETERANS OF AMERICA
STATEMENT OF MICHAEL OROS
Mr. Oros. Good morning. Thank you for holding this hearing
and for your work to ensure that veterans with limb loss
receive the highest quality prosthetic care.
My name is Michael Oros and I am a Board Member of the
American Orthotic & Prosthetic Association. I am also a
licensed prosthetist and the President of Scheck and Siress, a
leading provider of orthotic and prosthetic services in
Illinois.
For me, as a practicing clinician, there are really four
elements to high-quality care. The first would be access.
Veterans receive their care on a timely basis without having to
wait weeks or traveling hundreds of miles for that care.
Second, trust. Veterans receive care from a provider they
feel good about, one who listens to them and one who works with
them.
Third, experience and expertise. Clinicians serving
veterans design, fit, and adjust the best possible prosthetic
device to address the veteran's complex challenges.
And, finally, positive outcomes. The result of high-quality
prosthetic care is greater comfort, higher activity levels,
more independence, and greater restoration of function to those
veterans.
The potential quality of prosthetic and orthotic care for
veterans has never been higher. However, veterans' experience
of prosthetic care is really highly dependent on their ability
to advocate for themselves.
Several barriers seem to stand in the way of providing
uniform high-quality care to all veterans. These barriers can
be eliminated. I would like to suggest an achievable agenda to
promote quality prosthetic care. It has three elements.
The first would be to guarantee veterans meaningful access
to a trusted clinician of their choice. Currently, 80 percent
of all orthotic and prosthetic care is provided by community-
based providers. In some places, such as New York City, the
majority of veteran orthotic and prosthetic care is provided by
VA employees. However, in cities like Chicago, even veterans
who live close to a VA medical center may choose to receive
their care from those independent contracted providers.
Those who have served and sacrificed for our country should
be able to freely choose the provider who best meets their
needs, especially on an issue as personal and important as
prosthetic and orthotic care.
Reports from the field suggest there are real and
increasing administrative barriers to veterans choosing non-VA
providers. It has been suggested that the VA is moving care in-
house because it is cheaper. AOPA is disturbed by the OIG's
allegations that the average cost of a prosthetic limb
fabricated in-house by the VA is but 25 percent of that
fabricated by an outside contractor.
The costs quoted for the VA fabricated limbs almost
certainly omit the cost of things like VA salaries, benefits,
facility costs, and administration. We believe that a complete
and accurate cost comparison would show that O&P contractors
provide excellent value not only to the veterans but to our
taxpayers.
The second agenda point would be to elevate the clinician
expertise and experience. Over the past decade, the practice of
orthotics and prosthetics has grown increasingly complex and
the technology has grown increasingly sophisticated.
In response, the field has changed the entry level
credential to that of a master's degree. Currently there are
really only six institutions enrolling approximately eight to
twelve students each in master's degree programs, with a few
more in the credentialing process.
This is simply insufficient to meet the growing demand.
AOPA recommends the creation of small time-limited competitive
grant programs to offer grants to either create or expand O&P
master's programs.
And we are grateful to Chairwoman Buerkle for your work on
this issue.
And, finally, demand evidence-based practice to achieve
optimum outcomes. AOPA believes that it is important to hold
all O&P professionals accountable for the quality and the cost
of the care delivered. This is a challenge for the VA because,
frankly, there is currently little objective, comparative
outcomes research to support evidence-based practice as it
pertains to orthotics and prosthetics.
For example, 20 years ago, if you had a back problem, there
was no outcomes research to guide you as to whether the right
decision would be surgery or physical therapy. Today objective
research documents which treatment works best for which
patients.
The result is better outcome, obtained more cost
effectively. That is what we want for veterans who need
prosthetic and orthotic care. A comparative outcomes research
portfolio in the field of orthotics and prosthetics. This would
increase the quality of care for veterans and others with limb
loss, while protecting taxpayers by ensuring that patients
receive the most appropriate care.
Madam Chairwoman, thank you for your invitation to testify
and I look forward to answering any questions.
[The prepared statement of Michael Oros appears in the
Appendix]
Ms. Buerkle. Thank you very much.
Mrs. Ilem, you may proceed.
STATEMENT OF JOY ILEM
Ms. Ilem. Thank you.
Madam Chair, Ranking Member Michaud, and Members of the
Subcommittee, I am pleased to present the views of DAV on the
capabilities of VA to deliver state-of-the-art care to veterans
with amputations.
Many DAV members have experienced limb loss due to combat
trauma and are high-intensity users of VA health care and its
specialized services.
VA is responsible for ensuring that veterans with these
types of injuries have every opportunity to regain their
health, functioning, overall well-being, and quality of life.
As in previous generations of veterans, our newest war
veterans with amputations want to remain physically fit, highly
active, and participate in competitive sports post injury.
These expectations and interest require a team of health care
specialists and lifelong care.
The VA inspector general recently issued three reports
related to VA amputee care and its prosthetics and sensory aids
services. The IG found that overall most veterans contacted
were pleased with the quality of VA care and services they
received, but some have indicated that certain processes for
obtaining prosthetic limbs should be more streamlined and
simplified.
In one report, the personal comments from veterans related
to amputation care provide VA with good feedback and can help
to reduce identified hurdles and bureaucracy for routine
maintenance and repair of prosthetic limbs. We urge VA to
establish a permanent mechanism to receive continuing comments
from this population.
VA's extensive system for amputation care and
rehabilitation collectively delivers specialized expertise
across the VA health care system. In our opinion, this program
is functioning very well and we urge VA to continue to evaluate
these veterans over time to better understand their complex and
evolving health care needs and when necessary to readjust VA's
services accordingly.
The IG also conducted an audit of VA's acquisition
practices and purchasing prosthetic limbs and concluded that it
had overpaid private vendors by $2.2 million in the year
assessed and that VA is not getting the best value for these
purchased items.
We agreed with the IG's recommendations and it appears that
procurement reform and new policies to better manage prosthetic
acquisition functions are underway. However, DAV is very
concerned that during the transition of prosthetics, VA's
services should retain appropriate staff to ensure a strong
connection between veterans and clinical components of care.
While contracting will always be a dominant aspect of
prosthetic supply, the determination of what type of prosthetic
appliance is appropriate should remain with the physical
medicine and rehabilitation specialist aided by prosthetic
representatives in conjunction with direct involvement of the
disabled veterans being served.
One of our commenters put it best. Without clinical
precedence in ordering specialized prosthetic items and limbs,
veterans could experience unnecessary delays as they would
simply be invoice numbers rather than patients with unique
needs.
While VA could expand its in-house prosthetic manufacturing
with the IG's cost-cutting views to motivate them, cost should
not be the sole factor for an expansion of in-house fabrication
of limbs.
In our opinion, the most important aspect of amputee care
is maintaining options for a veteran's preference of selecting
a qualified prosthetist they feel most comfortable with and the
convenience of those services.
Current authority provides VA the flexibility to
manufacture and procure prosthetics, assistive devices to
wounded war veterans without any other provision of law
including cost.
However, while we believe this authority should be used to
provide patient-centered care and timely delivery of prosthetic
items, we do urge VA to focus on improving its business
relationships with private fabricators and to work to
internally improve controls, prosthetic training,
certification, and inventory management as recommended by the
IG.
A third IG report we reviewed evaluated the effectiveness
of VA's medical centers' management of its prosthetics
inventories. While DAV was very disappointed to learn of the
specific findings identified in this report, we understand,
however, that prosthetic services has been waiting a number of
years for the development of an integrated technology solution
for managing prosthetic inventories which has yet to be
approved by VA's Office of Information Technology.
We urge VA to expedite development of an IT solution and
take other necessary actions to resolve this issue.
In closing, while DAV agrees that prosthetic services is an
expensive area of operations and that changes can and should be
made to improve and leverage its purchasing power, these
expenditures are well worth their cost to partially repay the
sacrifices many disabled veterans have made in military service
and they are an integral component of holistic health care to
veterans in general.
Madam Chair, that completes my statement. I am happy to
answer any questions you may have.
[The prepared statement of Joy Ilem appears in the
Appendix]
Ms. Buerkle. Thank you very much.
Mr. Pruden, you may proceed.
STATEMENT OF JONATHAN PRUDEN
Captain Pruden. Chairwoman Buerkle, Ranking Member Michaud,
and Members of the Subcommittee, thank you for inviting Wounded
Warrior Project to share its perspective on issues facing our
amputees.
As Chairwoman Buerkle mentioned, I was wounded in 2003
while serving as an army infantry captain in Iraq and was one
of the first IED casualties. I subsequently underwent 20
operations at seven different hospitals including the
amputation of my right leg.
Over the course of the past six years with Wounded Warrior
Project, I have worked closely with thousands of wounded
warriors, many of them amputees, and have observed both VA and
DoD care.
My friend, Jim Mayer's earlier observation that VA
prosthetics is at a crossroads is perceptive and accurate. The
path VA should take is clear for us here at Wounded Warrior
Project. But with over 1,400 OIF/OEF amputees, many still
adapting to their life-changing injuries, it seems the VA is
headed down the wrong path and moving to institute changes that
will set back prosthetic care rather than improve it.
We hope this hearing can alter their current course which
may reverse years of progress towards appropriate and timely
care for our amputees.
Currently VA uses a process under which VA physicians and
prosthetists see a veteran to determine what type of prosthetic
equipment is most appropriate for that individual. With this
information, a prosthetics purchasing officer completes a
purchase order to obtain the needed item. Those purchasing
officers are specialists who handle exclusively prosthetics.
But the Veterans Health Administration intends to institute
a major change on July 30th and as you have described, under
the change, only a contracting officer could procure a
prosthetic item costing more than $3,000. This policy would
affect essential items including most limbs like mine and
wheelchairs. It would require the use of a system designed for
bulk procurement purchases that involves manually processing
over 300, that is 300 individual steps to develop a purchase
order.
This system may be great for buying cinder blocks and light
bulbs, but it is certainly not appropriate for providing timely
and appropriate medical care.
Equally troubling, this change offers no promise of
improving service to the warrior. Instead it would mean greater
delays. The change could realize modest savings, but at what
cost?
A warrior needing a new leg or wheelchair should not have
to wait longer than is absolutely necessary. I know warriors
who have stayed home from our events, stayed home from school,
from work, cannot play ball with their kids, or live in chronic
pain while they wait for a new prosthesis.
I know firsthand what it is like to not be able to put my
son in the crib while I am waiting for a new prosthetic, to
live in chronic pain, and to have my daughter ask my wife once
again why can't daddy come and walk with us.
With VA moving ahead on changing procurement practice,
wounded warriors need this Committee's help. A prosthetic limb
is not a mass produced widget. Prosthetics are specialized
medical equipment that should be prescribed by a clinician and
promptly delivered to the veteran.
We urge this Committee to direct VA to stop implementation
of this change in prosthetic procurement. Beyond this immediate
concern, our warriors face other challenges. Warriors who have
injuries that result in amputations are often complex and can
prove difficult for later prosthetic fittings, but it is
apparent that the paradigm shift promised some years ago is far
from complete and more progress is needed to realize VA's
vision for an amputee system of care.
As a bottom line, we have real concerns about the direction
of this program which appears to have lost the kind of focused
advocacy it once enjoyed and fallen victim to a
bureaucratization that has lost sight of its customer, the
veteran.
Today VHA seems intent on tossing out veteran-centered
procurement so essential to timely and appropriate care.
Tomorrow we fear centralized funding of prosthetics will be
tossed out and we may wind up where, as Jim mentioned earlier,
where we were 20 years ago where the fourth quarter meant that
all the money for a hospital's budget had been spent and you
could not get a new limb or a new wheelchair until the next
fiscal quarter.
Our goal is improved prosthetics care and service. To that
end, we offer the Committee with a number of recommendations in
our full statement.
In closing, let me highlight just a few areas in which the
Committee can make a profound difference.
First, ensure that through ongoing oversight that VA's
vision of an amputee system of care is actually realized.
Second, press VA to reestablish and re-energize a robust
steering Committee of experts to oversee and provide guidance
on the direction and operation of VA's prosthetics and
orthotics program.
And, finally, it is essential that VA reestablish itself as
a leader in prosthetics research and care and maintain that
position as a commitment to our wounded warriors.
That concludes my testimony. Thank you, and I welcome any
questions.
[The prepared statement of Jonathan Pruden appears in the
Appendix]
Ms. Buerkle. Thank you very much.
Ms. Predeoux, you may proceed.
STATEMENT OF ALETHEA PREDEOUX
Ms. Predeoux. Thank you.
Chairwoman Buerkle, Ranking Member Michaud, and Members of
the Subcommittee, thank you for allowing Paralyzed Veterans of
America to testify today concerning prosthetic services of the
Department of Veterans Affairs.
Ensuring that our Nation's injured veteran population is
able to receive state-of-the-art prosthetic devices in a timely
manner is an extremely important issue for PVA.
PVA has more than 19,000 members who all utilize VA
prosthetic services on a regular basis.
In recent months, the VA Office of the Inspector General
released numerous reports on VA prosthetics and sensory aids,
PSAS, inventory management, acquisition of prosthetic limbs and
prosthetic limb care.
PVA believes that these internal audits and investigations
have identified many areas in need of improvement within PSAS
and PVA generally supports the OIG recommendations.
These recommendations provide not only an opportunity to
improve upon the prosthetic services for veterans with
amputations but for all veterans that utilize VA prosthetic
services.
The OIG's evaluations and assessments are taking place
during a critical turning point for VA prosthetics. The
Veterans Health Administration is currently undergoing a
structural reorganization that directly impacts the delivery of
prosthetic services to veterans. Today I will limit my remarks
to this reorganization.
Under the current changes, VA prosthetics will no longer be
solely responsible for managing the purchases of prosthetic
items. Rather, the VA is currently implementing a joint
purchasing structure that includes both PSAS and the Office of
Procurement and Logistics making prosthetic purchases.
While the VA reports that this change will result in
increased oversight and review of prosthetic orders, PVA has
concern that this dual purchasing track has the potential to
create delays in the delivery of items to veterans.
PVA is further concerned that this new system will lead to
less VA accountability for veterans during the ordering and
delivery processes.
When an order for prosthetics is placed at any point before
the item is delivered, veterans or oftentimes National Service
Officers on behalf of a veteran is able to contact a PSAS
employee with questions regarding an ordered device or the
status of delivery.
With the VA Office of Procurement and Logistics now
handling prosthetic purchases, it is unclear which office will
serve as a point of contact to provide veterans with timely
assistance or questions or concerns that may arise.
PVA has reached out to PSAS leadership on several occasions
to identify the status of the reorganization and appreciates
the opportunity to provide input.
While we have been informed that the dual purchasing system
was piloted in three veteran integrated service networks
beginning in January 2012 and will be further implemented in
additional areas in July of 2012, we are not aware of how VA
intends to make sure that veterans are aware of these changes.
Therefore, PVA encourages VA leadership to consult with
veterans and their families as well as stakeholders who
regularly work with VA prosthetic offices to provide input as
they further develop the process for prosthetic purchases
through the Office of Procurement and Logistics.
PVA further recommends that the VA regularly update this
Committee with the findings that are compiled as a result of
the pilots that were implemented in January 2012 as well as
future findings as plans move forward.
Lastly, the Office of Procurement and Logistics is governed
by VA policies of VA acquisition. Such policies are meant to
address the purchasing of various items from many different
offices within VA. As such, PVA would like to make certain that
the change to the Office of Procurement and Logistics managing
the purchases of high-cost prosthetics does not lead to the
standardization of items, particularly highly specialized
prosthetics such as artificial limbs, specialized wheelchairs,
and surgical implants.
PVA strongly urges the VA to continue to abide by VA policy
that adheres to Title 38, United States Code Section 8123, a
statute that enables VA to meet the unique prosthetic needs of
veterans in a timely manner without the limitations of cost-
saving measures such as standardization of items or contract
bulk purchasing.
Veterans must have access to prosthetics that best fit
their individual needs. For many years, PSAS has done a good
job of ensuring that the number one consideration when ordering
prosthetics is quality, the ability to meet the medical and
personal needs of veterans.
The VA must make certain that the issuance and delivery of
prosthetics continues to be provided based on the uniqueness of
veterans and to help maximize their quality of life.
Again, PVA thanks this Committee for their attention to
this important issue and encourages continued oversight. I am
happy to take any questions from the Committee.
[The prepared statement of Alethea Predeoux appears in the
Appendix]
Ms. Buerkle. Thank you all very much.
I will now yield myself five minutes for questions.
Mr. Oros, in your opening statement, you mentioned the four
very important tenets of access, trust, experience, and
positive outcomes.
As you look at the VA prosthetic care, do you think that VA
encompasses those four tenets that you laid out for us this
morning?
Mr. Oros. I think it can, but, once again, it is somewhat
dependent on the veterans' ability to advocate for themselves.
I think the outcomes piece, frankly, is missing almost
across the board, both inside and outside the system.
Ms. Buerkle. Can you give us some insights? How do we
change that? How do we make those outcomes more positive? How
do we make sure of these tenets are included?
Mr. Oros. Well, I think specifically with outcomes, there
are validated instruments, tests that can be undertaken when
prosthetic limbs are prescribed so that, are we truly getting,
I am going to use the words the most bang for your buck when it
comes to prescribing a particular prosthetic foot or a
particular prosthetic need.
And, you know, there simply are no research dollars
allocated to studying comparative effectiveness when it comes
to orthotics and prosthetics. And in the absence of that, we
will continue to use our experience and our best judgment as to
what we think are the best particular components for a veteran,
without any necessarily evidence to support that.
Ms. Buerkle. Do you have any information or knowledge as to
why there has not been that kind of research done and, say,
compiled regarding outcomes?
Mr. Oros. My suspicion is we are really just too small of a
profession. And so if it is not industry-driven, then it,
frankly, has to come from the Federal government. And I cannot
explain beyond that.
Ms. Buerkle. Thank you.
Mr. Pruden, in your testimony, you say that VA prosthetics
research has lagged in recent years.
Now, Mr. Oros talked about outcomes, but I think you are
talking more generally in terms of the research.
What impact has that had on veterans and the services that
they need?
Captain Pruden. The VA has stepped up in a number of
capacities in the past few years. But as Mr. Mayer pointed out
earlier, DoD has taken the lead on the, you know, development
of the DEKA arm and all these advanced technology things.
In years past, VA has been--one of its key roles and one of
the reasons it exists is to provide specialized medical
equipment for our combat wounded, for our veterans. And VA
really needs to have the capacity and the focus on research for
their own medical equipment.
When DoD and Global War on Terror dollars go away, and this
also ties into the discussion about centers of excellence at
Walter Reed, Brooke Army Medical Center, and so forth, when
these dollars go away, those DoD facilities will certainly
scale back their capacity both for rehabilitation and for
research.
And what we are calling for is for VA through the amputee
system of care and enhancements in research to be prepared to
meet the needs as DoD scales back.
Ms. Buerkle. Thank you.
Ms. Predeoux, I am extremely concerned with regard to your
comments about the filing system being outdated and the backlog
that that creates.
Could you comment on that for us?
Ms. Predeoux. Yes. In my written statement with the filing
system, it refers to medical records within one VA medical
center and if, for instance, a veteran were to relocate, for
example, our director actually of benefits relocated to this
area from San Diego, and it took quite a bit of time for the
medical records to be transferred from San Diego to D.C. simply
because there is not one central system in which all the
medical centers are able to locate and actually view the
medical records of a veteran.
And as the panel before us testified, it is not just a wait
time. It is a matter of being able to be comfortable and
actually be mobile.
Ms. Buerkle. That was going to be my follow-up question. So
when those records are not able to be transferred expeditiously
that means the veteran then does not have----
Ms. Predeoux. The records are not being able to be
transferred for the medical provider to see them and they are
not able to get what is needed. It could be a chair. It could
be a repair, those type of items.
Ms. Buerkle. Thank you all very much.
I will now yield five minutes to the Ranking Member, Mr.
Michaud.
Mr. Michaud. Thank you very much, Madam Chair.
I will start with Mr. Oros. Mr. Mayer from the first panel
actually recommended that the Committee ask the VA to freeze
the pending reorganization until a full-scale program to
evaluate a new strategic plan can be achieved. And I know it
sounded like the Wounded Warrior Project agrees with that
assessment.
Do you agree with that as well, and each of the panelists
can answer that question, and why?
Mr. Oros. I guess I am not entirely familiar with the
differentiation between what Mr. Mayer is asking to be done and
the current system.
Mr. Michaud. Do you think we should ask the VA to freeze
the reorganization, bringing everything in-house?
Mr. Oros. Absolutely. Absolutely.
Ms. Predeoux. I am happy to provide a comment on that.
With regard to the reorganization, all of our concerns are
provided in our written statement. But until I think that we
can answer that, it would be great to be able to know the
results and how things worked in the pilots that were
implemented in January.
It is my understanding that within those pilots, the re-org
was implemented in different ways in different VISNs. So it
would be interesting to see how veterans were affected and the
delivery of items, the timeliness, those issues, and access.
Mr. Michaud. The different pilot programs, are they diverse
the way they implemented? Is the diversity great or is it
minor?
Ms. Predeoux. Oh, I think it is minor. It is administration
of certain policies and how they handed off items that needed
to be handed off to PL&O versus PSAS. That is my understanding.
Mr. Michaud. Why should the VA undertake research in
comparative prosthetics outcomes? Why couldn't this be done by
other agencies such as the Department of Defense or the
National Institute of Health? Start with, okay, anyone who
wishes to answer that.
Captain Pruden. I would say that the DoD's mission is to
rehabilitate troops to their maximum potential for
rehabilitation and either return them to the line or send them
on for further care.
VA's job is for the long-standing lifelong care once they
leave the service. Those are different goals. So the DoD's
focus is on acute care and acute rehabilitation. VA's should be
on long-term outcomes and long-term care for our warriors.
And certainly, if possible, it should be done in
partnership with NIH and DoD, but VA should be taking the point
on long-term care for our amputees.
Mr. Michaud. All the panelists agree with that?
Ms. Ilem. Yes. I would concur with that. I think that is
absolutely essential for VA just because of the paradigm shift
that did occur within DoD, maintaining veterans, disabled
veterans for so much longer, and providing this up-front
amputee care.
But as they transition into VA, that is certainly the
lifelong care. And they are focused on effective care and good
outcomes, so that would certainly be within their portfolio.
Mr. Michaud. I guess this would be for Mr. Oros or anyone
else who might want to answer it.
There has been some discussion about the cost in the
private sector versus the VA. Has anyone done an analysis of
what the cost is within the Department of Defense?
Ms. Ilem. We have not, but I think the comments that Mr.
Oros made were really pertinent.
The first thing we thought when we saw the IG report and
the difference between the two cost comparisons was, you know,
not factoring in a number of other things. You know, maybe that
was just material. So we would certainly like to see a better
analysis of that.
Captain Pruden. And may I say that $2.2 million, while it
seems like a lot of money, for us to allow our most severely
injured, the ones who will utilize devices that cost more than
$3,000, our blind, our wheelchair bound, our prosthetic using
or to bear the burden of cost savings at $2 million even
assuming that all those savings could be realized, I think, is
unconscionable. And that is where I stand on that.
Mr. Michaud. A point well taken and I agree with your
point. We will be asking the IG and the VA as far as how did
they come up with those cost comparisons because sometimes they
are not comparing apples to apples which will give you that
deviation, but as well as DoD.
It would seem to me that the cost should be similar to the
VA as far as, you know, if the VA and DoD costs are the same,
then probably their methodology is correct. If it is not, then
I would be interested in seeing that as well.
So I see I have run out of time, so I yield back. Thank
you, Madam Chair.
Ms. Buerkle. Thank you.
I now yield to the gentleman from Florida, Mr. Bilirakis.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it very
much.
I thank the entire panel for their testimony today.
My first question is for Mr. Pruden. First of all, thank
you for your service to our country.
You mentioned in your testimony, again, the same subject,
you mentioned in your testimony your concerns about the VA's
planned changes in the prosthetics acquisition process.
Will you elaborate on the real-world implications that this
will have on our veterans? Specifically from the time a
prosthetic is ordered, how long does it typically take to
arrive under the VA's current process and what timeframe would
you anticipate under the new proposed acquisition process? And
then what are the quality of life and health issues that could
arise from these delays?
Captain Pruden. Thank you for the question, sir.
Under the current system, there are safeguards in place to
ensure that VA is being fiscally responsible. And it can take a
month, two months. Some of this is predicated on the clinical
needs of the patient and availability of the product in their
area which is appropriate.
Our real concerns is that with the new system, it would be
supposition, but it may take months and months longer to get
purchase orders for needed equipment. And the veterans should
not have to wait and the clinicians' hands should not be tied.
If they feel that a device is appropriate and going to provide
the best care for a warrior, they should be able to prescribe
that device.
I have had the opportunity to speak with over a dozen VA
clinicians and prosthetists who are currently serving and
several former chiefs of prosthetics and every single one of
them said they share our concerns about the ability to remain
timely and potential delays in veterans receiving needed
prosthetic devices under this new system.
Dr. Beck will come up in a few minutes and she will say
that one of the things that we are going to consider is if a
device is generally available and interchangeable, then it will
fall under the Federal acquisition regulations.
Who is determining what is generally available and
interchangeable? It is going to be somebody in acquisition, not
a physician, not a clinician who has the patient's best
interest at heart. And that is our real concern.
The VA was given wide discretion by Congress to provide
prosthetic and assistive devices without consideration of
applicable Federal acquisition regulations years ago because
Congress recognized this very special and unique role in
prosthetics for providing care for our warriors.
And, unfortunately, this seems to be a step in the opposite
direction.
Mr. Bilirakis. Thank you.
Again, maybe for the entire panel, let's address this
specifically. What are the quality of life and health issues
that could arise from these delays? If anybody would like to
testify on that.
Captain Pruden. Well, I will say it again that I have
personally experienced this through the natural and appropriate
delays that occur from the time, say, I break a prosthetic foot
to the time I need a new one, but my quality of life is
hindered. My ability to go on walks with my kids, my ability to
do some aspects of my job are directly hindered.
And I could tell you story after story about warriors that
I have worked with who have been stuck in wheelchairs, who have
gained weight, and had subsequent health issues due to an
inability to get up on their prosthetic limbs.
A buddy of mine, Katlin Mixon, is a bilateral above the
knee amputee who lost both his legs in Iraq and a clinician
that worked with him was able to use some discretion, some
latitude to get him the appropriate devices in a timely manner
recently.
And that same physician told me I am really concerned that
if this goes through, I would not have been able to do that for
Katlin. Katlin would still be in his wheelchair today because
he would not have been able to stretch and go outside to take
care this veteran. And that is the last thing we want to see
happen.
The mantra in hearings from the past several years within
PSAS has been take care of the veteran first and foremost. That
is our end goal, ensure they receive the devices they need. And
it is concerning to see us stepping back from that.
Mr. Bilirakis. Yes. What about maybe mental health issues
as a result of these delays? Anyone want to comment on that?
Ms. Ilem. Yeah. I think from DAV's perspective, certainly
we, you know, we have a number of members and people that we
work with and our staff, you know, in Washington, D.C. and the
local area that are prosthetic users that have been long-time
users, and certainly when something goes wrong, whether they
have to have a revision of their stump, whether, you know,
there is a broken foot or some sort of issue with their
prosthetic appliance, it is absolutely critical, and you can
see it in them how frustrated they are not to be able to
ambulate, to be able to do the things they are used to doing,
if there is a delay in getting those items fixed and getting to
their prosthetist of their choosing, oftentimes the person that
has worked with them over years and years, so I think that it
definitely can impact on their mental health. And, you know,
they want to be functioning, you know, all that they can.
Mr. Bilirakis. Thank you.
Anyone else?
Ms. Predeoux. My colleagues have discussed quality of life
and mental health. Quality of care is also an issue. Oftentimes
when there are delays, there are sometimes quick fixes and
other times they could be larger issues, but veterans are able
to step in, figure out what the issues are, and kind of
interrupt that process that could extend the delay.
When it comes to acquisitions, as it stands, it is not an
office that generally sees many veterans or that veterans can
call and see what is going on or their representative can call.
So with regard to the reform and moving over to
acquisitions, systems must be put in place that will allow
veterans to know the exact process in which the order will be
going so that when there is a delay, they can call and say
there has been a delay, what is the problem, and then hopefully
the problem can be fixed.
Mr. Bilirakis. Very good. Thank you, Madam Chair. I
appreciate it. I yield back.
Ms. Buerkle. Thank you.
I now recognize the gentleman from Florida, Mr. Stearns.
Mr. Stearns. Thank you, Madam Chair.
Let me welcome the panel.
And, Mr. Pruden, I understand you went to University of
Florida?
Captain Pruden. Yes, sir.
Mr. Stearns. That is good.
Captain Pruden. Go getters.
Mr. Stearns. Go getters. It is my honor to represent the
University of Florida in Congress and so I am delighted that I
could come over here in time. I have two other Committees at
the same time, but I wanted to especially be here to welcome
you personally and to thank you for your service. And I just
admire your ability and leadership here in testifying and
presenting to the American people some of the problems for the
wounded warriors.
I think what I am asking is sort of an overview. I
understand you were one of the first improvised explosive
devices, IED casualties of Operation Iraqi Freedom. Is that
perhaps true?
Captain Pruden. Yes, sir.
Mr. Stearns. Yeah. You also testified before the Oversight
Subcommittee on seamless transition issues in 2010.
Captain Pruden. Yes, sir.
Mr. Stearns. Have you discussed any of your concerns raised
in your testimony with the VA clinicians or other VA officials?
Captain Pruden. I certainly have, sir. I had the
opportunity to speak with numerous current VA physicians and
prosthetic chiefs, several candid off-record discussions. And
all of them had real concerns about this process and about us
moving forward in changing our procurement requirements and
potentially tying the hands of our clinicians and hampering the
delivery time for our veterans.
Mr. Stearns. I guess particularly the Members here on the
VA Subcommittee which I have served for 24 years, I guess with
the growing population of wounded veterans, do you feel
confident that the transition that we are making will not
encounter greater delays perhaps in our veterans receiving the
care they need and the prosthetics they need?
Captain Pruden. Sir, I certainly feel that that is a real
danger. And that is why we are asking the Committee to stop the
implementation of this until we either are assured that there
are safeguards in place that will not cause this to happen or
just find another way to find savings.
The IG report that was cited several times here today in no
means and nowhere in the report does it call for the use of
Federal acquisition personnel in procuring these assistive
devices. It asks for stricter cost controls and certain control
measures. And certainly we are all for fiscal responsibility
and for, you know, saving taxpayer money, but not on the backs
of our most severely injured.
Mr. Stearns. I am looking at some of the statistics my
staff provided and it says as of March, there were 1,288
servicemembers who experienced major limb loss and of that
number, 359 lost more than one limb. And that is just this past
month.
The Walter Reed National Naval Medical Center received two
quadruple amputees. This is sort of mind boggling to think that
there is that many.
Do you think that with that number, should we organize all
these people together in an en masse type of grouping to work
with them in a focused way rather than sort of in a broad way?
I mean, is there something--since we can identify these people
and we know the problems they are going to have and the
enormous challenges they have, shouldn't we try to single out
these folks and try to have a very special program?
Captain Pruden. Sir, I think that would be appropriate. And
what you are hitting on is that it is a real challenge. And
actually the number I got this morning is, I think, 1,458 new
amputees from Iraq and Afghanistan.
And it is a challenge. I had the honor of being on a 27
member expert panel that made some recommendations about the
amputee system of care. And VA to their credit has implemented
that amputee system of care in large measure. But it is not
there yet. It has not met all its stated objectives.
And certainly we want to encourage the Committee to provide
oversight and support as needed for prosthetic and sensory aids
services, to continue that program of enhancing care for our
warriors.
Dr. Beck, Dr. Miller, as Jim said, these are professionals.
They are doing a good job, but certainly there is need for
oversight and we certainly do not want to see, you know, penny
pinching curtail all of the advances that have been made in the
past 20 years.
Mr. Stearns. Madam Chair, I would think that the Committee
might just think about this. Since we can define who these
people are, we should give advantage in the job market for
these people either through tax credits or tell the employer if
you hire one of these people, you are going to get advanced
depreciation on your capital assets or you are possibly going
to get write-offs or incentives for them to hire these people
so that all of these people get a job because in the end, the
challenge that they have mentally and physically is so
enormous. It can be overcome if they have a job that they feel
they have strong self-esteem and they are self-sufficient and
independent. And they need this job more than anything else.
Would you agree with that?
Captain Pruden. I think that is an excellent idea. And in
principle, I certainly agree with that, yes, sir.
Mr. Stearns. Yeah. Yeah. And, in fact, those employers that
hire these people should be singled out with merit and
recognized somehow in their corporation with a designation that
they are hiring these roughly, you know, 13, 14 hundred people.
So across America, everywhere you go, a person could look and
say that is a company that is doing a great service for our
veterans and for this Nation.
So, Captain, I want to thank you for your service, for your
sacrifice. It is truly a pleasure for me to represent you and
the folks in Gainesville. Thank you.
Mr. Roe. [Presiding] Captain Pruden, I was going to cut you
some slack until I found out you went to the University of
Florida, so you and I are probably going to have to go head to
head. All kidding aside, after this is over, I want to talk to
you about something I want to do privately with wounded
warriors.
Captain Pruden. Yes, sir.
Mr. Roe. I think what I have heard from certainly with the
prosthesis and with limb loss and so on are the very individual
care that veterans need and that relationship they have with
their provider is very important and may go on a lifetime as
that person--either in private practice or with the VA.
I can understand saving taxpayers money, but, Captain, I
could not agree more. We are not going to balance this budget
on the backs of people who have lost limbs in service to this
country. Whether it is going to a private prosthetist or to the
VA or wherever they may go, they need to get the best care
wherever it is.
And I think we need to see if we are measuring apples to
apples, too, because I do not think $3,000 probably looks at
the cost of the light bill, the water bill. If you really dig
down into it, my bet is it is the cost of them and just the
actual cost of the prosthesis, the materials and putting it
together which that is not anywhere near the total cost. If you
have ever run a business you understand, all the things that go
into just running a business.
And I think what I heard you say about how we could set
this back if we do what the VA is going to do and delay and
what was said by Mr. Mayer right before you about it is not
just an inconvenience. It is like you said, you cannot go out
and walk your daughter or whatever it may be, whatever function
you may have.
The other thing I would argue a little bit, I would not
argue, but just to comment with Congressman Stearns, is that
what I see with a lot of these wounded warriors, they want to
go back to just a regular life. And they use this prosthesis
not to have any advantages, but just to be able to do what they
could do before they went in the military.
Am I wrong on that or not?
Ms. Ilem. I think, too, and the employment issue is
obviously important for many veterans, but it all comes down to
again their ability to be able to do what they want to do, to
regain their function, to live, you know, to have a quality of
life. And that comes down to the care that they are going to
get, the lifelong care that they are going to get at VA and
maintaining their prosthetic items and getting them in a timely
manner.
Mr. Roe. Just a brief example. I had been here probably six
months in Congress. This is only my second term, and had been
to Walter Reed and was walking down the steps with Spanky. You
remember him who worked here. He is a major who lost his--I did
not know he was an amputee until I saw him go down the steps.
He had returned to duty and was carrying on exactly like he
always had. And when I saw him, and then we sat down and had a
little talk about that, but that was amazing to me that he was
able to do that. And for months I saw him walking out of here
and did not even know he was an amputee.
I think that is the kind of return to duty that people
want. And when they have lost an extremity, and some obviously
are more horrific than others, but I believe that is the goal
of every wounded warrior is to be able to go back to what they
did and assume the life they had before they signed on and took
the pledge.
I appreciate you all's testimony and certainly every one of
your service to our Nation. And I will now call our next panel.
Thank you all.
Now, joining us on our third panel is Linda Halliday,
Assistant Inspector General for Audits and Evaluations for the
Office of Inspector General, IG for the U.S. Department of
Veterans Affairs.
Ms. Halliday is accompanied by Nicholas Dahl, Director of
the Bedford Office of Audits and Evaluations for the IG; Kent
Wrathall, Director of the Atlanta Office for Audits and
Evaluations for IG.
And we are also joined by Dr. John Daigh, the Assistant
Inspector General for Health Inspections for the IG. Dr. Daigh
is accompanied by Dr. Yang, a physician for the Office of
Healthcare Inspections for the IG.
Thank you all for being here today and to share your
expertise.
Ms. Halliday, we will begin with you.
STATEMENTS OF LINDA A. HALLIDAY, ASSISTANT INSPECTOR GENERAL
FOR AUDITS AND EVALUATIONS, OFFICE OF THE INSPECTOR GENERAL,
U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY NICHOLAS
DAHL, DIRECTOR OF THE BEDFORD OFFICE OF AUDITS AND EVALUATIONS,
OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS
AFFAIRS; KENT WRATHALL, DIRECTOR OF THE ATLANTA OFFICE OF
AUDITS AND EVALUATIONS, OFFICE OF INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND JOHN D. DAIGH, JR.,
ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE
OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY ROBERT YANG, PHYSICIAN, OFFICE OF HEALTHCARE
INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF
VETERANS AFFAIRS
STATEMENT OF LINDA A. HALLIDAY
Ms. Halliday. Representative Roe, Ranking Member Michaud,
and Members of the Subcommittee, thank you for the opportunity
to discuss the results of our two recent reports on VHA's
management and acquisition of prosthetic limbs and the
management of prosthetic supply inventories.
We conducted our work at the request of the House Veterans'
Affairs Committee.
Today I will discuss our efforts to evaluate VA's
capabilities to deliver state-of-the-art prosthetic limb care
and manage prosthetic supply inventories at its medical
centers.
In our first report, we examined the procurement practices
and the cost paid for prosthetic limbs. We identified
opportunities for VHA to improve payment controls to avoid
overpaying for prosthetic limbs and to improve contract
negotiations to obtain the best value for prosthetic limbs
purchased from contract vendors.
With regard to the cost comparisons in our report
addressing VA fabricating the prosthetic limbs or purchasing
these limbs via contract, our report concluded VA lacked
information to make the decisions it needs to know whether it
should continue with the use of the labs or to rely on
contractors to provide these limbs.
In no way did we address cutting the quality of the
requirements to purchase a limb. The focus was on contract
administration. And the contract administration piece occurs
when VA enters into contracts with vendors to provide limbs at
certain prices.
What we looked at was the invoices coming into VA. We found
they lacked an adequate review process prior to certification
for payment which resulted in overpayments. This is a contract
administration issue and I want to be very clear, did not say
cut the quality of a prosthetic limb for any of these veterans.
But clearly VA has an opportunity to fix controls, so they
can then reprogram the funds saved to provide more prosthetics
care for veterans.
The overpayments for prosthetic limbs were a systemic issue
in 21 Veteran Integrated Service Networks and we identified
overpayments in 23 percent of all the transactions paid in
2010.
The overpayments generally occurred because invoices
received from vendors lacked adequate review. As a result, the
vendor invoices were just processed with charges in excess of
the prices in the vendor contracts.
We reported VHA would continue to overpay prosthetic limbs
for about $8.6 million over the next four years if it did not
take action to strengthen these controls.
We also found that VISN contracting officers were not
always negotiating to obtain a better discount rate with
vendors. Without negotiations for the best discount rates
obtainable, VHA cannot be assured it receives the best value
for the funds it spends to buy prosthetic limbs.
We noted that taking action to ensure contracting officers
consistently negotiate better discount rates in no way
compromises the quality of the prosthetic limbs VA buys.
We also found and made a clear point in our report that the
VHA guidance states the prosthetic service should periodically
conduct evaluations to ensure prosthetic labs are operating
effectively and economically as possible. We found that the VA
officials suspended their review of labs in January 2011 after
reviewing only nine of the 21 VISNs nationwide.
Because reviews of all VISNs were not conducted, prosthetic
service was unaware of its in-house fabrication capabilities or
cost. VHA lacked the information to know if its labs are
operating effectively or efficiently.
We were never trying to draw a cost comparison between the
numbers in the report. Those were the only numbers available at
the time and we clearly recognize it was not an apples to
apples comparison. We footnoted differences in the report to
talk of the costs that are not involved in the VA's cost such
as profit and overhead of a contract vendor.
In our second report, we addressed VA's prosthetic supply
inventory management and offered a comprehensive perspective of
the suitability of VHA's prosthetic management, supplies, and
procedures. We also recommended VHA replace its current
inventory systems with a modern inventory system.
We reported that strengthening VA's management of
prosthetic supplies inventories in VA medical centers will
reduce costs and minimize the risks of supply expiration and
disruption to patient care due to supply shortages.
For almost 60 percent of the inventory of prosthetic items,
VAMCs did not maintain optimal inventory levels. For almost
93,000 inventory items, we estimated VA inventories either
exceeded current needs for approximately 43,000 items or the
inventories on had were too low for 10,000 items.
Further, we saw that documentation for an annual required
wall-to-wall physical inventory had not been performed. This
occurred because VAMCs did not consistently apply basic
inventory practices or techniques.
For example, VAMCs did not set normal reorder or emergency
stock levels in their automated inventory system for over 90
percent of the prosthetic items.
Weak and often ineffective inventory practices led to VAMCs
spending about $35 million to purchase prosthetic supplies in
excess of their needs and that clearly increased the risk of
supply expiration, theft, and shortages. In fact, if controls
are so weak, the losses associated with any diversion could go
undetected.
Improvements in inventory practices and accountability over
prosthetic inventory is still needed. VHA must improve its
inventory management systems and remain committed to replacing
its existing inventory systems by 2015.
We are pleased to see that VA is adopting practices to
achieve greater savings along with providing more attention to
ensuring the fiscal stewardship and contract administration of
the funding needed for prosthetic care in response to the
issues we reported on.
We will be happy to take any questions.
[The prepared statement of Linda A. Halliday appears in the
Appendix]
Mr. Roe. Thank you, Ms. Halliday.
Dr. Daigh.
STATEMENT OF JOHN D. DAIGH
Dr. Daigh. Dr. Roe, Mr. Michaud, Members of the
Subcommittee, it is an honor to be here to speak with you on
our report on prosthetic limb care in the VA.
We have done a series of reports on what I would call
transition to care and in those reports, we have allied
ourselves with the DoD, IG, specifically Elias Nimmer who has
helped us gain access to DoD data.
And also we have used Dr. Clegg in my office who is a
biostatistician to get the metrics right and who is quite an
expert on population health.
We have reported on moderate TBI, access to mental health
in Montana, combat stress, women veterans, this report on
prosthetics and one we just published on homelessness in this
population.
So this issue of transition to care is important to us, and
again we thank you and your staffs' support for this work.
We looked at two populations in this report. One is a
population of about 500,000 veterans who left DoD and became
veterans in the 2005, 2006 timeframe. And we were then able to
follow those veterans as they transitioned through VA and then
received several years of VA care.
And there were a couple of outcomes from that data that I
think are worth noting. One was surprising to me, maybe not to
those who work with this population all the time, it was not
just the limb that was affected in these patients. Every organ
system you looked at by diagnostic category had significantly
elevated disability or medical disease burden in this
population.
So whether it is the blast injury they suffer at the time
that they are injured or the other circumstances of trauma and
recovery on the battlefield are unclear, but this is a
population that has quite a significant disease burden beyond
those that you would think of.
The second feature that stood out from that analysis was
the problem of pain management and substance use disorders, I
mean, in addition to the normal mental health issues that this
population would be expected to have.
Again, I cannot speak out enough the difficulty that this
population has with these disorders and the difficulty that VA
currently has and society has in dealing with these issues.
The second population that we looked at we got with the
help of Dr. Paul Pisquina at Walter Reed, both the old Walter
Reed and the new Bethesda campus, who is a physiatrist there,
and Mr. Charles Scoville who works with TMA, was in charge of
the prosthetic program, I believe.
And they provided us their data set of combat-injured
veterans from the recent wars who had major amputation. At the
time that we got our data, there were 1,506 major amputations.
Of that number, 180 were not traumatic. They were related to
some other feature. Thirty-eight of those individuals were dead
which left us with 1,288 individuals with combat-related major
amputations.
Of that number, about 450 remained on active duty, some of
whom were employed and some of whom it appears to us were
severely medically ill and DoD seemed to be keeping them to
make sure that they were in a better condition when discharged
from DoD. That left us with about 838, again, traumatic major
amputations of the upper and lower extremities that we tried to
assess.
If you take that number and divide it by 150 medical
centers, and we did plot out addresses for these folks, you
find out that this population, they are everywhere in the
United States. So there is a simple problem of having ten or
less on average without knowing specifically patients who have
these problems across the VA just as a point of reference.
Whereas, when you look at the elder population the VA
normally takes care of where it looks to us they have several
thousand amputations a year, major amputations a year, that is
mostly older gentlemen who have diabetes or other vascular
disease. So there is a significant difference there.
We also went out and telephone surveyed and visited in
person these returnees from the war trying to get a feeling of
whether what we were seeing on TV and in the press was an
accurate reflection of how well these gentlemen and women were
doing. In other words, the same ten people we were seeing
playing softball all the time or in general these folks doing
very well.
And I would say that we are very, very impressed that this
population which entered the military with a can-do and follow-
me attitude has really maintained that and I do not believe
that what we see on TV is an aberration. I believe that in
general this population is doing extremely well.
There is one caveat to that. The folks at Walter Reed were
very concerned about the 33 veterans at the time that I give
you the number 1,500 who had three and four limb amputations.
And that population, we were unable to see enough of to get a
clear feeling of how they are doing. But I do believe that they
are significantly more impacted in a total body sense from
those who have one or two amputations, enough to be really, I
think, a different category of disease.
I think that we also heard in our interviews and in our
discussions with these veterans essentially the same comments
that you have heard from the previous two panels. And I will
not go through those except to say that people wanted to know
why they could not take a picture of their broken prosthesis
and send it in by e-mail and, you know, try to expedite the
paperwork involved in trying to get the billing process and the
bureaucracy of things done.
We have had conversations with Dr. Beck and her staff. They
are well aware of these issues and I am confident that they are
thinking about how to best deal with these issues. And they
will be on the next panel to discuss the changes that they
would propose. But they have been very cooperative, I think, in
trying to come up with what the right answer is.
We made three recommendations. One was we asked VA to
consider this data set which I think has really previously not
been available in the detail that we have published it and I
think VA has done that in trying to tailor their care.
We do believe that the upper extremity veterans both in the
surveys that we have done, have for a variety of reasons, a
great deal more difficulty than those with lower extremity and
we do urge that research be done and that the appropriate level
of effort be made to get those upper extremity prosthetics up
to speed.
And, thirdly, we asked VA to deal with the bureaucracy,
that is the fee basis or contract complaints in a way that
would sort of lessen the aggravation that veterans who have
these difficulties have in trying to make their way through the
system.
With that, I will end my testimony and be glad to answer
any questions that you have. Thank you.
Mr. Roe. I thank the panel.
And I just have a couple of observations and, of course, we
appreciate you being here and testifying today.
Ms. Halliday, it does not look like a huge issue, but just
with the simple changes in contracting, and I certainly
understood what you were saying, this does not change the
quality of the prosthesis----
Ms. Halliday. Right.
Mr. Roe. --at all. It may be the same one if you just
negotiate a lower price for the same. Am I correct on that? Is
that what you were saying?
Ms. Halliday. You are correct. What we were concerned about
was if we have an existing contract with a vendor and it says
that you are going to charge $10.00 for an item and the
invoices start to come in, if they are not reviewed and you are
really charged $15.00 or $20.00, that is the point we wanted to
see the correct prices paid. That money could be reprogrammed
to prosthetics care.
Mr. Roe. And that should not be a big issue. I mean, money-
wise, it is a significant amount of money that could be spent
because as either Captain Pruden or whoever said a minute ago
there is $54 million in the VA budget. That is not a lot of
money that is spent on prosthetics.
So I guess the savings there would be fairly significant.
And prosthesis, I think, in the VA terminology is--we would
think of as a limb. It could be a hearing aid or a wheelchair
or a crutch. Am I correct on that?
Ms. Halliday. Yes. But this report that we issued looked at
the limbs.
Mr. Roe. Okay. Just at the limbs?
Ms. Halliday. Yes.
Mr. Roe. Okay. And you also agree that this was not an
apples to apples when you were looking at it? You are not
really sure what that $2,900 figure----
Ms. Halliday. We absolutely agree with that. It was the
only cost information available. We put it in the report and
clearly said it was not apples to apples in our footnote there.
The fact was VA did not have good information to make
decisions on whether it should have labs, whether the labs
could provide these items at a more economical cost and the
same quality. They just did not have that type of information
available when my audit team went out.
Mr. Roe. Dr. Daigh, that was fascinating data that you had
that you presented. And did I hear right that there were 33
that had three amputations, more than two?
Dr. Daigh. Yes, sir. I believe the number we had in the
report was 33 individuals who had three or four limb
amputations who were alive at the time we did this report.
Mr. Roe. Well, I think the challenge is now, and I will
just be very brief here, but Mr. Michaud and I went to
Afghanistan together three years and then I went again in
October of this past year, and just from a physician's
viewpoint, the treatment of trauma care has changed
dramatically from the time I was in the service.
And you can see the results. The results are a lot of
people are surviving horrific injuries. And if you do not die
of your injury on the battlefield, you have about a 95 percent
chance now of surviving that injury as opposed to when Mr.
Reyes was in Vietnam which was a lot less than that, I can tell
you.
So we are going to have to deal with these issues going
forward and we should.
And I guess the question I have for you is, do you agree
with what Captain Pruden said a moment ago about if the VA
changes its procurement and so forth, this will be detrimental?
In other words, should we just keep doing what we are doing and
then tighten up on what Ms. Halliday said?
And inventory, I mean, Walmart can tell you when a tube of
tooth paste went out the door, they can replace it. So we
should be able to do that.
And the VA it sounds like by 2015, that should be
implemented. Do you agree with what the captain said?
Dr. Daigh. Well, sir, I did not look at the business
practices by which these prosthetics are determined which is
appropriate and procured. We simply in this report looked at
the populations that existed and tried to understand who they
were and what was going on with them.
Similarly to the gentleman on the second panel, we did not
look at the effectiveness of one prosthetic over another or the
cost effectiveness of different measures. We simply did a
population health study.
So I do not have a comment on that, sir.
Mr. Roe. And I think the other thing you said just to make
sure that we all understand it is that the cohorts in this
study had multiple comorbidities. It was not just I lost my leg
below the knee and that is the only thing that is wrong with
me. There are multiple. Am I correct there?
Dr. Daigh. It was very impressive to me that the total body
injury that these men and women had sustained which to the
outward appearance would mostly be looked at as a prosthetic
arm or leg.
Mr. Roe. I yield now to Mr. Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman.
My question is on one of your recommendations, and I will
quote, and I quote, consider veterans' concerns with the
approval process of fee based and VA contract care for
prosthetic service to meet the needs of veterans with
amputations, end of quote.
Would you expound a little bit more on that recommendation
in detail? Is the reason why you came up with that is because
you were finding that veterans are being denied care or unduly
delayed in receiving care?
Dr. Daigh. What we found in interviews with veterans were
complaints similar to what the first panel expressed and that
was these men and women are active. They are going to school.
They have families. They have lives.
If their prosthetic breaks, they want it fixed immediately.
They do not want to have to get in the car and drive some place
to have an examination done or to get the paperwork
accomplished appropriately.
Our work did not analyze the business practices of making
that happen. So I did not feel I was in a position to offer
advice to VHA as to how to fix that problem, but we did sit
down and have discussions with Dr. Beck and others to lay out
what we thought the problem was.
Dr. Yang and others gave comments directly as to what we
heard and then we asked VHA to consider how they are doing
their work and see if they can't improve that.
At this point in time, I am not knowledgeable enough
unfortunately to give you advice on exactly what I think they
should do different. I wish I could, but I do not have that
information.
Mr. Michaud. There has been some discussion and was
clarified as far as the cost and the savings comparing apples
to apples and the management of the inventory.
Have you or your sister agency ever done a report within
the Department of Defense to find out what the cost comparing
DoD to VA? Is the cost equal, number one?
And, secondly, you talked about the inventory management.
Is your recommendation consistent with what actually the
Department of Defense is doing or do they have the same
problems that VA has in regards to cost and inventory
management?
Dr. Daigh. With respect to the provision of care and the
way VA and DoD are different, I think, is that DoD has, I
believe, focused the care of patients who are badly injured
from war at several discrete centers and by then getting a
large enough group of patients continuously there, they are
able to put the resources in those select several places, D.C.,
maybe San Diego, San Antonio, maybe one or two others and then
provide cost-effective state-of-the-art care.
VA is a much more dispersed organization and veterans live
throughout the country. They have already been through the
acute trauma. They are up and about. So it is a little bit of a
different problem.
As to the second question, we have done no work on the cost
of DoD compared to VA on providing the same level of care.
Mr. Michaud. When you talk about the wounded warrior
utilizing the DoD versus VA, the numbers are higher in DoD. Do
you know how many veterans, the newer generation veterans are
still utilizing the Department of Defense versus going into the
VA because they feel, you know, that they are getting better
service at DoD and how many veterans are using DoD versus the
VA?
Dr. Daigh. We have found in looking at transition to care
that there is a flow back and forth between DoD and VA for
veterans. Some veterans have DoD disability that allows them to
go to a DoD facility or they are retired and, therefore, they
are able to use DoD facilities.
In our report, we show that the veterans with prosthetic
issues transferred to VA fairly quickly and in much larger
numbers than the average veteran who left DoD did.
Actually when we started this study, I was concerned that
DoD might hold on to or that those veterans might reside around
the cities where these areas of--the DoD areas of expertise
have highlighted. But I think we found that really they have
not stuck there. They have transitioned very quickly to VA
which was somewhat of a surprise to me.
And I could get back with specific numbers at specific
times, but there is a nice chart that shows over four or five
years, they are almost all in the VA.
Mr. Michaud. Great. Thank you very much.
Mr. Roe. Mr. Reyes.
Mr. Reyes. Thank you, Mr. Chairman. I apologize for being
late. As you know, we have competing hearings taking place.
In Fort Bliss, we have the wounded warrior transition
center. And one of the questions that I get asked is, the
research and development that is going on in the area of
prosthetics.
Can any of you comment on what kind of R&D is going on
because I know just seeing the kinds of prosthetics that are
being used today from my viewpoint, it is phenomenal? But I am
not sure that I understand where that R&D is taking place for
prosthetics.
Dr. Daigh. Sir, I apologize. I do not know the answer to
that in detail that you need. I could get it for you. And,
again, Dr. Beck may be able to in the next panel explain what
VHA is actually funding and how they are dealing with that. I
cannot give you a good view of that, sir.
Mr. Reyes. Okay. And the other question I have, there have
been many concerns expressed about the proposed changes to the
procurement. I am not sure I understood the issue and the
concern from veterans that there might be a further delay in
getting their service for the prosthetics.
Can you comment on whether or not that is a valid concern
on the part of veterans using the VA?
Ms. Halliday. To some extent, I can offer some comments on
that.
The VA is changing its procurement practice bringing more
involvement to contracting officers which I think will help
with strengthening the contract administration process that we
found problems with.
My concern is that it really requires communications
between the prosthetic assistants and the contracting people so
that the veterans' needs are truly met.
In the past, VA has had some communication issues between
these offices. I think the new leadership is working very hard
to fix those.
And I cannot comment to whether the veterans will
experience delays. VA has just put a pilot in place to look at
this new model, but they have not shared that information with
us nor have I had an opportunity to see it in practice to
really measure its effectiveness.
I think the question should also go to VA.
Mr. Reyes. Okay. So can you comment on whether or not there
is either going to be or there is a process of providing
feedback?
Ms. Halliday. I cannot comment on that. I think that is a
question for VA.
Mr. Reyes. Okay. Thank you, Madam Chair.
Ms. Buerkle. [Presiding] Thank you.
With that, if there are no more questions from the
Committee, we thank you very much for your testimony this
morning.
And we will now invite the fourth and final panel to come
to the witness table.
Joining us this morning in our fourth panel is Dr. Lucille
Beck. Dr. Beck is the Acting Chief Consultant for the
Prosthetics and Sensory Aids Service for the Veterans Health
Administration for the United States Department of Veterans
Affairs.
Dr. Beck is accompanied by Dr. Joe Webster, National
Director for the Amputation System of Care; Dr. Joe Miller,
National Program Director for the Orthotic and Prosthetic
Services; and Norbert Doyle, Chief Procurement and Logistics
Officer, all of which are with the VA Administration or the
Department of Veterans Affairs.
Thank you all very much for being here this morning or I
guess it is afternoon now.
And, Dr. Beck, if you would proceed. Thank you.
STATEMENT OF DR. LUCILLE BECK, ACTING CHIEF CONSULTANT,
PROSTHETICS AND SENSORY AIDS SERVICE, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY JOE WEBSTER, NATIONAL DIRECTOR FOR THE
AMPUTATION SYSTEM OF CARE, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; JOE MILLER, NATIONAL PROGRAM
DIRECTOR FOR ORTHOTIC AND PROSTHETIC SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; NORBERT
DOYLE, CHIEF PROCUREMENT AND LOGISTICS OFFICER, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF DR. LUCILLE BECK
Ms. Beck. Thank you.
Good morning, Chairman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee. Thank you for the opportunity to
speak about the Department of Veterans Affairs' ability to
deliver state-of-the-art care to veterans with amputations.
I am accompanied today by Dr. Webster, our Director of the
Amputation System of Care; Dr. Miller, our National Program
Director for Orthotic and Prosthetic Services; and Mr. Norbert
Doyle who is VHA's Chief Procurement and Logistics Officer.
VA's Prosthetics and Sensory Aids Service is the largest
and most comprehensive provider of prosthetic devices and
sensory aids in the world, offering a full range of equipment
and services. All enrolled veterans may receive any prosthetic
item prescribed by a VA clinician without regard to service-
connection when it is determined to promote, preserve, or
restore the health of the individual and is in accord with
generally accepted standards of medical practice.
I will briefly summarize the major initiatives underway to
improve the quality and availability of amputation care. These
fall under five general headings: Staffing and community
partnerships; accreditation of VA laboratories; improved
training for VA staff; greater research into amputation and
clinical issues; and collaborations with the Department of
Defense.
First, VA's Prosthetics and Sensory Aids Service has a
robust clinical staff of orthotists and prosthetists at more
than 75 locations and also partners with the private sector to
provide custom fabrication and fitting of state-of-the-art
orthotic and prosthetic devices.
VA maintains local contracts with more than 600 accredited
O&P providers to help deliver care closer to home. Commercial
partners help fabricate and fit prosthetic limbs for veterans
across the country.
Since its creation in 2009, VA's Amputation System of Care
has expanded to deliver more acceptable, high-quality
amputation care and rehabilitation to veterans across the
country.
This system of care utilizes an integrated system of VA
physicians, therapists, and prosthetists working together to
provide the best devices and state-of-the-art care.
Second, VA promotes the highest standards of professional
expertise for its workforce of more than 300 certified
prosthetists, orthotists, and fitters. Each VA lab that is
eligible for accreditation is accredited by the American Board
for Certification in orthotics, prosthetics, and pedorthics,
and also the Board of Certification Accreditation International
or both. This accreditation process ensures quality care and
services are provided by trained and educated practitioners.
Third, to support the continued delivery of high-quality
care, VA has developed a robust staff training program. We
offer clinical education, technical evaluation, and business
process and policy education in addition to specialty product
training to help our staff provide better services to veterans.
Further, VA has one of the largest orthotics and
prosthetics residency education programs in the Nation with 18
paid residency positions at 11 locations across the country.
Fourth, VA's Office of Research and Development is
investing heavily in prosthetics and amputation health care
research. It is issuing a request for applications for studies
to investigate a variety of upper limb amputation technologies
and applications.
VA also works with the Department of Defense to support
joint research initiatives, determine the efficacy and
incorporation of new technological advances.
Finally, the partnership between VA and DoD extends further
to provide a combined collaborative approach to amputation care
by developing a shared amputation rehabilitation clinical
practice guideline for care following a lower limb amputation.
VA is also supporting the Department of Defense by
collaborating on the establishment of the extremity trauma and
amputation center of excellence. The mission of this center is
clinical care including outreach and clinical informatics,
education and research, and is designed to be a lead
organization for direction and oversight in each of these
areas. The center is currently being implemented and will
obtain initial operating capacity by the end of this fiscal
year.
In summary, VA supports high-quality amputation and
prosthetics care by supporting groundbreaking research into new
technologies, training a highly qualified cadre of staff, and
pursuing accreditation of all eligible prosthetic laboratories
in VA's Amputation System of Care.
We are improving our oversight and management of
prosthetics purchasing and inventory management to better
utilize resources we have been appropriated by Congress and to
serve America's veterans.
We appreciate the opportunity to appear before you today to
discuss this important program. My colleagues and I are
prepared to answer your questions. Thank you.
[The prepared statement of Dr. Lucille Beck appears in the
Appendix]
Ms. Buerkle. Thank you, Dr. Beck, for your testimony and
for being here today.
I have a number of questions. A lot of it is based on what
we heard from the three previous panels, especially the
veterans and the veteran service organizations. I think they
provide for us a reliable source of information and they
identify needs for us.
My first question is, what was the impetus behind the
change? You heard the concern from the previous panels. What
was the impetus behind the change in the procurement policy and
did you consult with the veteran service organizations and/or
veterans? Who did you talk to to make this change?
Ms. Beck. The impetus for the change is an impetus from the
department to assure compliance with Federal acquisition
regulations.
I have with me Mr. Norbert Doyle who is VHA's Chief
Procurement and Logistics Officer today. We were anticipating
some of these questions and he is available to provide more
information about the change and what is happening.
Ms. Buerkle. And just if you would before you start, does
that mean heretofore the VA was not compliant? I mean, if that
is the basis for this change. Maybe you could make that clear
to us.
Mr. Doyle. Yes, ma'am. Thank you.
Thank you, Dr. Beck.
Ma'am, yes, the impetus was to bring the VA contracting to
include VHA and all the other VA contracting organizations in
better alignment with the Federal acquisition regulations.
It is my understanding the department recognized several
years ago actually that they were weak in certain areas in
contract administration and awarding of contracts. And this was
also to bring it in-house to ensure proper stewardship of the
government dollars.
In reference to your question, did we talk with veteran
service organizations, actually last--I do not believe we did
before we started the process. However, last week--and I am
happy to meet with any organization to discuss what we are
doing. I heard the complaints of the veteran service
organizations that they feel out of the loop.
I met last week with Dr. Beck with the Secretary's Advisory
Committee on Prosthetics and Special Disabilities. We spent a
great deal of time with them, and I think that group has
representatives from many veteran service organizations, to
address their concerns that they may have.
Again, I make that offer that I will be happy to meet with
any group to discuss these.
Ms. Buerkle. Thank you.
I think it would be in the best interest as we go forward
to do what is best for veterans and to hear from the veteran
service organizations and from the veterans themselves and from
those who have gone through this process and who understand
intimately as did the first two panelists. It would seem very
basic to talk with them and to have them identify needs and
concerns.
You heard Wounded Warriors say we are asking you, Congress,
to please freeze this change until, and the other point I
wanted to bring up was the pilot.
You heard Paralyzed Veterans, their organization asked or
mentioned a pilot. Have you done a pilot? If so, what were the
findings? You know, is that the justification for this change?
Mr. Doyle. Yes, ma'am. I actually have a number of issues
to address along those lines.
First, to put it in context, and, granted, we are talking
about the more expensive items that we are talking about today,
the transfer of the contracting authority from prosthetics to
contracting only impacts those procurements above $3,000 which
is the mandated Federal acquisition or Federal micro-purchase
threshold.
So only three percent of orders that we estimate fall in
the realm. So 97 percent of prosthetic orders will stay with
prosthetics.
As I said, we are doing this to bring us more in line with
Federal acquisition regulations and also to address many of the
issues that the IG has mentioned, although those were
identified, I think, previously.
Now, I want to assure everybody that if a clinician
specifies a specific product for a veteran, contracting will
get that product for that individual.
I do not as the chief contracting person in the Veterans
Health Administration, I do not want my contracting officers
making a decision as to what goes in the veteran's body or gets
appended to it. That is clearly a clinician decision.
And how are we going to get that product that the clinician
specifies for the veteran, and we are going to do it under the
auspices of the Federal acquisition regulations. We are going
to cite the authorities of 8123 which is--one individual
mentioned that the broad latitude given by Congress to the
Veterans Administration.
We are going to do that by properly preparing justification
and approvals for sole source, citing in paragraph four the
authorities granted under 8123.
And there are seven exceptions in part six of the FAR to
full and open competition. Exception five is the one that is
authorized by statute and that is what we will use.
We have gone through great pains to ensure success in this
transfer. And a little bit of history. Even starting last
summer when we started this process under the direction of the
department, Dr. Beck's and my folks, we formed a team and that
team included field personnel, both prosthetics and
contracting, which we thought was critical.
They developed a plan for the transfer. It was a very
detailed plan. The plan actually as we got into it got more
detailed as we identified other issues.
We then worked with our union partners to ensure that they
did not have issues and that we could proceed successfully.
There were pilots as part of the plan which is probably the
best part other than bringing field people into the planning
process. The pilots was a great aspect.
We did the pilot in three VISNs, in VISNs 6, 11, and 20,
and that is the Virginia, North Carolina area, the Michigan
area, and the Pacific Northwest.
We piloted beginning in January for about 60 days. Those
pilots concluded in March. We did learn from those pilots and
we are implementing changes to ensure that care is not
impacted.
Some of the things we learned is that our staffing models
were incorrect and the number of procurements that we could do
in a day and the contracting officer we are hiring, we received
approval to hire additional people to ensure we can keep up.
We are streamlining the process by, I mentioned,
justification approvals by templating that process, so it
becomes more fill in the blank with the clinician's
prescription. Those are the type processes.
We are slowly now implementing in the rest of the Veterans
Health Administration. I think four more VISNs are starting
that process now and the rest of the VISNs will be coming on in
June and July. The goal is to have all this done by the end of
July.
There is a contingency plan that we have discussed. We
still have the legacy procurement system if something does not
go right or something unexpected happens that we can fall back
on. But we do not expect that to happen.
Ms. Beck. And I would like to add that this has been a very
strong collaboration and partnership. Prosthetics and Sensory
Aids Service is very concerned that we can continue to provide
the services to the veterans that they deserve and that we have
always been able to do.
And so our prosthetics organizations at our local medical
centers and at the VISN level remain the eyes and the ears. So
all orders still come through prosthetics. Prosthetics is
managing them and working with contracting officers to achieve
the placement of the order as is required to be meeting all of
our acquisition requirements.
And we are, as Mr. Doyle has said, very aware of the
ability to use 8123 and have spent a significant amount of time
developing justifications and approvals that allow us to use
that and really reflect the needs of our--the individualized
rehab needs of our veterans.
We are very much aware that we customize these products and
services, that they are selected based on an individual
veteran's needs. And that has been our goal as we have managed
this transition.
We are coming into a critical time as we move the
transition forward and extend it to other VISNs and we have
very well-developed and exact procedures in place to monitor
this as we go.
And we are prepared, I think, Mr. Doyle and I as a team to,
and our office as teams, to review this very carefully and make
recommendations as the way forward based on how this process
affects veterans.
Mr. Doyle. And I am sorry, ma'am.
Ms. Buerkle. Go ahead.
Mr. Doyle. May I add that when I met with the Advisory
Committee on Prosthetics and Special Disabilities last week,
they had many of these very same concerns. I think after
spending some degree of time with them, they at least
understood what we were doing. They are still very interested
in ensuring we do achieve success. But I will let Dr. Beck
comment.
I do not think we left there with a burning issue, at least
I did not, that we needed to address.
Also, as a veteran myself who made several trips to Iraq
and Afghanistan both in a military and a civilian capacity, you
know, I am very sympathetic to the needs of the veteran
population. And I can assure you I will do nothing that hurts
the veterans because, you know, there but for the grace of God
go I, actually and that is the way I look at it.
Ms. Buerkle. Thank you.
My time has way run over. However, if my colleagues will
indulge me, I just have a couple follow-up questions and I will
allow you to have as much time as you need.
My first concern is that you said with procurement, it only
pertains to those over $3,000 and you stated only three percent
of the orders are over $3,000.
How many requests do you have?
Mr. Doyle. That is still not an insignificant number. Based
on our planning estimate or our planning figures for fiscal
year 2010 in which we planned the transfer over, three percent
of the orders equals roughly 97,000 orders.
Ms. Buerkle. So I would suggest that because we are talking
about 1,500 warriors with amputations that probably are in need
of prosthetics that that is going to be a small percentage of
what you are doing. However, all of those are going to exceed
that $3,000 threshold.
We heard earlier about a $12,000 limb and if it is $25,000,
that does not matter because the veterans need prosthetics and
they need state-of-the-art prosthetics. That concerns me, that
piece right there.
The other thing that concerns me is you mentioned that you
talked with your union partners. It would seem to me more
appropriate to talk to your veteran partners and to the
veterans who have gone through this and be more concerned with
their thoughts about this being a program that works versus
talking just to the union partners.
And, lastly, if I could respectfully request that you would
provide us with the results of those pilots. I think you said
you did three, in 6, 11, and 20 VISNs. If you could provide us
with the findings from those pilot programs, I would appreciate
it.
Mr. Doyle. Yes, ma'am.
Ms. Buerkle. Thank you.
And I now yield to the Ranking Member, Mr. Michaud.
Mr. Michaud. Thank you very much, Madam Chair.
I just want to follow-up, Mr. Doyle, on your comment that
you made where you mentioned that contracting officers do not
change what the clinicians prescribe, but actually in testimony
we heard earlier from PVA, that is not the case, that their
testimony states that contracting officers when they do receive
the orders, the request for the devices is modified and even
denied in cases because of the cost.
So that is a huge concern. There seemed to be a disconnect
from what you are hearing versus what the VSOs are hearing
because that is not the case. The cost is a factor. It is not
the veterans of health care.
So do you want to comment on that?
Mr. Doyle. Yes, sir.
Mr. Michaud. Yeah.
Mr. Doyle. First of all, all contracting officers do have a
mandate under Federal acquisition regulations to ensure that
there is a price reasonableness aspect to the cost we are
providing. So I do not know if that is a concern or not.
I cannot really speak to what may have happened before, but
I have put out to the contracting community that under 8123, if
the contracting officer receives a physician's consult for a
specific product, we will do due diligence to ensure we pay a
fair and reasonable price for that product, but we are going to
get that product for that individual.
So I do not know if it is a concern. Again, I will take
full blame for not bringing the veteran service organizations
into the loop and to this discussion and we can fix that. But I
do not know if that is part of the issue there, that's why that
concern was being raised.
Mr. Michaud. Well, it is very clear from the VSOs, some of
their statements, that it is not uncommon for clinicians to
prescribe something and it is being modified by contracting
officers and primarily because of cost. And that is a big
concern that I would have.
My other question is, Mr. Oros talked about older veterans
at his practice complaining that there appears to be a new
administrative hurdle to prevent their continuing to receive
care at Scheck and Siress.
The VA has assured veterans that they may choose their own
prosthetist and, yet, veterans who wish to use community-based
providers report widespread administrative hurdles and other
pressures to choose in-house VA care.
How would you explain the perception among the veterans and
the community-based providers because there seems to be a
disconnect here as well as far as what you have told us versus
what is actually happening out there?
Ms. Beck. Yes, sir. I will start. And we do have contracts
with 600 providers, approximately 600 providers. We do offer
choice to our veterans. And in our amputee clinics, when we
initiate the process for the multi-disciplinary care that we
provide, we have our physicians and our clinicians and our
prosthetists there.
We also have our vendors, our contracted community
partners, our contracted prosthetic vendors from the community
are there as well. The veterans do have that choice. That is
part of our policy. And as we become aware of, we will reaffirm
that policy with the field based on what we have heard from our
veterans today. And we are improving the processes.
I think the Inspector General report pointed out that there
are some contract administration initiatives that we need to
undertake including streamlining the way we do our quote
reviews so that they happen in a more timely fashion and that
they really clarify the prescriptive elements for fabrication
of the leg and we are doing that, or fabrication of the limb
and we are doing that.
The second thing that we are doing is we are making sure
that our contracting officers and their technical
representatives who have as part of their responsibility to
review those quotes and certify that they are doing that
regularly and in a timely fashion.
There is guidance that is being prepared even now to re-
instruct the field and educate them on that.
And the third thing we are doing is we are taking a
contracted, what we call contracted templates where we are
developing policy and guidance that can actually go into our
contracts so that it is clearly specified for the contracted
provider and the VA exactly what the requirements are and the
timeline.
So we have taken the report that we have from the Inspector
General about the need to improve contract administration to
support our veterans seriously and we are making those
corrections and have been doing that over the last several
months.
Mr. Michaud. And do you feel that with the new changes that
you are providing, gets back to my original question, that the
clinicians will have final say in what a veteran receives
versus a contracting officer who has to look at contracts and
saving costs which I believe that we have to do?
But the bottom line for me is to make sure that the
veterans get the adequate prosthetics that they need. And if it
costs a little bit more, then they should be able to get it if
it fits them more appropriately.
And the concern that I have is, yes, you have got to look
at saving cost, but not at the cost of providing what our
veterans need. And I do have a concern with contracting
officers injecting more cost versus the clinician looking at
the veterans' needs.
Ms. Beck. Yes, sir. I have a concern with that too. I am a
clinician myself working in another area who provides rehab
technologies to veterans. And it is critically important that
what the clinician requests, and that, of course, is done in
collaboration and in partnership with the veterans, these are
choices and decisions about technologies that our veterans make
with our clinicians.
And we are absolutely. Rehabilitation is not effective
unless we are able to provide the products and services that
our veterans need. And our role in prosthetics and in
rehabilitation is to assure that any contracts and the way we
procure items enhances and--well, not only enhances, but
provides high-quality individualized care.
We have done that successfully for a long time and we
believe that we are able to do that as we move forward. And as
Mr. Doyle has cited, we can certainly work within the framework
of contracting requirements and the added authority that
Congress gave us many years ago for 8123, I think, is the other
piece of sole source procurement that we can do when we need to
provide and when we are providing highly individualized
products and services.
Mr. Michaud. Thank you.
Thank you, Madam Chair.
Ms. Buerkle. Thank you.
I now recognize the gentleman from Texas, Mr. Reyes.
Mr. Reyes. Thank you, Madam Chair.
Dr. Beck, you mentioned the center of excellence. Where is
that located and how much of the work being done there is
medical research as it pertains to prosthetics?
Ms. Beck. The center of excellence that I spoke about is a
joint VA/DoD center of excellence for extremity care. That
actually will be a virtual center or it is a virtual center. It
will have locations in San Antonio, Texas and in Washington,
D.C.
Staff will be distributed across our system so that some of
our staff will be in various centers, both VA and DoD centers
around the country so that we are collaborating, coordinating
our efforts.
And I think you mentioned research earlier, sir.
Mr. Reyes. Right.
Ms. Beck. And one of the things that we talked about that
we will be able to do by leveraging the capability with DoD and
VA is that we will be able to do clinical trial type of
evaluations at a number of different centers at the same time.
And that is one of the missions of this joint VA/DoD center
of excellence is research coordination and studying and
reporting on new technologies and developing better outcomes
for care.
Mr. Reyes. And how will you ensure that at least the
medical research that is going on is somehow tied back with the
feedback being given back by the veterans, you know, their
experiences with the different types of prosthetics, the
challenges that they have, and also pain management? Is that
all part of that?
Ms. Beck. It is. I will comment and then I will ask Dr.
Webster to comment.
The participants in these studies will be our veterans and
active-duty servicemembers. So they will be able to report to
us firsthand what their experiences are. So that is how we will
tie in the feedback.
We also listen carefully to our veterans as we look at
their outcomes of care and their successful use of prosthetic
limbs and technologies to gain information about where the
research needs are.
I am going to ask Dr. Webster to comment just for a minute
on what we are doing with pain management.
Mr. Webster. Thank you. I really appreciate the opportunity
to be here today and provide this testimony.
And I would agree that, you know, it is extremely important
that we get feedback and information from the veterans and
servicemembers with amputations on, you know, what is important
in research.
You know, we can do research looking at various things, but
if it is not important to the veteran or servicemember, it is
not going to do us much good. So that is critically important.
And that is done on a routine basis.
Captain Pruden provided his testimony earlier, kind of this
expert panel that was put together previously that was looking
at the amputation care as well as the prosthetic care. And that
will continue to occur as we move forward with our research
efforts.
Again, with the center of excellence, several of the
physicians, the more administrative headquarters will be in San
Antonio and the National Capitol region, but many of the
research staff are actually located within our treatment
facilities, so they are located within Walter Reed, they are
located within the Center for the Intrepid. So they are
completely integrated with the clinical staff and with the
soldiers and veterans who are being treated in those
facilities.
Mr. Reyes. And I am curious how the process works. Is there
like a case worker that will have a caseload of the particular
veterans to make sure that feedback is coming to the case
worker and that feedback goes into the R&D component? How does
the process work?
Mr. Webster. I think it can occur both directly from the
servicemember or veteran, you know, to the researchers. Again,
they are going to be collocated in the clinical area, so that
feedback can come directly.
But, you know, there is also opportunities for the feedback
to the people who are doing the research to come from the case
managers, to come from the other providers, whether it be a
physical therapist or a physician. Any of those providers who
are providing care for people with amputations can also provide
that input into what is important for research and research
initiatives.
Mr. Reyes. And when will this process be implemented? Is it
already going on and, if so, are there examples or an example
of how that is working to make sure that the feedback of the
veteran is taken into account?
Ms. Beck. Well, the center that we spoke about is standing
up now and we expect it to be operational by the end of this
year.
I want to talk about, I think, a couple of research
projects which are good examples of the work that we are doing.
And I think that one of them is what is known as the DARPA arm
which is the probably most advanced research activity that is
going on. And that is the Defense Agency project for the
development of a prosthetic and upper extremity prosthetic arm.
And the way that is working and VA's participation, that,
of course, has been funded by the Defense Department----
Mr. Reyes. That is the one that Medal of Honor winner----
Ms. Beck. Yes.
Mr. Reyes. --Dr. Petri has, right, the one that the hand
comes off?
Ms. Beck. Does he have that arm? Oh, we are going to find
out that for you. We are not exactly sure, but----
Mr. Reyes. I think that is right because I visited with him
in my office and he actually took the hand off and put it back
on. And I am not a hundred percent sure, but I think either he
or somebody with him referred to it as the DARPA arm.
Ms. Beck. Oh, did they? Okay. We will check on that for you
and find out.
But one of the things, and this is a good example of
veteran feedback, in the first study that was done to evaluate
the DEKA arm, our veterans participated in that study and
actually came to VA facilities and participated in the study.
We anticipate the second part of the study which will now
be a take-home study where veterans will actually be able to
take the arm home and use it in their everyday activities and
so they will then be providing feedback on the arm and how it
works and what is required next.
And we do that frequently with technologies. I think the
Genium knee, the iWalk foot are two examples of technologies
that VA and DoD have worked on together and had our veterans
and active-duty servicemembers participate in those
evaluations.
Mr. Reyes. So each veteran, again so I can understand, is a
case onto him or herself and the responsibility will be with
the equivalent of a VA case worker to make sure that all of
these things take place?
Ms. Beck. Okay. So the VA has in place a type of case
manager for amputees or amputation care and that person is
known as an amputation rehabilitation coordinator. And at all
of our major amputation care sites that we talked about, our
seven regional centers, our additional 15 network sites spread
throughout the country, we have in place this special kind of
case manager who is case managing our amputees and providing
those services and seeing that their needs are met.
So it is a case management kind of function similar to the
other types of case manager, but it specialized to address the
needs of our amputees. And many of those case managers are
therapists, either physical therapists or occupational
therapists.
Mr. Reyes. Very good. Thank you for your indulgence and the
time.
I think this may be an area we as a Subcommittee can
follow-up on because----
Ms. Buerkle. I was actually going to ask if you all would
like a second round of questions or we can certainly have
follow-up.
So with that, I think we will start a second round of
questions if you have the time and you would indulge us for a
few more questions----
Ms. Beck. Of course.
Ms. Buerkle. --this afternoon. In the panel with Mr.
Pruden, Captain Pruden, I should say, he talked about this new
system that you are going to go to, the electronic contract
management system, and talked to us about the fact that it
requires 300 steps to get the request in.
Can you comment on that?
Ms. Beck. I am going to ask Mr. Doyle who is our expert in
this area to comment on that electronic contract management
system.
Mr. Doyle. ECMS, it is new and that we will be putting in
place as part of the system, the advanced planning model, which
is the part where the requiring people, in this case
prosthetics, can put in their requirements and that is how it
is transferred over to the contracting office.
We have had the electronic contract management system
actually in VA for several years and that is our contract
writing tool in effect. And that is what we will use to write
the contracts for the prosthetics that come across to us.
As for the 300 steps, I will say that I know it is not
probably the easiest system to use and it can be laborious. I
would have to sit with the individual to say how they came up
with the 300 steps. That is a new figure on me, however.
Ms. Buerkle. My concern is when we are talking about light
bulbs or tissues or any sort of items that we need to purchase
and contract out within the VA, that is one thing. But we are
talking about in the whole scheme of things a very small
quantity, a very specialized product.
And this morning in the testimony, I heard the word
intimate. It becomes a part of the veteran's body. It is not
like some isolated product that we use. It is specific to that
person.
And to take that request or that contract and to dump it
into a system like this, it seems to me that the opportunity
for a lack of timeliness, a lack of personalization, you name
it, I mean, this thing is rife with the possibilities that the
veterans, and you heard their testimony, it means I cannot walk
my daughter down the aisle, it means I cannot put my baby in
the crib.
Those are intimately personal that we, the VA or whatever
the system, we may run the risk of not allowing our veterans to
do that. And every day that goes by without a wheelchair or
without a prosthetic, shame on us, shame on this country
because we ought to be--if we are ever on our game, we ought to
be on the game when we are providing for our veterans and our
military.
And so my concern with this is as soon as you take away the
personal piece of this, we run the risk of government
bureaucracy and making sure that veteran has exactly what they
need as soon as they need it and it is state-of-the-art so that
they can get back to the life that they had as best they can
and that we maximize that for them. That is my concern.
Our responsibility is to maximize a quality of life for
these veterans and when I hear this, I just think to myself you
all know what it is like to deal with the government. You all
know how impersonal even in a hospital, in a smaller setting,
you know, with prescriptions or anything else, but this goes
right directly to the veteran's quality of life.
My concern is that this was arbitrary. I will be anxious to
see the results of the pilot studies, that not enough thought
was given to this, not enough consultation was had with the
veterans and the VSOs, not enough work was done before this
change was being made.
We are not talking about 25 or 30 thousand prosthetics. We
are talking about a much smaller group and I think the very
least this government can do is make sure we are doing it right
for these veterans.
And with that, I will yield to the Ranking Member if he has
additional questions.
Mr. Michaud. Thank you very much.
Just two additional questions. My first is, does the VA
have an objective measure to evaluate the prosthetic outcome
for a veteran?
Mr. Doyle. May I, Dr. Beck?
Yes, sir, we do. Our workload staffing when we first
entered into this project, we took the number of orders that
were expected to come over into acquisition and we had a
workload factor model and we anticipated or assumed a number of
people that would be required in procurement to staff that.
It turns out through the three pilots that our staffing
model was wrong and we are hiring additional people.
Unfortunately for Dr. Beck, many of the people we are hiring in
procurement are her purchasing agents who are coming across
from the purchasing agent career field to the contracting
career field and will be now working procurement which is
probably good for them because there is much more career
opportunity as what we say an 1102 versus a purchasing agent,
1105.
We are staffing at the level of, I believe, two to three
complete orders per day. That is the metric. And we will be
tracking those metrics to ensure we do not fall behind on those
metrics.
And as I mentioned earlier, if we do start falling behind,
if the unexpected does happen because we are approaching the
fourth quarter as well which is traditionally the busiest time
of the year for contracting folks, we have the legacy system
and those purchasing agents in prosthetics that could fall back
upon.
Mr. Michaud. What about the individual veteran themselves
as far as are they really satisfied? If they do not come back,
do you ever contact them to see why they have not come back
with the services they received from the VA?
Mr. Doyle. Yes, sir. At all times, the face to the veteran
is going to remain prosthetics, the prosthetics office. They
should have no interaction with the contracting folks
whatsoever.
And as the IG mentioned, it does come down to communication
between the offices or actually in many cases setting up
prosthetic cells where the joint contracting and the
prosthetics people working together to make sure we meet the
needs of the veteran again.
But the prosthetics people will be the up-front face to the
veteran identifying what they need. The requirement will come
to contracting. We will get under 8123, if it is a specific
product, we will get that product for them and then the product
will come back to the prosthetics people for the follow-up
aspect with the veteran.
And I am sure that there will be, if there are delays, that
the prosthetics folks will let us know and ensure that there is
an issue.
Mr. Michaud. You are talking about delays in getting the
limb. My question is, the veteran themselves, have you done an
evaluation? Is the customer, the veteran satisfied with the
service and, if not, why not, or if they have not come back,
have you ever followed up with the veteran themselves to find
out whether everything is satisfactory?
Mr. Doyle. Well, I know in procurement, we have not because
we are just getting into this ball game, but I do not know if
we do customer satisfaction surveys.
Ms. Beck. In prosthetics, we have done a number of surveys
over the years, some extensive ones where we have looked at
using our VA SHEP type surveys, our overall customer service
and veteran satisfaction with care as we do for our medical
centers. We have done two of those specialized surveys over the
years.
We also did a Gallop poll survey in 2009 which looked at
evaluating what our amputees thought at that time.
The IG has actually, Inspector General in this most recent
report also provides us with veteran satisfaction data.
We realized we needed to do more in that area and are now
looking at a couple of options that we have. One is a
standardized survey that related to patient satisfaction that
the Committee on Accreditation of Rehab Facilities uses. We
intend to use that. And for our Amputation System of Care, we
will be able to use that better in satisfaction surveys in all
of our amputation care clinics.
And we are also looking at other ways that we can assess
veteran satisfaction.
Mr. Michaud. Could you provide the Committee with your
latest survey for the----
Ms. Beck. Yes.
Mr. Michaud. --veterans and their satisfaction? My last
question is, do you find it difficult since this is a special
field to find and hire, you know, qualified clinical personnel?
Ms. Beck. We have done a lot of hiring in the field of
rehabilitation and for orthotists and prosthetists over the
last several years and I think we have added a lot of new
providers, providers who are highly experienced and very
capable.
For this profession as we have with physical therapy and
occupational therapy and some of the high rehab professions,
the jobs are extremely competitive.
We have done a couple of things in our system. One is our
orthotists and prosthetists are Title 38, so we are able to
recognize them for their clinical capabilities and advance them
based on that performance and pay scale.
So while it is a challenge, we have been able to attract
high-quality providers and fill our positions.
I am going to ask Dr. Miller who is our lead prosthetist to
also give you some comment.
Mr. Miller. Thank you very much for allowing me to testify
today.
I am an Iraqi vet and I have had the honor of serving both
at Walter Reed Army Medical Center as the Chief of prosthetics
there before coming over and serving here in the VA.
With regards to our workforce, the VA is very competitive
in that. We are able to attract and retain quite a few of the
private sector orthotists and prosthetists. One reason is
because we offer them the ability to treat and care for
veterans. And that is a mission that they enjoy and are wanting
to do.
We also offer training and education. We offer the
accessibility to the technology that the veteran receives and
many times that technology is only available within the VA or
DoD. And that is enticive to those prosthetists and orthotists
that like to practice and do clinical care.
Ms. Buerkle. Mr. Reyes, do you have any additional
questions?
Mr. Reyes. Just, I think, a couple of brief points.
Of the 600 vendors that you mentioned, the contact with our
veterans, are they independent of the VA or are they through
the VA? Is it like sometimes happens that a patient will be
contacted outside of the system and be convinced that maybe
this product is something they ought to try? How do those 600
vendors have contact with our wounded warriors?
Ms. Beck. You want to take that?
Mr. Miller. Sure.
Yes, sir. The 600 contracted vendors are our community
partners and so they are active within our own VA facilities.
They attend clinics and they help in the prescription rationale
of that item for that veteran. And so they are involved
extensively with us in the care.
Mr. Reyes. So they would not have independent contact with
the veterans themselves?
Mr. Miller. Yes, sir, they would. If the vendor was
selected to provide that limb, the veteran then would typically
go to their private facility and have that prosthesis
fabricated and designed for them independent of what is going
on at the VA medical center.
Mr. Reyes. Okay. And those vendors, are they just doing
these prosthetics based to VA specs or do they do them
independent?
Mr. Miller. So whenever a prescription is written for that,
it is done to what we refer to as the industry standards. So we
contact with those providers that have accreditation and
certification just like the VA providers do.
Mr. Reyes. For a specific product?
Mr. Miller. That is correct.
Mr. Reyes. Okay. The other thing is, on the surveys, part
of what I think does not reflect the sentiments of the veteran
base, and I say this from experience that we have had there in
El Paso, the veterans that are not getting either access to
health care or are upset about something, they are really good
about taking these surveys and sending them back in.
It has been my experience, and I say this because I have
had even some of the members of my family that have gotten
those surveys and because they are satisfied, they do not even
return them. They just chuck them.
So is there a way or a process that you factor that into
that? In other words, if you send out 20,000 surveys and you
only get back 1,000, is there some way to factor in those
veterans that do not send it in because they are satisfied?
These surveys are multiple pages and they do not want to
take the time to or can take the time to answer all those
questions. And I think that that really skews the results for
the VA facility.
So is there some way that can be done or is that being
done? Is that taken into consideration?
Ms. Beck. That is a very challenging question and I could
answer that a couple of ways.
I think when any of us use surveys or when we publish
surveys or when we read about surveys, we will very often see a
statement about the response rate because if the response rate
is very low, if you send out 20,000 questionnaires and only
1,000 people respond, then your questionnaire does not have a
lot of validity because the number of people that you sampled,
and I think that is a challenge in our Gallop polls and every
way we do surveys, so that would be the first thing that we do.
And I think our survey folks try to design surveys that
will be easy so that people return them. And I think we, you
know, need to do better with that. I think as we are developing
outcome measures and satisfaction measures, we are very focused
on making them short and easy for the clinicians and for the
veterans to fill out.
And I think that is what we are trying to do as we address
patient satisfaction, veteran satisfaction, and even outcome
measures.
Mr. Reyes. Because I think if you just include a postcard
that----
Ms. Beck. Yes.
Mr. Reyes. --basically says, hey, I am satisfied, I cannot
or do not want to go through the whole survey, count me as
satisfied or somehow like that because----
Ms. Beck. Okay.
Mr. Reyes. --because I believe that the results are being
skewed----
Ms. Beck. Okay.
Mr. Reyes. --because veterans do not want to go through
those multiple pages. Whoever is designing those to be short is
failing. I have gotten them myself and let me tell you----
Ms. Beck. Thank you.
Mr. Reyes. --16 pages is not short.
Ms. Beck. Yes. No, I do not want to fill those out either,
so thank you.
Mr. Reyes. Thank you.
And thank you, Madam Chair.
Ms. Buerkle. Thank you, Mr. Reyes.
Before we adjourn this afternoon's hearing, I would just
respectfully request that you would provide us--earlier, Dr.
Beck, you mentioned there is shared clinical practice
guidelines. So much of the testimony was saying that DoD has
taken the lead in prosthetics and you are assuring us that
there is some collaboration between DoD and VA.
Ms. Beck. Yes.
Ms. Buerkle. If you could provide for the Committee or for
the Subcommittee, I should say, all of the initiatives that are
going to ensure that the VA at least is working with and trying
to emulate and catch up to DoD's prosthetic programs, I think
that would be helpful for us.
Ms. Beck. Thank you. Yes, we will do that.
Ms. Buerkle. If there are not any further questions, I just
want to thank this fourth panel for your endurance, this was a
long hearing, and for your willingness to be here. Thank you
and thank the both of you, Dr. Miller and Mr. Doyle, for your
service to this country.
And before we adjourn the meeting, this is always a good
opportunity for this Subcommittee to say thank you to all of
the veterans, and to our veteran service organizations for your
service and for your sacrifice to this country.
The United States is the greatest country in the history of
the world and it is because of the service and the sacrifice of
the men and women who serve this country and who have served
this country. So thank you very much.
With that, I ask unanimous consent that all Members have
five legislative days to revise and extend their remarks and
include any extraneous materials. Without objection, so
ordered.
Thank you again to all of our witnesses, to all the
participants in today's hearing, and our audience members for
joining in today's conversation.
The hearing is now adjourned.
[Whereupon, at 12:58 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Ann Marie Buerkle, Chairwoman
Good morning and welcome to today's Subcommittee on Health Hearing,
``Optimizing Care for Veterans with Prosthetics.''
Our Nation's commitment to restoring the capabilities of disabled
veterans struggling with devastating combat wounds resulting in loss of
limb began with the Civil War.
Restoring these veterans to wholeness was a core impetus behind the
creation of the Department of Veterans Affairs then and it continues to
play a vital role in the Department's mission now.
Prosthetic technology and VA care have come a long way from the
Civil War era wooden peg legs and simple hooks. Following World War II,
in 1945, veterans dissatisfied with the quality of VA prosthetic care
stormed the Capitol in protest. Congress responded by providing VA with
increased flexibility for prosthetic operations and launching Federal
research into the development of new mobility and assistive devices.
With these reforms, VA led the way in prosthetic care and research,
guided by dedicated professionals both inside and outside the
Department who worked tirelessly to provide veterans with the quality
care they earned and deserved.
As a result, the model of VA care for today's veteran amputees
include leading edge artificial limbs and improved services to help
them regain mobility and achieve maximum independence.
Still, the magnitude of the heartbreaking injuries sustained by
servicemembers and veterans returning home from military service in
Iraq and Afghanistan find VA struggling to keep pace with the rising
demands of younger and more active veterans with amputations.
Prosthetic care is unlike any other care provided by the
Department.
Prosthetic devices, particularly prosthetic limbs, quite literally
become a part of their owner, requiring the integration of body, mind,
and machine.
The goal is not just to teach amputees to walk or use an artificial
arm and hand, but to provide multi-disciplinary continuing care to
maintain long-term and life-time functioning and quality of life.
Which is why I am troubled by the Department's proposed changes to
prosthetic procurement policies and procedures. The forthcoming reforms
will, among other things, take prosthetics purchasing authority from
prosthetic providers and transfer them to contracting officers.
This is alarming to me and - as we will hear soon - it is also
alarming to many of today's witnesses. I would like to read a quote
from Capt. Jonathan Pruden, a wounded warrior himself, who states in
his testimony that:
``We see no prospect that this planned change in prosthetics
procurement holds any promise for improving service to the warrior.
Instead, it almost certainly threatens greater delay in VA's ability to
provide severely wounded warriors needed prosthetics devices . . .
.[and] . . . heightens the risk that a fiscal judgment will override a
clinical one . . . ''
We cannot allow that to happen and this morning we look to the
Department for assurance it won't happen.
It is nothing short of inspiring to see how far modern technology
and - most importantly - the spirit, courage, and resolve of our
veterans themselves has come in restoring mobility, dignity, and hope
to our Nation's heroes.
It is vital that we set VA prosthetic care on a course that matches
the courage and bravery of the men and women who serve our Nation in
uniform.
Again, I thank you all for joining us this afternoon. I now
recognize our Ranking Member, Mr. Michaud [ME-SHOW] for any remarks he
may have.
Prepared Statement of Hon. Michael H. Michaud,
Ranking Democratic Member
Good morning. I would like to thank everyone for attending this
important hearing today.
The purpose of today's hearing is to look closely at VA's
Prosthetic and Sensory Aids Service and to examine the:
1. Demand for prosthetic services;
2. Any quality of care and access issues;
3. The impact of ongoing procurement reform; and
4. If current acquisition and management policies are sufficient.
As the three Office of Inspector General reports have shown, there
are numerous concerns, including:
1. The frequency of overpayments - in nearly a quarter of
transactions, totaling over $2.2 million in FY2010;
2. The absence of negotiations, pricing guidance, and other
controls; and
3. Limited information to assess if current prosthetic limb
fabrication and acquisition practices are effective.
I have said it on this Committee before--What seems to be the case
is that there is little accountability in management and once again
procedures and policies were not in place or not followed in managing
nearly $2 billion worth of prosthetics and sensory aids.
The VA, in last year's budget submission, claims $355 million in
savings in 2012 and 2013 due to ``acquisition improvements.'' But if
the VA cannot follow its own policies and procedures, how much faith
can we have in claims of acquisition savings?
I hope that VA can help us understand today what accountability we
should expect - to make certain that:
1. VA does not continue to overpay for prosthetics in the future;
2. That taxpayers and veterans receive the best value for these
devices; and
3. For management to ensure that the Prosthetic and Sensory Aids
Service is fully meeting veterans' needs.
Finally, it has come to my attention that VA has proposed changes
in the procurement of prosthetics and that there is a high degree of
concern among some of our witnesses today as to the effectiveness of
these changes. I look forward to hearing from VA on that issue as well.
I thank our panelists for appearing today.
I am committed to working with all of you to ensure that our
wounded veterans, those who have served honorably and made such great
sacrifices, are able to go about their lives more comfortably with
these devices and with the best support and services from the VA.
Madam Chair, I yield back.
Prepared Statement of John Register
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
Thank you for this opportunity to testify on the ability of the
Department of Veterans Affairs (VA) to deliver state of the art care to
veterans with amputations. I testify today on behalf of myself and an
organization for which I serve on the Board of Directors, the National
Association for the Advancement of Orthotics and Prosthetics (NAAOP).
NAAOP is a non-profit trade association dedicated to educating the
public and promoting public policy that is in the interest of orthotic
and prosthetic (``O&P'') patients and the providers who serve them. My
service on NAAOP's board has exposed me to the field of limb
prosthetics from a policy perspective and that perspective is further
informed by my own experience with amputation and prosthetic limb use.
The issues to be addressed in this hearing are critical to the
ability of veterans with amputations and other injuries and conditions
to live active, fulfilling lives, to live as independently as possible,
to participate in community activities, to raise families, and to work.
I served in the U.S. Army through Operations Desert Storm and Desert
Shield over a period of six years. I speak today from personal
experience as an amputee veteran who has worn a prosthesis since 1994
when I lost my leg at the knee joint due to a severe injury sustained
during an athletic competition. I currently work for the United States
Olympic Committee (USOC) and direct the Paralympic Ambassador Program
and the Paralympic Experience Youth Outreach Program, as well as the
USOC's Paralympic Military Program, a program for service-members who
return from conflict with physical disabilities.
Office of Inspector General Reports on Prosthetics: I have reviewed
the three reports recently issued by the Office of Inspector General
and have some general observations to offer on the two reports that
were issued on March 8th entitled, ``Veterans Health Administration:
Audit of the Management and Acquisition of Prosthetic Limbs,'' Report
No. 11-02254-102, and ``Healthcare Inspection: Prosthetic Limb Care in
VA Facilities,'' Report No. 11-02138-116. The third report issued by
the OIG on March 30, 2012 (Report No. 11-00312-127) and entitled,
``Audit of Prosthetics Supply Inventory Management'' addresses the
broader VA prosthetics benefit and goes well beyond limb prosthetics.
I, therefore, will not address this report in my comments.
The term ``Prosthetics'' is used by the VA to describe a
wide variety of devices that have nothing to do with limb prosthetics
or artificial limbs. In fact, the data establish that of the $1.8
billion spent by the VA on ``prosthetics'' in FY 2010, only $54 million
(or 3 percent) was spent on prosthetic limbs. This is a relatively
small portion of dollars spent by the VA on the broader category of
prosthetics.
The VA's nomenclature (i.e., defining ``prosthetics'' as
virtually any device that assists a veteran, including internally-
implanted devices) does not easily mesh with the field of limb
prosthetics, which is closely aligned with the field of orthotics
(commonly referred to as custom braces for the back, neck, legs, and
arms).
The VA has made a major investment in its internal limb
prosthetics capacity since 2009 with the development of the Amputee
Systems of Care (ASoC) program, a series of prosthetic centers with
differing levels of prosthetic expertise and capacity. The VA has
emphasized accreditation of these programs and certification of the
professionals in these programs as a measure on quality. The new
investments in amputee care are designed to integrate care for veterans
and treat the whole patient, not just the prosthetic needs of the
amputee. Maintaining internal VA capacity and expertise to treat
amputees in an integrated manner is important and the VA should be
commended for its commitment and focus on this important population.
At the same time, especially with respect to its
practices with private prosthetists who have contracts with the VA, the
VA appears to treat limb prosthetics in much the same way they procure
other prosthetic commodities such as wheelchairs and hearing aids,
without fully recognizing that prosthetic care is highly clinical and
service oriented. The component parts of a prosthesis are but one
aspect of quality prosthetic care that results in an amputee walking or
functioning consistently well without significant pain.
The Healthcare Inspection Report (11-02138-116) details
relatively high satisfaction levels with lower limb prosthetics, most
of which are provided by contract prosthetists, but less satisfaction
with upper extremity prosthetics. This is a small but important veteran
population and we support the recommendations to improve care for these
veterans. Notably, the Department of Defense and the VA have made
significant investments in technology in the area of upper limb
prostheses and even held a joint research conference in Baltimore,
Maryland two years ago. However, we understand that a written report of
this conference has not yet been published. We encourage the VA to
publish this report and to make additional improvements to its upper
limb prosthetic program to improve access to appropriate technology and
good quality care.
We note that despite some internal payment controls that
need improvement, the Healthcare Inspection Report (11-02138-116)
concludes that the vast majority of veteran amputees have high
satisfaction rates with their prosthetic care which are primarily
provided by private practitioners under contract with the VA.
NAAOP questions several conclusions in the VA OIG Report
entitled, ``Veterans Health Administration: Audit of the Management and
Acquisition of Prosthetic Limbs'' (11-02254-102).
NAAOP takes strong issue with the OIG's calculation of
the difference in what it asserts it costs the VA to provide a
prosthesis, on average, to a veteran through its in-house capability at
the Veterans Health Administration (VHA) versus what it costs the VA to
purchase an average prosthesis under contract from a private
prosthetist. The OIG asserts that VA spent $12,000 on average for a
prosthesis while the average cost of a prosthetic limb fabricated in
the VHA's prosthetic labs was approximately $2,900. This is a highly
suspect calculation of VA's true costs of providing prosthetic care to
veteran amputees and sends the erroneous signal that the VA is vastly
overpaying for contract prosthetic care. This is simply not the case.
It is not clear which costs the OIG factored into its analysis because
the report offers no detail on its calculations, but it is highly
likely that OIG failed to include the critical costs of labor (salaries
for certified prosthetists and technicians), overhead (the costs of
maintaining clinical facilities, laboratory machinery, information
processing, etc.), and myriad other costs that go into the fabrication
and fitting of prosthetic limbs. In fact, if the OIG were to factor
into the calculation the recent investments the VA has made on its
Amputee Systems of Care initiative, the cost of providing prostheses to
veterans through its internal capacity would be significantly higher
than calculated.
As the VA enhances its internal capacity to meet the
needs of veteran amputees, it is important to recognize the legitimate
role of private prosthetists who have provided prosthetic care to
veterans for decades under contract with the VA. Allowing veterans to
access private prosthetists in their own communities preserves quality
by allowing choice of provider. The relationship between a prosthetist
and a patient can mean all the difference in successful prosthetic
rehabilitation. Proximity to care is also very important for veterans.
It is important that the VA maintains access to local private
prosthetists under contract with the VA to conveniently serve
veterans--within the overall plan of care designed by the VA clinical
team. Finally, choice of prosthetic technology is critical in order to
allow veterans to access the most effective prosthetic alternatives
that address their medical and functional needs.
NAAOP agrees with and strongly supports the
recommendation in the Healthcare Inspection Report (11-02138-116) that
VA's Under Secretary for Health consider veterans' concerns with the VA
approval processes for fee-basis and VA contract care for prosthetic
services to meet the needs of veterans with amputations. This is a key
area that addresses the satisfaction of prosthetic care among amputee
veterans. In fact, there is legislation pending before this Committee
that seeks to address this very issue, H.R. 805, the Injured and
Amputee Veterans Bill of Rights.
My Experience with VA Prosthetic Care: I currently live and work in
Colorado Springs, Colorado. I began my initial care at the amputee
clinic in the Denver VA Hospital and was referred to a local
prosthetist in Colorado Springs for my primary prosthetic care. This is
typical of VA prosthetic care. I sought this prosthetist out because a)
they were close to my home and b) they understood the high level of
activity to which I was accustomed. This was done in no way to
disparage the care I received at the Denver VA. In my experience, I
have always been treated with dignity and respect at the three VA
hospitals I have been fortunate to work with. Finding a local
prosthetist is typical of VA prosthetic care. Just a few years ago,
approximately 97% of prosthetic limbs were provided by private
prosthetic practitioners under contract with the VA. \1\ (I understand
this percentage has decreased in the past few years as the VA has
invested in their internal capacity to fit and fabricate limb
prostheses.) I developed a close working relationship with my local
prosthetist over the years and would like to continue seeing him. This
prosthetist is certified and accredited by one of the two accrediting
organizations that VA recognizes and requires. My local prosthetist's
office in my town is seven minutes from my house by car. He has signed
a VA contract to provide prosthetic services to veterans and he is, in
fact, a fine prosthetist.
---------------------------------------------------------------------------
\1\ Congressional Testimony of Frederick Downs, House Small
Business Committee, Subcommittee on Contracting and Technology, Hearing
on Ensuring Continuity of Care for Veteran Amputees; The Role of Small
Prosthetic Practices, Serial No. 110-105 (July 16, 2008).
---------------------------------------------------------------------------
Working in concert with the VA amputee care system, which brings
together a comprehensive team to assess my prosthetic and other health
care needs, my local prosthetist's services have kept me a very active
and energetic amputee, walking well, engaging in strenuous exercise,
and functioning fully. The ongoing care I received from my contract
prosthetist was very convenient, creating little disruption with my
USOC job, my family, and my lifestyle.
Unfortunately, my prosthetic needs changed recently and I became
interested in a new technology that permits microprocessor control of
the prosthetic knee. This new technology is an incredible advance in
prosthetic care in that it prevents my knee from ``buckling'' which
causes instability and could cause a fall. Using microprocessor
technology, the prosthetic knee anticipates your movements and adapts
instantaneously in order to function as close to a natural leg as
possible. The VA Hospital in Denver told me that the only way to be fit
for this new technology would be to have my new limb fit, fabricated,
and serviced at the Denver VA Hospital's amputee program.
I did not realize I had a choice in the matter and believing the
new technology would meet my prosthetic needs, I agreed and began the
fitting process at the Denver VA, driving 70 miles each way to receive
the prosthetic care I could have accessed just seven minutes down the
road from my home. I also did not realize that I could have been
reimbursed for my travel expenses until my fourth visit.
I traveled to Denver numerous times during the fitting process
before I finally received my new limb. Every time I need adjustments or
servicing of the prosthesis, I must take the better part of a day off
from work, drive a significant distance, and obtain my care at the
Denver VA. Again, I have no complaints with the amputee/prosthetic care
they provide at this hospital. They are professional and knowledgeable,
but the wasted time and energy is a major imposition in my life and a
disruption to my job and family responsibilities. In addition, I have
had times when a quick visit to my local prosthetist could have
resulted in quick adjustments to maintain the fit and function of my
prosthesis. Instead, I have found myself delaying care until something
significant happens or the need for prosthetic care intensifies. This
is not an efficient, convenient, or patient-friendly system.
I consider myself very fortunate that I am not in a position where
I am vulnerable or uneducated about my prosthetic options. But I worry
about those veterans who are not in the position to advocate for
themselves and simply accept what they are told about their prosthetic
care options. And such options appear to be very inconsistent across
the Veteran Integrated Service Networks (VISNs). The VA needs to ensure
that all veterans with amputations consistently receive the high
quality prosthetic care they need and deserve. One of the primary ways
to ensure this is to make sure that veterans know that they have rights
and responsibilities. They should have a choice of prosthetic
practitioner, a choice of technological options, and a choice to seek a
second opinion when desired by the patient. This is completely
consistent with the OIG's recommendation that the VA improve its
approval processes for fee-basis and VA contract care for prosthetic
services to meet the needs of veterans with amputations.
In fact, this recommendation, and the agreement by the Under
Secretary of Health to this recommendation, seems at odds with the VA
manual provisions that suggest that each VISN maintain between three
and five contracts with private prosthetists, an exceedingly low number
that does not square with the notion of veteran choice of practitioner.
This is perhaps why some regions examined in the OIG reports maintain
far more contracts with private practitioners than three to five. We
would hope the VA revises this guidance in the future to more
accurately reflect the needs of veteran amputees.
Support for H.R. 805, the Injured and Amputee Veterans Bill of
Rights: H.R. 805, the Injured and Amputee Veterans Bill of Rights, has
been introduced in the past three Congresses by Ranking Member Bob
Filner. In fact, this bill--its predecessor, H.R. 5730--passed the
House in December 2012 but the Senate did not have time to act before
the 111th Congress adjourned. This legislation proposes the
establishment and posting of a ``Bill of Rights'' for recipients of VA
healthcare who require O&P services. This Bill of Rights will help
ensure that all veterans across our country have consistent access to
the highest quality of care, timely service, and the most effective and
technologically advanced treatments available, all in concert with the
enhanced internal capacity of the VA in the prosthetic field. NAAOP
believes that adoption of this ``Bill of Rights'' will establish a
consistent set of standards that will form the basis of expectations of
all veterans who have incurred an amputation or injury requiring
orthotic or prosthetic care.
The bill proposes a straightforward mechanism for ``enforcement''
of this ``Bill of Rights,'' with an explicit requirement that every O&P
clinic and rehabilitation department in every VA facility throughout
the country be required to prominently display the list of rights. In
addition, the VA's websites would also post this Bill of Rights for the
interest of injured and amputee veterans. In this manner, veterans
across the country would be able to read and understand what they can
expect from the VA healthcare system in terms of their orthotic and
prosthetic care. And if a veteran is not having their orthotic or
prosthetic needs met, they will be able to avail themselves of their
rights and become their own best advocate. But above all, no veteran
will be in the position of resigning him or herself to the fact that
they are not functioning well with their O&P care for lack of
information about their rights.
This bill would simply condense to writing the O&P rules and
procedures that the VA has used for years. An analysis of Congressional
testimony delivered in 2008 by the Chief of the VA Prosthetic and
Sensory Aids Service before the House Small Business Committee confirms
that none of the rights listed in H.R. 805 (and its predecessor, H.R.
5730) would expand the rights the VA has granted veterans for years,
including in the area of practitioner choice and choice of prosthetic
technology. \2\ But the bill would, in fact, put these rights in
writing and post them for veterans to see, understand, and employ to
help ensure they receive the quality O&P care they need and deserve.
This bill would also provide Congress with easy access to the level of
compliance with this ``Bill of Rights'' across the country and could
identify particular regions of the country where problems persist.
---------------------------------------------------------------------------
\2\ Congressional Testimony of Frederick Downs, House Small
Business Committee, Subcommittee on Contracting and Technology, Hearing
on Ensuring Continuity of Care for Veteran Amputees; The Role of Small
Prosthetic Practices, Serial No. 110-105 (July 16, 2008).
---------------------------------------------------------------------------
I understand the Congressional Budget Office gave the bill a
nominal ``score'' in terms of what this would cost the VA. This is
because none of the rights in the bill expand the rules and procedures
the VA has acknowledged it uses for veterans in need of O&P care.
Thirty-five veterans' organizations, rehabilitation associations, and
consumer and disability groups support passage of H.R. 805. While
passage of H.R. 805 will not solve all the problems and shortcomings
with the current VA prosthetics program, I believe it will have a
material effect on the ability of the VA to deliver consistent, state
of the art care to all veterans with amputations.
NAAOP and a number of national O&P associations recently met with
senior VA officials in charge of the Prosthetic and Sensory Aids
Service. While the VA does not appear to support passage of the
legislation, they do appear to recognize the problems that I have
personally experienced as representative of some veterans' experiences
with the VA limb prosthetics program. We have agreed to continue
discussions to see if there are ways to address issues raised by H.R.
805. But passage of legislation would establish, in law, a baseline of
expectations for injured and amputee veterans that would not subject
the contents of the ``Bill of Rights'' to the discretion of future VA
administrations.
Conclusion: On behalf of NAAOP, I want to thank you, Madam
Chairwoman, and this Subcommittee for examining this critical issue.
The OIG's Healthcare Inspection Report provides valuable information on
this subpopulation of veterans that will guide advancements in O&P care
in the future. On the other hand, NAAOP questions significant aspects
of the data presented in the Audit of the Management and Acquisition of
Prosthetic Limbs Report. My organization, NAAOP, and I hope to continue
working with this Subcommittee and the VA to help ensure that veterans
with amputations and other injuries receive the highest quality
orthotic and prosthetic benefit possible. Finally, we call on this
Subcommittee to seriously consider passage of H.R. 805, the Injured and
Amputee Veterans Bill of Rights, in subsequent legislative hearings as
soon as possible, and to ultimately enact this legislation this year.
I thank you for this opportunity to testify before the Subcommittee
and welcome your questions.
Prepared Statement of Jim Mayer
Chairwoman Buerkle, Ranking Member Michaud, thank you for the
opportunity to appear before you and the Subcommittee concerning the
capabilities of the Department of Veterans Affairs (VA) to deliver
state-of-the-art care to veterans with amputations. I commend your
Subcommittee for its continued work to ensure that veterans receive the
best possible VA health care.
I am a combat disabled, former US Army infantryman, Vietnam veteran
and a bilateral below the knee amputee for over 43 years. I am a
retired VA employee with 27 years of service and 12 additional years of
experience working for veterans service organizations. I have received
prosthetic care from VA, Walter Reed Army Medical Center (WRAMC) and
the Walter Reed National Military Medical Center (WRNMMC).
I also have been an amputee peer visitor and mentor for over 21
years primarily at WRAMC but also at the National Naval Medical Center
and now at WRNNMC. I have made thousands of visits with wounded
warriors and have witnessed firsthand the catastrophic injuries they
and their families overcome through quality and comprehensive military
health care and rehabilitation. I am a certified trainer for the
Amputee Coalition for the Peer Amputee Visitor and the Wounded Warrior
Project Peer Mentor programs.
I would summarize my observations about VA's prosthetics and its
Amputation System of Care by noting that while I understand VA has
recently initiated internal efforts to design improvements--it's clear
to me that America's military prosthetic care for warriors with
amputations has far surpassed VA's previous long standing leadership
position. In my opinion, VA is going to have to work hard and
creatively to regain that leadership.
Now is an opportune time for a full scale program evaluation and
development of a new short and long term strategic plan for VA
Prosthetics & Sensory Aids Service (PSAS) and the Amputation System of
Care. VA's Amputation System of Care includes--the Regional Amputation
Centers (RAC), Polytrauma Amputation Network Sites (PANS), Amputation
Care Teams (ACT), and the Amputation Points of Contact (APOC).
The VA Prosthetics program has been under acting leadership for
about 9 months after the retirement of its leader of some 30 years. I
understand that the Veterans Health Administration (VHA) is working on
a prosthetics reorganization that will include VA acquisition staff
taking over the purchasing of prosthetic items over $3,000. From what I
have heard of the VA supply function taking over prosthetics purchases
- I am very concerned by this change and how it will impact veterans.
Prosthetics are a truly individualized extension of one person's body
and mobility, not your typical bulk supply purchases. I don't believe
VA supply staff has the expertise in prosthetics to pull this transfer
through without introducing major obstacles for veterans with
amputations. Taking prosthetic purchase warranting authority out of
PSAS to VA acquisition could dramatically increase complaints from
veterans. I also understand VHA is poised to relax its long standing
``centralized funding'' rules which prohibit VA medical facility
managers from diverting prosthetics monies for other uses - a major
problem which was originally corrected by ``centralized funding'' in
VHA years ago and has since served veterans with amputations well.
I recommend that this Committee ask VA to freeze its pending
reorganization until a full scale program evaluation and new strategic
plan can be achieved. I suggest that this effort include representation
to include--
I Veterans with amputations from various eras, particularly those
wounded in Afghanistan or Iraq who received prosthetic care from VA and
a DOD center of excellence
I VA's Prosthetics & Sensory Aids Advisory Committee
I VA, military and private industry clinicians with stellar
amputation and prosthetics experience
I Prosthetists/Orthotists
I Therapists experienced with amputee rehabilitation
I Private sector prosthetics and orthotics manufacturers
I Veterans service organizations
It's my sincere belief that majority of the program staff of VA's
PSAS and the Amputation System of Care are dedicated professionals.
Given my previous experience as a VA staffer and as a member of a past
blue ribbon task force on VA prosthetics development and management, I
would recommend that this evaluation and strategic plan include VHA
participation but operational control of the effort be centralized to
the Secretary of Veterans Affairs. I believe Secretary Shinseki has
shown in the past a propensity for deciding to do what's right for
veterans.
From my perspective, certain events of past years epitomize a
culture of reluctance on these issues within the senior management
ranks of the VHA which appears to me from these past 9 months to be
alive and well.
On February 2, 2004, then Secretary Principi told the House
Committee on Veterans Affairs--
. . . I will tell you that one area that I really think that the
VA needs to spend more of its resources, and I think the current war
highlights it, is building a center of excellence in amputee research
and rehabilitation. Again, I go back to our core mission, to care for
people who have been wounded and disabled in combat or in training . .
. And we need to do everything in our power to develop the most modern
prostheses available for them and to have a rehabilitation program
that's second to none in this country. And I think we've lost the edge
... We're not doing enough . . . \1\
\1\ Source: http://democrats.veterans.house.gov/hearings/
schedule108/feb04/2-4-04/2-4f-04.pdf
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Secretary Principi's words of 8 years ago would accurately apply to
VA if said again today. The day before Secretary Principi's testimony
he had tasked VHA with implementing the VA Amputee Center of
Excellence. I attended that meeting. Four months later VA's PSAS had
identified 14 potential Prosthetics and Orthotics Labs as potentially
eligible for upgrade to Amputee Center of Excellence status and
indicated a Request for Proposals was imminent. VHA's work then slowed
down in the preparatory stages.
In 2006, in light of no definitive VA progress, S. 2736 was
introduced to create five such VA centers. The then Deputy Under
Secretary for Health, one VHA leader originally tasked by Secretary
Principi in 2004 to implement such a center, testified before the
Senate Committee on Veterans Affairs on May 11, 2006 opposing that
legislation. \2\
---------------------------------------------------------------------------
\2\ Source: https://www.va.gov/OCA/testimony/svac/060511MK.asp
---------------------------------------------------------------------------
Since that 2006 VA opposition, military medicine has filled the
void. DoD has opened two state-of-the-art, multi-million dollar amputee
centers of excellence at WRAMC (and recreated anew at WRNMMC) and the
Center for Intrepid at Brooke Army Medical Center. The Navy also
established the C5 (Comprehensive Combat and Complex Casualty Care) at
the National Medical Center San Diego. I have received care from the DC
based military centers and have visited both the CFI and the Navy's C5.
To me, VA's efforts pale in comparison. It's like day and night, with
VA being the night.
Those comprehensive military facilities are primarily for active
duty wounded warriors and offer limited access to warriors discharged
from the military. According to staff from whom I receive prosthetic
care, the real enabler for these military programs and staffing is
known as ``GWOT Funding'' within DoD. My concern is how long will DoD
have the funding available to continue these centers? Even if continued
at today's levels for the foreseeable future - these fine military
centers do not serve a large number of those no longer in military
service.
When today's warriors are referred to VA and seek the newer,
cutting-edge, technologically superior prosthetics they have been
accustomed to--will VA be able to meet that demand? DoD centers of
excellence provide state of the art and often newly evaluative
prosthetics that have allowed the warriors to thrive incredibly, not
just in the walking ability--but also run competitively, compete in the
Paralympics, rock climb, play a myriad of sports and other athletic
endeavors. Most warriors receive multiple, special purpose prosthetics
prior to discharge. VA must develop the clinical expertise necessary to
continue that level of clinical care and must have administrative
processes in place to ensure warriors receive prosthetics in a timely
manner - including increasing the number of prosthetic devices VA
currently allows an individual veteran.
Quality and speed are not the only superior aspects of DoD
provision of prosthetics - it's the holistic merging of excellent
clinical, physical and occupational therapy, adaptive sports and
recreation events and alternative medicine strategies that produces
such excellent results. The key question is--can VA Amputations System
of Care meet the needs and expectations of this new generation of
warriors and yet maintain its prevalent focus on care for the thousands
of amputations performed annually by VA which are usually involve more
senior age veterans with post-vascular complications?
Please accept my compliments to you for holding this hearing and
for your continued leadership in ensuring state-of-the-art care in VA
for veterans with amputations. I would be pleased to answer any
questions or provide any additional information you may require.
Prepared Statement of Michael Oros
Good morning Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee. Thank you for the opportunity to provide
testimony today. The American Orthotic and Prosthetic Association
(AOPA) is grateful for your work to ensure that Veterans with limb loss
receive state of the art prosthetic care. We applaud you for convening
this hearing, Madam Chairwoman, and deeply appreciate the invitation to
shed some light on current issues facing the fields of prosthetics and
orthotics when it comes to quality care for our Veterans.
My name is Michael Oros, and I am a member of the AOPA Board of
Directors. The American Orthotic & Prosthetic Association (AOPA),
founded in 1917, is the country's largest national orthotic and
prosthetic trade association. Our membership draws from all segments of
the field of artificial limbs and customized bracing for the benefit of
patients who have experienced limb loss, or limb impairment resulting
from a chronic disease or health condition. AOPA members include
patient care facilities, manufacturers and distributors of prostheses
(artificial limbs), orthoses (orthopedic braces such as those used by
TBI and stroke patients) and related products, and educational and
research institutions.
In my day job, I am a licensed prosthetist and President of Scheck
and Siress, Inc., a leading provider of O&P services based in Illinois.
Like many other community-based providers, Scheck and Siress is
committed to serving Veterans, and does so through contracts with the
VA. Scheck and Siress is also proud to employ Melissa Stockwell, the
first American service woman to lose a limb in Iraq. After sustaining
the injury that resulted in her limb loss, Ms. Stockwell went on to
become a Paralympic athlete, and had the honor of carrying the American
flag at the closing ceremonies of the Paralympic Games in Beijing.
Melissa is now a certified prosthetist, and a member of the staff at
Scheck and Siress.
It seems to me that, before we can have a conversation about the
quality of prosthetic and orthotic care provided to our Veterans, we
need to agree on what ``quality'' prosthetic and orthotic care is. I'm
not certain that I've ever seen an official VA definition of
``quality'' care, so at the risk of being pushy, I'd like to suggest my
own for the purposes of our discussion today. For me, as a practicing
clinician who has been taking care of Veterans with limb loss for 26
years, four major elements comprise quality prosthetic care:
1) Access. Veterans must be able to receive care on a timely
basis, without waiting for weeks or having to travel hundreds of miles
for their prostheses to be checked, adjusted, repaired or replaced.
2) Trust. Veterans must know about and be able to exercise their
right to receive care from a provider they trust, who listens to them
and works with them to achieve the most functional prosthesis possible.
Fitting a good prosthesis is as much art as it is science, and a
positive, ongoing working relationship between the Veteran and the
prosthetist is an important element of getting it right.
3) Expertise and experience. Clinicians serving Veterans must
have the training and clinical know-how to select, custom-build, fit
and adjust the best possible prosthetic device to address the complex
challenges Veterans with limb loss face every day.
4) Outcomes. The result of high quality prosthetic care is
greater comfort, higher activity levels, more independence and greater
restoration of function for Veterans with limb loss, so that they can
live their everyday lives successfully and continue to do the things
they want to do despite the absence of one or more limbs.
Overall, the quality of prosthetic and orthotic care for Veterans
has never been better. New technology has restored previously
unachievable levels of function for servicemembers returning from Iraq
and Afghanistan with Traumatic Brain Injury or having lost limbs.
However, in my experience, there is really two types of prosthetic care
being provided to our nations' Veterans. Some Veterans are very well
informed, technology-savvy, very aggressive and successful advocates
for themselves and their care. These are the Veterans that we are most
likely to see at a practice like Scheck and Siress, and for them, the
Veterans' Administration creates relatively few administrative and
other barriers to care.
However, there is also another group of Veterans, typically older,
typically non-service connected new amputees. These Veterans are less
likely to advocate aggressively for their own care. It is difficult for
me to say whether they are aware of their right to see a prosthetist of
their own choice, but they are certainly less likely to request an
appointment at a practice like Scheck and Siress. Veterans in this
category who have been patients with Scheck and Siress for some time
have begun to complain to us about new administrative hurdles to care.
We are hearing more about administrative pushback, increased paperwork,
and new requirements to be seen at a VA clinic prior to approval to
receive care from Scheck and Siress.
So several barriers persist that stand in the way of providing even
higher quality O&P care to Veterans, Veterans who are returning from
overseas and Veterans of other conflicts who may be losing limbs to
diabetes and cardiovascular disease. Each of these barriers is directly
related to the elements of quality care I outlined at the beginning of
my testimony. All of these barriers can be eliminated, if they receive
enough intentional focus by this Committee and by the Veterans'
Administration. If I may be so bold, I would like to outline a concise,
achievable agenda for this Committee to promote quality prosthetic care
for Veterans. It has three elements:
1) Guarantee Veterans meaningful access to trusted clinicians.
2) Elevate clinician expertise and experience.
3) Move towards evidence-based practice to achieve optimum
outcomes
I will briefly discuss the elements of these recommendations now,
and would ask that my written testimony, which contains a more detailed
overview of these issues, be included in the record.
1) Guarantee Veterans Meaningful Access to Trusted Clinicians.
As you are aware, between 10 and 20 percent of O&P care provided to
Veterans nationally is delivered by direct employees of the Veterans'
Administration. 80 to 90 percent of Veteran O&P care is provided by
community-based providers, often small businesses, that contract with
the VA. This system of contracting with a large network of community-
based providers helps to ensure that all Veterans, regardless of
geographic location, have access to quality O&P care without having to
travel hundreds of miles to reach a VA facility. In some regions of the
country, such as New York City, the majority of Veteran O&P care is
provided by VA employees. In other cases, such as Chicago, even
Veterans who live close by a large VA Medical Center prefer to receive
their care from independent providers such as those at Scheck and
Siress.
Unfortunately, despite their legal right to choose an O&P provider,
in many cases Veterans are under significant pressure to receive their
O&P care from VA centers rather than community-based providers.
Veterans frequently are unaware that they have the right to receive O&P
care from their preferred provider, be it VA or community-based. AOPA
strongly supports the right of all veterans to receive O&P services
from the provider who they feel best meets their needs. It is
imperative that those who have served and sacrificed for our country be
aware of their rights, especially on an issue as personal and important
as orthotic and prosthetic care. AOPA has supported Ranking Member
Filner's legislation to require the VA and its facilities to take
proactive steps to educate Veterans about their right to choose the O&P
provider who best fits their needs. However, it is regrettable that
this legislation has been made necessary; this is a problem the VA
could and should solve administratively.
AOPA believes that the vast majority of community-based providers
working under contract with the VA provide high quality care to
Veterans at highly competitive rates - rates, in fact, that represent
an average discount of 10% below the published Medicare fee schedule.
This has been challenged recently by a VA Inspector General's audit
that we are concerned may have been poorly researched and is, if not
completely inaccurate, at least extremely misleading. AOPA is disturbed
by allegations put forth in the IG's Audit of the Management and
Acquisition of Prosthetic Limbs issued on March 9, 2012, claiming that
the average cost of a prosthetic limb fabricated by the VA in house is
$2,900, while the average cost of a limb fabricated by a third party
contractor was $12,000. We have been unable to determine precisely
which costs were taken into account by the IG when making these
calculations, and we are disappointed that this analysis was not
challenged by the VA Prosthetics and Sensory Aids staff before the
report was published. Nevertheless, this is not an apples to apples
comparison, and it offers you and the VA leadership no useful
information. It is not unusual for Veterans with extremely complicated
devices to choose community-based providers rather than VA staff, which
would skew the cost of devices provided in-house downwards. Further,
the costs quoted for the VA-fabricated limbs almost certainly only take
into account only the cost of components, without accounting for VA
staff salaries, benefits, facilities costs, administration and taxes.
We believe that, with few exceptions, a complete and accurate cost
comparison would show that community-based O&P contractors provide
excellent value to Veterans and taxpayers.
2) Elevate Clinician Expertise and Experience.
There is another challenge looming that will affect the quality of
care for Veterans across the entire O&P field, at VAMCs and independent
providers alike. Over the past decade, the practice of orthotics and
prosthetics has grown increasingly complex. This is true both in terms
of the types of medical challenges presented by Veterans, as well as
the technologies used to treat these problems.
Whether they treat young Veterans returning home from the wars in
Iraq and Afghanistan who have lost limbs on active duty, or older
Veterans who have had limbs amputated as a result of other health
problems like diabetes and cardiovascular disease, O&P clinicians are
faced with more and more complicated issues in caring for our Veterans,
active duty servicemembers, and the civilian population with limb loss.
For example, most traumatic amputations from the current conflicts in
Iraq and Afghanistan are suffered the result of IEDs, causing
additional complications never before seen. The concussive force of the
blasts can result in microfracturing in the otherwise undamaged portion
of the limb. These fractures lead to the formation over time of bone
spurs, which greatly complicate the fitting and use of a prosthesis. On
the other end of the spectrum, increasing numbers of aging Veterans
undergo amputations due to diabetes, cardiovascular disease, and other
health conditions. As Veterans age, their skin becomes more fragile and
their circulation deteriorates. This can cause significant challenges
in attaching a prosthesis to the residual limb and greater issues in
avoiding skin breakdown, ulcers, and infection.
In recognition of the increasing complexity of O&P care, the field
recently changed the entry-level credential for orthotists and
prosthetists to a master's degree. Clinicians simply need more time in
academic, as well as clinical, settings to emerge prepared to provide
high quality orthotic and prosthetic care to Veterans, and the limb
loss population at large.
As we sit here today, there are only six institutions of higher
learning in the United States that are accredited and enrolling
students in master's degree programs in O&P. Several received federal
support in the form of Congressional earmarks to garner the start-up
funding required to get their programs off the ground. Graduating
classes are very small - in many cases, well under a dozen students.
There are an additional six programs at various stages of accreditation
that hope to start offering O&P master's degrees in the coming years.
This is an insufficient number of programs to meet the growing demand
for highly skilled orthotics and prosthetics professionals and offer
Veterans the highly technical, high quality care they deserve. The
existing programs simply cannot graduate enough students to meet the
need.
If we are to provide the best possible prosthetic and orthotic care
to our Veterans--and to the rest of the country - we must quickly and
significantly increase the number of accredited master's degree
programs in O&P, as well as expand existing graduate programs. The VA
has funding sources s that help to support education for doctors and
nurses. The DoD and HHS support graduate medical education in various
ways, (mostly through grants of financial resources to students to
attend graduate programs, rather than to institutions to create them).
But there is currently no legislation that authorizes any federal
agency to support the creation or expansion of accredited graduate
education programs in prosthetics and orthotics.
Part of the VA's mission is to support high quality medical
education for clinicians who will work in various parts of the health
system--VA and non-VA facilities--caring for Veterans and the broader
population. The advanced education of the next generation of
prosthetists and orthotists is critical to restoring the maximum
possible function for our Veterans, and to doing so in an efficient and
cost-effective manner.
AOPA recommends the creation of a small, time-limited competitive
grant program that could offer federal grants of up to one million
dollars each to approximately fifteen universities to create or expand
accredited master's degree programs in prosthetics and orthotics. Only
institutions with a demonstrated ability to create or expand accredited
programs to grant master's degrees and/or doctoral degrees in
prosthetics and orthotics should be eligible to apply, and one-time
grants should be made available to universities that have not
previously received competitive awards through this funding source. We
recommend that these grants should support curriculum development;
accreditation costs; purchase of needed training equipment;
development, recruitment and retention of qualified faculty members;
and limited expansion or renovation of space to house programs. Use of
these grants to support major construction should be prohibited.
As part of the condition of receiving such a VA grant to expand
advanced O&P training, O&P programs should be required to work with VA
Medical Centers and/or private O&P practices that serve significant
numbers of Veterans. One of the reasons the field has moved to the
master's degree requirement is to make sure that O&P professionals have
more clinical experience when they secure their credential. By caring
for Veterans as part of their clinical training, the next generation of
highly qualified prosthetists will be more familiar with the needs of
Veterans with limb loss and better able to meet their needs.
We are grateful to Chairwoman Buerkle for your examination of this
issue, and look forward to continuing to work with you to create a
small, time-limited competitive grant program to enable colleges and
universities to create or expand accredited master's programs in O&P.
3) Move Towards Evidence-Based Practice to Achieve Optimum
Outcomes
While AOPA is firm in our belief that the vast majority of private
sector clinicians are providing care to Veterans that is as good or
better than that they could receive at the VA, we also believe that it
is important to hold O&P professionals accountable for the quality of
care and the cost of that care. This poses something of a challenge for
the VA, due to the fact that there is currently no body of objective,
comparative outcomes research to support evidence-based practice in
O&P. Currently, the only mechanism available to evaluate the quality of
prosthetic and orthotic services offered by any provider - inside or
outside the VA - is the patient satisfaction survey. While community-
based providers typically score very highly on such surveys, we know
that more could and should be done to evaluate O&P outcomes for
Veterans.
This leads me to my final point. Unlike other health professions,
there is no body of comparative outcomes research to guide O&P
professionals. Their judgments about which prosthetic device, service
or support is most appropriate for which patient is based largely on
personal experience and expertise developed over years in the field.
However, there is almost no objective research on outcomes to validate
or inform that experience.
In this regard, O&P is stuck where many other health care
professions were twenty years ago. Twenty years ago, if you had a back
problem, there was no outcomes based research to guide your primary
care doctor in advising you on what kind of care to seek out. If she
sent you to physical therapy, the PT would tell you the best way to
treat your back was PT. If she sent you to a back surgeon, the surgeon
would tell you that you could only be cured with surgery. There was no
objective research to suggest who was right, and under which
circumstances.
Today, if you went to the doctor with severe back pain, your doctor
would have the benefit of extensive research that compares the outcomes
of physical therapy and surgery in different circumstances, and informs
your caregivers' recommendations. Now that doctors and patients have an
objective picture of what treatment works best for which patients,
today more patients with back pain have better outcomes, obtained more
cost-effectively.
That's what we want for Veterans who need prosthetic and orthotic
care. Our field has important, unanswered questions with significant
cost implications for DoD, the VA,
Medicare and health care more generally. Significant research
questions remain, including:
What interventions can prevent amputation or subsequent
surgeries?
At what point in the in the course of patient treatment
is orthotic and prosthetic intervention most effective?
Which patients benefit most from which technologies?
What O&P practices facilitate successful aging, and how
does the aging process affect the use of prosthetics, including
increased skin breakdown, loss of balance, falls and other issues, such
as promoting return to work?
What conclusions could longitudinal data relating to
amputees and their treatment provide that would improve quality and
cost effectiveness of their care?
What is the optimal timing of O&P intervention to prevent
lost of activity, mobility and ability to work and carry out activities
of daily living?
Such elements of a coherent O&P research agenda are vitally
important
to ensuring that Veterans receive appropriate, necessary care as
well as to eliminating unnecessary future health care costs. These and
other key questions being asked by the field remain unanswered. An
outcomes-based research portfolio, and the resulting body of evidence,
in the field of O&P would increase the quality of care for Veterans and
others with limb loss while protecting taxpayers by ensuring that
patients receive the most appropriate care, and that quality and cost
effectiveness objectives are attained in a data-driven manner that
generates the best possible outcomes, from the beginning.
AOPA applauds the VA for working toward this end by joining with
the Department of Defense in March of 2010 to hold the joint State of
the Art Conference on Orthotics and Prosthetics. This conference
generated much discussion related to the creation and execution of an
outcomes-based research portfolio in the field of O&P. While the
discussion was encouraging, we have been disappointed to see that no
progress toward the implementation of the recommendations has been
made. No report on the conference has ever been made publicly
available, and so far as we can tell, no steps have been taken by the
VA or DoD to implement any of the conference recommendations.
Despite the government-wide focus on health care outcomes, there is
currently no federal research agenda on prosthetic and orthotic
outcomes. Not at the VA. Not at the DoD. Not at the NIH, the CDC, or
NIDRR. AOPA strongly encourages the VA, DoD and NIH to help improve the
care for Veterans, servicemembers, and seniors by implementing a robust
comparative outcomes research agenda that addresses the questions in
the field and helps to inform effective, efficient delivery of O&P
care. We believe this will also yield dividends in assuring that the
major technological advances precipitated by research commitments from
VA and DoD for Veterans and active duty military are actually pulled
through to have a practical impact on care provided to our nation's
seniors and other members of the general public..
Madam Chairwoman, Members of the Committee, thank you very much for
the invitation to testify, and for your commitment to providing the
highest quality prosthetic and orthotic care to our nation's Veterans.
I look forward to answering any questions that you might have.
Prepared Statement of Joy J. Ilem
Chairwoman Buerkle, Ranking Member Michaud and Members of the
Subcommittee:
On behalf of the 1.2 million members of the Disabled American
Veterans (DAV), all of whom are wartime disabled veterans, I am pleased
to present our views at this hearing to examine the capabilities of the
Department of Veterans Affairs (VA) to deliver state-of-the-art care to
veterans suffering from amputations. I will focus my remarks on the
VA's Amputation System of Care (ASoC)--the demand, utilization and
quality of that specialized care; impact of VA's procurement reform and
suitability of acquisition and management policies; and, veterans'
satisfaction with VA prosthetic services. DAV appreciates the
Subcommittee's interest and oversight of these issues. Many DAV members
have experienced limb loss due to their wartime service and are high-
intensity users of VA health care and its specialized services. This
topic of prosthetic services is very important to DAV and our members.
War is the primary cause of traumatic limb loss and amputation in
large population cohorts. Advances in military medicine, forward-
deployed emergency capabilities and faster triage, along with the
government's mission to care for and rehabilitate wounded service
members, have corresponded with development of specialized systems of
care for veterans with polytrauma and amputations in both the
Department of Defense (DOD) and VA. Throughout history, wars have led
to advancements in military medicine, saving mores lives, and creating
conditions that advance development of prosthetics and post-injury
rehabilitation care. Our newest generation of war veterans from wars in
Iraq and Afghanistan (OEF/OIF), many of whom have suffered catastrophic
injuries, including limb loss, has again spurred research and
development of new prosthetic technologies.
In the aftermath of the current wars, both DOD and VA have been
charged by Congress with ensuring that veterans with these types of
injuries have every opportunity to regain their health, functioning,
overall well-being and quality of life. As in previous generations of
veterans who have experienced limb loss, OEF/OIF veterans want not only
to gain their independence following an amputation; they want to follow
meaningful careers, pursue new occupations or in some cases retain
their positions in the military ranks. Likewise, many veterans,
especially those from OEF/OIF, want to continue to be physically fit,
highly active and participate in competitive sports. This variety and
intensity of needs and interests requires a team of specialists and
lifelong care.
Over the recent past, media attention has been focused primarily on
DOD and the types of computerized and innovative prosthetic devices
that this new generation of war veterans has been furnished. As the
first injured troops began to arrive home from Iraq and Afghanistan in
2002, we saw a paradigm shift in the way these veterans were medically
handled by DOD. In the Vietnam War, most wounded, ill and injured
personnel were discharged from the military as soon as they were
medically stabilized. Their subsequent care was provided at VA medical
centers (VAMCs) around the nation. Today, most seriously wounded OEF/
OIF veterans are being cared for by DOD at military medical treatment
facilities from months to years post-injury, and are maintained on
active duty status while continuing their rehabilitation at Walter Reed
National Medical Center and select other regional military medical
facilities where state-of the-art prosthetics laboratories have been
established to provide for their customized needs. This new generation
of war veterans is being provided the best and newest prosthetic items
available on the market today and their rehabilitation begins
immediately within DOD, not VA. Unfortunately, newly injured service
personnel (and to an extent, DOD officials) were under the false
impression that VA could not provide these new-technology prosthetic
items or assist young veterans in their rehabilitation needs. DAV
agrees that VA did not seem well prepared as the first war-injured
veterans began their transitions from DOD into VA's rehabilitation
services, including prosthetic care. Also, many veterans were not
familiar with VA's long history in prosthetics and the transformation
VA had undergone to improve quality of care across the realm of
primary, acute, rehabilitative and long-term care.
Historical Perspective of VA Prosthetics and Sensory Aids Service
At the end of World War II, prosthetics were only rudimentary aids
for disabled people, at best. The few sensory aids that existed were
primitive. Tens of thousands of war veterans with amputations and other
severe injuries poured into VA and demanded earlier versions of many of
the kinds of assistive devices we see today's veterans demanding, but
VA fell short of their expectations. The old Veterans Administration
procured prosthetics on the basis of cheapest bid price and as a result
furnished inferior quality and ill-fitting devices to wounded war
veterans with much higher expectations. The veterans service
organization community, including DAV, expressed our collective outrage
at such shoddy VA treatment of our wounded, and Congress responded by
granting the prosthetics program a highly flexible authority (title 38,
United States Code, section 8123) to manufacture and procure
prosthetic, assistive and orthotic devices without regard to any other
provision of law, including cost. After the war, under the leadership
of VA Administrator Omar Bradley and Dr. Paul Hawley, Chief Medical
Director, VA had formalized a Prosthetics and Sensory Aids Service in
every VA hospital, and staffed these activities with disabled veterans
(primarily amputees) who themselves were users of prostheses. Also,
later VA broadened the mission of its biomedical research and academic
affairs programs to include a focus on research related to prosthetics
and sensory aids and rehabilitation from traumatic injuries.
These changes created a true, modern renaissance in development of
sophisticated prosthetic devices. VA became and remains the world
leader in prosthetics development and distribution. Our new wars simply
continued and accelerated that legacy at VA.
2012 Report from the Office of the Inspector General: Prosthetic Limb
Care in VA Facilities
On March 8, 2012, the VA Office of Inspector General (OIG), issued
its report of an inspection, entitled ``Prosthetic Limb Care in VA
Facilities'' (report no. 11-02138-116), raising one of the
Subcommittee's concerns about VA's prosthetics program.
This inspection evaluated VA's capacity to deliver prosthetic care,
VA's credentialing requirements for prosthetists and orthotists, demand
for health care services, and psychosocial adjustments and activity
limitations of OEF/OIF and Operation New Dawn (OND) veterans who had
suffered amputations. The inspectors also studied and reported these
veterans' overall satisfaction with VA prosthetic services.
It found that this subgroup of veterans was adapting to living with
their amputations, and that those with lower extremity limb loss were
noted to exhibit good mobility. Veterans with upper extremity
amputations were found to function similarly to those in the general
population; however, over half of veterans with upper extremity
amputations reported moderate to severe pain, and the inspection
reported that they did not fare as well as those with lower extremity
amputations in their psychosocial adaptation, physical abilities and
prosthetic satisfaction.
The OIG narrowed its focus to 838 living veterans of OEF/OIF/OND
with major amputations. It found that veterans with amputations have a
variety of co-existing medical conditions and are high users of VA
health care services--not only prosthetic services. Of the data
reviewed from 500,000 veterans they found that 99 percent of OEF/OIF
veterans with traumatic amputations transitioned to VA care within five
years following discharge. As of September 30, 2011, approximately 92
percent were service connected with an average disability rating of 100
percent and 88 percent receiving a disability rating of 70 percent or
higher. Over 80 percent of this group had diagnoses in each of the
following categories; mental disorders, diseases of the musculoskeletal
system and connective tissue, and diseases of the nervous system and
sense organs in addition to their unique category of injury. Notably,
35 percent of these veterans were diagnosed with traumatic brain injury
(TBI). Likewise, the percentage of post-traumatic stress disorder
(PTSD), mood disorders, substance-related disorders all increased after
discharge.
The OIG conducted in-person visits for a sample of the group
evaluated to assess their psychosocial adjustment, physical abilities,
and prosthetic satisfaction. Some of the veterans reported receiving
excellent care at VA facilities but many indicated that VA needed to
improve. Concerns with VA prosthetic services centered on VA's approval
process for fee basis and contract services, prosthetic expertise and
difficulty accessing VA services. Many veterans reported the VA process
should be more streamlined, simplified and require fewer visits to get
approval for a new prosthetic limb. They did not understand VA's
requirement for multiple in-person visits, since the diagnosis was
known and the need for the device was so clear. Others expressed
concern about the timeliness and reliability of paperwork for
processing prosthetic requests, particularly between the VA and outside
vendors, and when difficulties arose reported having to act as a
liaison between VA and the vendor.
However, despite the challenges of major limb amputation, 91
percent of lower limb and 80% of upper limb-only veterans agreed or
strongly agreed that ``life is full,'' and the OIG researchers reported
they were inspired by the high spirits of veterans they visited. An
estimated 55% of OEF/OIF veterans with lower extremity amputations
strongly agreed that they had become accustomed to wearing an
artificial limb, but only 23 percent of those with upper limb extremity
amputations agreed. Nearly half of both groups agreed that having an
artificial limb makes one more dependent on others than desired.
We appreciate the OIG's comprehensive report on prosthetic limb
care in VA facilities and were pleased that VA concurred with all
recommendations. We agree that VA can improve the overall quality of
care to veterans with amputations if it works to adjust the provision
and management of health care services to this population; improves
satisfaction for veterans with traumatic upper limb amputations; and
re-evaluates its approval process for fee-basis and contract
prosthetics services. The ``open comments'' part of the OIG report
provides VA with thoughtful comments and feedback from these amputees.
One veteran suggested VA should arrange a meeting with all upper
extremity amputees to gain better insight about how to improve
functioning for this group. Another veteran asked that VA be more
sensitive to child care issues, difficulties in getting time off from
work to access care and long wait times for getting into primary care
for needed referrals to specialized prosthetics appointments. We urge
VA to establish a simple mechanism to receive continued feedback from
this population to provide more patient-centered care, and to improve
identified hurdles in their accessing care for routine maintenance and
repair of prosthetic items.
VA's Amputation System of Care
VA has an extensive program for amputation care and rehabilitation.
In fiscal year (FY) 2011, 6,026 veterans underwent amputations, with
2,248 having major amputations. Within this total, 107 (1.8%) were
women and 24 of these women were OEF/OIF/OND veterans. In 2007, in
response to the growing need to provide patient-centered amputation
care to a younger population of combat-injured veterans, VA developed
the ASoC. By 2009, this specialized program was operational and
functions to ensure that there were a sufficient number of VA
facilities system-wide with the expertise to handle the most complex
patients and act as leaders in the field of amputation rehabilitation;
decrease the variance in amputation rehabilitation care provided across
the VA system and improve access to specialized care for veterans with
amputation.
Four Components of ASoC:
The ASoC consists of four-division levels of responsibility to care
for new amputees making a military-to-VA transition, as follows:
Regional Amputations Centers (RACs). These are seven
primary VA facilities for amputation care in VA that offer the highest
level of expertise and clinical care and use the latest prosthetic
concepts and designs in dealing with new injuries. RACs have highly
developed accredited prosthetic laboratories and services as well as
specialized rehabilitation equipment. These Centers provide
comprehensive rehabilitation services through an interdisciplinary team
of physical and occupational therapists, physiatrists, nurses,
recreational therapists and case managers.
Polytrauma Amputation Network Sites (PANS). The 15 PANS
provide a full range of clinical and supplementary services and
consultations for other facilities within the Veterans Integrated
Service Networks (VISN). They provide prosthetic services through
accredited labs or via contracts with private fabricators. PANS are
assigned responsibility to provide for the lifelong needs of veterans
with amputations.
Amputation Clinic Team (ACT). Over 100 ACTs are situated
across the VA health care system. These clinics are located at smaller
VA facilities. These facilities offer a core interdisciplinary team but
locally may not have available an accredited inpatient rehabilitation
program or accredited prosthetic laboratory. Typically, these
facilities refer amputees to PANS, RACs or community contract providers
for specialized services.
Amputation Point of Contact (APOC). An APOC is an
individual who is knowledgeable about the ASoC and refers amputees to
facilities that can best meet their needs, based on individual case
assessment.
VA's specialty amputation programs outside of the four primary
treatment divisions are:
The Servicemember Transitional Amputation Rehabilitation
Program. Located in Richmond, Virginia, this program assists service
members in returning to unrestricted military, federal or civilian
employment and is designed to reduce the time required for disability
evaluations to be completed. The program highlights a care coordination
approach, and provides individualized physical and amputation-related
rehabilitation services in a residential setting.
VA Center of Excellence for Limb Loss Prevention and
Prosthetic Engineering. Located in Seattle, Washington, this center's
aim is to improve prosthetic manufacturing by developing novel
approaches to improve the current standard of care. The goal of the
center is to improve an amputee's mobility and comfort and to prevent
further injury.
Prosthetic and Sensory Aids Service (PSAS). System wide,
VA provides veterans with equipment and limb manufacturing through PSAS
and is the world's largest and most comprehensive provider of
prosthetic devices and sensory aids. In FY 2010, PSAS served about
43,000 individuals with limb loss. However, VA defines a prosthetic
device as any device that supports or replaces a body part or function
and includes items such as artificial limbs; supportive braces; hearing
aids; wheelchairs; wheelchair ramps; home improvements and structural
alterations; surgical implants or devices; low-vision or blindness
aids; service dogs; certain medical equipment and supplies, and sports
and recreational equipment adapted for use by disabled veterans,
including amputees.
With regard to VA's definition of ``prosthetic,'' DAV recommends VA
consider partitioning or grouping these devices by some non-generic
categorization scheme so that artificial limbs, for example, will not
be seen as the same as heart stints. Their criteria for use are vastly
different, yet under VA's definition they are both considered
prostheses. The same holds true for many other devices, such as
implantable pacemakers, bone marrow, and orthopedic surgical supplies.
VA expects amputee veterans to use existing VA prosthetic and
orthotic laboratories as their primary sources for prosthetic limbs,
but VA will authorize eligible veterans to purchase prosthetics from
any commercial artificial limb fabricator under VA local contract or
with a veteran's preferred private prosthetist, provided that supplier
of services agrees to accept Medicare rates from VA for the service
involved.
In 2011, the OIG conducted a survey of its ASoC and received 124
facility responses. According to the OIG, all of VA's 56 prosthetists
and orthotists from the RACs and PANS were verified to be board
certified in their fields. Likewise, all prosthetic laboratories were
properly certified. In our opinion, VA's ASoC is fully established and
functioning properly. We concur with the IG that due to the number of
co-existing medical conditions of this patient population VA should pay
special attention to coordinating services to ensure comprehensive and
interdisciplinary care. We urge VA to continue to follow this
population through time to better understand their complex and evolving
health care needs and adjust services accordingly.
The VA OIG issued a second report in March concerning VA's
prosthetics program, entitled ``Veterans Health Administration: Audit
of the Management and Acquisition of Prosthetic Limbs,'' (report no.
11-02254-012).
This audit was conducted to examine VA management and acquisition
practices in procuring prosthetic limbs. According to the OIG, the VHA
serves nearly 12,000 amputees annually, and obtains most prosthetic
limbs from private vendors, but that some limbs are fabricated in VA
accredited prosthetic laboratories. Based on the audit, OIG reported a
system-wide weakness of internal controls and routine overpayments for
prosthetic limbs--with overpayments found at each of the 21 VISNs. In
FY 2010 alone, the OIG found that VA overpaid vendors about $2.2
million--23 percent of all payments and that if new procedures are not
implemented immediately VA would be overpaying about $8.6 million over
the next four years.
The OIG also argued that VA is not receiving the best value for the
prosthetic limbs it is purchasing and that VISN contracting officers
(COs) are not negotiating discounts in pricing with vendors and are at
times purchasing without appropriate pricing guidance. For example, in
FY 2010, VHA spent $49.3 million to purchase over 4,000 limbs from
vendors at a cost of about $12,000 each--versus the average cost
($2,900) VA's own prosthetic laboratories could fabricate the same
types of limbs. The OIG concluded that VISN contracting staff were not
uniformly documenting prosthetic limb contracts in the VA's mandatory
Electronic Contract Management System (eCMS), a lapse that results in
PSAS ineffectively balancing the combination of in-house fabrication
and vendor procurement to properly meet veteran amputees' needs.
In April 2009, PSAS staff at VA Central Office requested that VISNs
start requiring certified prosthetists to review vendor quotes to
search for inappropriate Medicare billing codes that resulted in
overpayments. At the time, we understand that many prosthetic
purchasing agents (PPAs), who are subordinate to prosthetics chiefs,
were not proficient in using Medicare billing codes to detect price
variances. Since implementation of that policy, one VISN identified
nearly $400,000 in cost avoidance using Medicare codes, but it was
noted that VACO's guidance did not address what actions local officials
should take related to vendors discovered to have overcharged. The OIG
concluded that in addition to VA's needing to pursue recovery of
overpayments, that segregating the work of VA's PPAs from other PSAS
staff would offer an opportunity to improve its acquisition practices.
VA concurred with the OIG's recommendations and noted it is
establishing a new program with a number of related processes to better
manage prosthetic acquisition and management practices. Nevertheless,
the Subcommittee should take note that while VA is in the process of
making a major transition related to prosthetic warrants and associated
staffing, PSAS has lacked permanent leadership for more than a year due
to retirement of a long-term incumbent, and the person in the deputy
director position has been reassigned to another program office. Given
the sensitivity, scope and cost of this program, we urge VA to commit
new permanent management as quickly as possible.
A third OIG report (report no.11-00312-127), also released in March
and of concern to the Subcommittee, evaluated the effectiveness of VAMC
management of prosthetic supply inventories.
VHA's prosthetic costs increased from $1 billion to $1.8 billion
annually between FY 2007 and FY 2011. The OIG estimated that from April
through October 2011, VA facilities were maintaining inventories of
nearly 93,000 specific prosthetic items with a total value of about $70
million. Among these stored items, almost 43,500 (47%) exceeded current
needs, while PSAS was in short supply for more than 10,000 items (11%).
For some prosthetics such as artificial limbs, VA facilities do not
maintain formal inventories since these appliances are designed for
individual veterans.
The OIG identified that facilities use two automated systems to
inventory prosthetic items and that these inventory systems are not
integrated with each other or other VA records systems, a situation
that some attribute as the root of this problem. However, beyond a
synchronization of electronic records, the OIG also cited a number of
specific examples of gross mismanagement of VA's prosthetic supplies in
inventory.
DAV was very disappointed to learn of the problems and failures
identified in this report. It is clear that the offices that have
responsibilities related to prosthetic inventory management should
collectively work together and take immediate action to correct these
issues. We understand, however, that PSAS has been waiting a number of
years for the development and implementation of an integrated
technology solution, which is yet to be funded by the Office of
Information Technology (IT). We urge VA to expedite development of an
IT solution to resolve this issue.
This OIG report recommended cyclical site visits to PSAS offices.
We concur that VA would benefit from site visits to assess VAMC
management of prosthetic inventories. The OIG estimated that if
prosthetic supply inventory management were improved, VA could reduce
prosthetic inventory value by approximately $35.5 million. These
resources cannot afford to be lost--particularly if they could be put
to better use through a software solution for inventory control, and
reinforced by occasional visits from outside entities.
VA Winter Sports Clinic - A Prosthetic and Athletic Success Story
DAV is a proponent of disabled veterans of all abilities and ages
taking part in active adaptive sports, a specialized form of recreation
therapy. Strong evidence validates such activities as both therapeutic
and empowering to those who lost function as a consequence of war. To
that end, DAV jointly sponsors the annual VA National Winter Sports
Clinic in the mountains in Colorado. Participation is open to
approximately 400 male and female veterans with spinal cord injuries,
amputations, visual impairments, certain neurological problems, and
other severe injuries. Veterans who are enrolled in VA or military
treatment facilities receive first priority to attend the events and
are guided by more than 180 ski instructors, including several members
of the U.S. Olympic Disabled Ski Team, along with hundreds of other
volunteers.
Adaptive sports have been shown to increase independence, improve
health, well-being, confidence and professional goal attainment all
while reducing a person's dependency on medications to address their
pain and other challenges. For many veterans who attend this special
event, everyday challenges of life seem much more surmountable after
conquering a snow-covered mountainside or participating in the many
other adaptive sports options available. Participating veterans focus
their energies on `` . . . the ability, not the disability.'' We firmly
support VA's longstanding policy to provide adaptive sports equipment
for use at the Winter Sports Clinic, and to do so through PSAS.
The Critical Prosthetics Mission of VA Research
For 85 years, VA has managed a broad and extensive intramural
portfolio in biomedical and health services research that is focused on
meeting the particular needs of sick and disabled veterans. According
to VA's Office of Research and Development (ORD) over the past decade,
the number of veterans accessing VA health care for prosthetics,
sensory aids or related services has increased more than 70 percent.
For these reasons, VA's research portfolio includes studies on
traditional prosthetics, for example replacing an amputated limb, to
more advanced neural prostheses that actually integrate into a person's
tissues. Since 2008, VA has been involved in a study to obtain needed
data to advance the development and refinement of the DEKA arm system
that enables a person with an upper extremity amputation to control an
artificial arm and fingers in a highly sophisticated fashion, even
exhibiting fine motor skills and full range of motion. Information
gained from this study will be used to develop training materials for
prosthetic specialists, physical and occupational therapists and
veteran amputees, and to lead the way to additional clinical trials.
Given the difficulty many veterans have expressed related to upper
extremity amputation, including residual chronic pain and loss of
functionality, and the relatively poor substitution of existing
prosthetic devices, the DEKA Arm could revolutionize prosthetics
science. We encourage VA to continue this collaboration with industry
in a remarkably important new development.
Women Veterans with Traumatic Amputations
DAV is pleased that the PSAS focuses particular attention to the
needs of women veterans. In 2008, the PSAS established the Prosthetics
Women's Workgroup (PWW), an interdisciplinary collaboration of subject
matter experts on Women's Health from across VA. The purpose of the PWW
is to enhance the care of women veterans by focusing on their unique
needs and how those needs can best be met by the range of devices
provided to include a focus on technology, research, training, repair
and replacement of prosthetic appliances. The PWW has established a
multi-part goal of eliminating barriers to prosthetic care experienced
by women veterans by:
Providing medically necessary prosthetic devices and
medical aids to women veterans in accordance with policies governing
PSAS programs;
Ensuring uniformity in the provision of prosthetic
appliances across VA;
Encouraging VA to seek legislative remedies if needed to
aid women veterans;
Exploring and improving contracting and procurement
actions that provide devices made specifically for women; and
Identifying emerging technologies applicable to women
amputees and proposing ideas for research and development focused on
women veterans' needs in prosthetics.
Members of VA's PWW are mostly veterans but also include an
interdisciplinary team of experts from VA, DAV, PSAS, and the Office of
Women's Health. We urge VA to continue this group's work to ensure VA
meets the unique prosthetic needs of women veterans.
CLOSING
The OIG noted in one of its reports that many veterans praised VA
for the comprehensive medical care they receive. Veterans were
especially appreciative of their ability to choose a prosthetics vendor
and the location in which to receive those services, for home
accommodation and automobile adaptive benefits, and for the dedicated
efforts of the OEF/OIF coordinator staffs in VA facilities.
In preparing for this hearing, DAV reached out to DAV members from
different eras of military service who are amputees and are using the
VA health care system for their primary and prosthetic health care
needs. We asked them to tell us about their experiences with VA
prosthetics services and if they were satisfied with that care or if VA
could make improvements to better meet their needs. Similar to the
OIG's report, we received a variety of comments both positive and
negative. Several commenters expressed concern that PSAS retain a
strong connection to clinical activities rather than be relegated to a
dry, standardized and inflexible acquisition function. While
contracting will always be a dominant aspect of prosthetic supply, the
determination of what type of prosthetic appliance needs to remain with
physical medicine and rehabilitation specialists aided by a prosthetic
representative, accompanied by the full, continuing involvement of the
disabled veterans being served. One of our commenters put it best:
``without it [the clinical presence], veterans would surely suffer
tremendously as they would only be invoice numbers and not patients.''
In conclusion Madame Chairman, DAV urges VA to achieve and maintain
a balance in prosthetics and sensory aids procurement versus simply
expanding in-house development of limb prostheses, and we ask this
Subcommittee to oversee that process. While VA could surely and
significantly expand its prosthetic manufacturing capabilities with the
OIG's cost-cutting views as motivation, the available supply of private
fabricators has spent decades developing their arts and crafts to a
highly refined state of excellence. As these innovative prosthetic
technologies seep into the public marketplace, we are confident VA will
adopt them. While we strongly support the research element as indicated
in this statement, VA should not in our judgment try to replicate all
or even most of those advances internally. Instead, VA should improve
its business relationships with the private fabrication enterprise and
work to improve internal controls, prosthetic training, certification
and inventory management as recommended by the OIG in these several
reports. In cases in which VA laboratories are already manufacturing
satisfactory limbs, however, we believe that process should continue--
but we do not see this moment as justifying a large expansion of in-
house VA manufacturing or fabricating, especially in high-technology
devices.
While we at DAV agree that prosthetics is an expensive area of VA
operations, Congress and the American public believe these expenditures
are well worth their cost, to partially repay the sacrifices veterans
made in military service, and as a major increment of holistic health
care to veterans in general. Also, the health of the general public
benefits from this progress within VA, since these VA-developed, tested
and perfected devices and the research that accompanies them make their
way into broader societal use in addressing rehabilitation from
traumatic injury. In that regard, we believe that Administrator Bradley
and Dr. Hawley would be proud to know that VA continues to carry
forward their legacy.
Madame Chairman, this concludes DAV's testimony. I would be pleased
to consider any questions from you or other Members related to my
statement, or to PSAS.
Prepared Statement of Capt. Jonathan Pruden, U.S. Army, Retired,
Wounded Warrior Project
Chairman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee:
Thank you for inviting Wounded Warrior Project to share its
perspective on issues facing our amputees.
My name is Jonathan Pruden and in 2003 while serving as an Army
Infantry Captain I became one of the first IED casualties of Operation
Iraqi Freedom and subsequently underwent 20 operations at 7 different
hospitals including amputation of my right leg. I was medically retired
from the Army and found a new mission working with my fellow wounded
warriors. In my role as an Alumni Manager for the Wounded Warrior
Project (WWP) I've had the honor of personally interacting with
thousands of warriors over the past six years, often working hand in
hand with VA and DoD to ensure our warriors and their families receive
the care they deserve.
Over the past decade DoD and VA have made significant strides in
prosthetic care, particularly in comparison to the Vietnam war era when
some 6000 veterans with amputations returned to a woefully unprepared
system. \1\ Today, improvements in protective gear, rapid medical
evacuation, and innovations in military trauma medicine help account
for a nearly 90 percent survival rate among those injured in Iraq and
Afghanistan, compared to a 75 percent survival rate among those injured
in Vietnam. \2\, \3\ While the survival rate has increased,
many warriors are returning home with injuries, including major limb
loss, which require extensive rehabilitation and present long term care
needs. As of March, 1,288 servicemembers experienced major limb loss as
a result of combat in OEF/OIF/OND; of that number, 359 lost more than
one limb. \4\ Just this past month, WRNNMC has seen the arrival of two
quadruple amputees. The long road to recovery and rehabilitation has
both physical and psychological dimensions and for those warriors who
have suffered an amputation, excellent prosthetic care is critical to
ensuring the opportunity for an active, fulfilling life.
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\1\ Sigford BJ, ``Paradigm Shift for VA Amputation Care,'' J
Rehabil Res Dev; 47(4): (2010) xv-xx.
\2\ Dougherty PJ, ``Wartime Amputations,'' Mil Med, 1993 158(12):
755-63.
\3\ Peake JB, ``Beyond the Purple Heart - Continuity of Care for
the Wounded in Iraq,'' N Engl J Med; 352(3): (2005) 219-22.
\4\ VA Office of Inspector General. ``Health Care Inspection:
Prosthetic Limb Care in VA Facilities'' Report No. 11-02138-116, 8
March 2012. Accessed at: http://www.va.gov/oig/pubs/VAOIG-11-02138-
116.pdf
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Short term Challenge:
Just as our warriors are adapting to wrenching, life-changing
injuries, the health care system whose mission is to care for and
rehabilitate them--the VA--is moving to institute changes that, in our
view, will set back prosthetic care rather than advance it.
It is disappointing that we have come to this point given the long,
proud history of steady leadership within VA's prosthetics program and
Congress' strong support for that program. Congress has long recognized
that VA's prosthetics program is critical to meeting the specialized
rehabilitative needs of disabled veterans. This Committee, in
particular, has played a key role in sustaining that vital mission. For
example, a proposed Veterans Health Administration (VHA) reorganization
in 1995 led this subcommittee, and ultimately Congress, to enact
legislation directing the Secretary ``to maintain [VA's] capacity to
provide for the specialized treatment and rehabilitative needs of
disabled veterans (including veterans with amputations) in a manner
that affords those veterans reasonable access to care and services for
those specialized needs. \5\ Congress further directed the Secretary to
carry out that requirement in consultation with the Advisory Committee
on Prosthetics and Special Disabilities. \6\ Congress certainly
recognized that prosthetics is not just another service, but a
fundamental component of VA health care.
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\5\ 38 U.S.C. sec. 1706(b)(1).
\6\ Ibid.
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While there are areas of VA prosthetics service that need
improvement, as we will discuss, WWP is deeply concerned about proposed
changes in VA prosthetics' procurement that could reverse decades of
progress, and substantively erode both the quality of care and quality
of life of our nation's most severely wounded. As discussed below,
planned changes to VA's prosthetic acquisition and procurement policies
may greatly impair clinician's ability to provide the most appropriate
prosthetics and at the same time create substantial delays in a system
that is already too slow for the amputee who is unable to walk while
waiting for a new ``leg''.
Under current practice, VA physicians and prosthetists are able to
see a veteran, make a determination regarding the most appropriate type
of prosthetic equipment for a veteran, and relay that information to a
Prosthetics Service purchasing officer to complete a purchase-order to
obtain the needed item. Those purchasing officers exclusively handle
prosthetics' purchases, and are specialists in ordering medical
equipment specified by health care providers. A major change that the
Veterans Health Administration intends to institute on July 30th, would
require that any prosthetic item whose cost exceeds $3000--to include
such essential items as limbs, wheelchairs and limb-repair components -
must be procured by a contracting officer. This is not simply a matter
of substituting a generalist for a specialist. Under the proposed
change, these contracting officers would use a labor-intensive system
(the Electronic Contract Management System (eCMS)) designed to achieve
cost savings. That system, designed for high-dollar bulk-procurement
purchases that benefit from using the Government's purchasing power,
requires over 300 individual steps to manually process a purchasing
order. While well-suited for buying widgets, the system was neither
designed for nor well-suited to procuring highly specific,
individualized medical equipment. Ill-suited to prosthetics, this new
process would also require increased coordination between clinicians
and off-site contracting officers who would be responsible for
purchasing everything from light bulbs to now highly specific
prosthetic legs.
This is not a small change. Moreover, it not only increases the
margin for error but also the potential for prolonged, delaying ``back-
and-forth,'' with the likelihood of clinicians having to justify why a
more expensive wheelchair is clinically necessary when a seemingly-
similar less- costly model exists. We see no prospect that this planned
change in prosthetics procurement holds any promise for improving
service to the warrior. Instead, it almost certainly threatens greater
delay in VA's ability to provide severely wounded warriors needed
prosthetic devices.
WWP is aware of concerns raised in a recent IG report that called
for separating the duties of Prosthetic Purchasing Agents (PPAs) to
ensure that each prosthetics' order is reviewed and that VA receives
the greatest possible discount on prosthetics. \7\ The IG recommended
strengthening controls for the review process and issuing improved
guidance to Certified Prosthetists. But VHA's response was vastly
disproportionate to the IG's modest recommendation. Rather than simply
concur with IG's recommendation, VHA cited its plan to remove
purchasing authority for items over $3,000 from PPAs altogether. WWP
believes VA's plan goes many steps too far. While we agree that VA must
be a smart buyer, its overriding responsibility is to the veteran and
to its service mission - and its plan appears to compromise both those
responsibilities.
---------------------------------------------------------------------------
\7\ VA Office of Inspector General. ``Veterans' Health
Administration: Audit of the Management and Acquisition of Prosthetic
Limbs.'' Report No. 11-02254-102, 8 March 2012. Accessed at: http://
www.va.gov/oig/pubs/VAOIG-11-02254-102.pdf
---------------------------------------------------------------------------
Instead, its planned change in processing procurements will, at a
minimum, inject greater delay - lengthening the time between when the
clinician and prosthetist see and evaluate a veteran for a new device
and when he actually receives it. Even more problematic, the change
heightens the risk that a fiscal judgment will override a clinical one
- that is, the risk that a contracting officer's judgment will override
the clinical judgment of clinicians and prosthetists who are attempting
to provide flexible, timely, and appropriate care for our veteran
amputees.
In conversations with several highly placed current and former VA
officials in this arena about the decision to use federal acquisition
agents, all expressed concerns about creating additional delays for
purchase orders and decreasing discretion to do the ``right thing'' for
our amputees. These potential additional delays are especially
troubling because VA outsources the vast majority of prosthetic
fabrication. VA currently contracts with over 600 independent labs,
accounting for about 97% of the limbs provided to veterans. \8\
Currently, most contract prosthetic labs will start fabrication on a
limb before a VA purchase order is received to ensure the veteran
receives the prosthetic as soon as possible. However, as a former VISN
Prosthetics Director warned, chronic ``delays in providing purchase
orders and subsequent payments will mean that many contracted
prosthetists will not make a limb if they do not have a purchase order
in hand.''
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\8\ Ibid.
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This plan may hold potential for modest savings, but at what cost?
When a warrior needs a new leg or wheelchair, they have to wait. Every
day they wait their lives are tangibly impaired. I personally know
warriors who stay home from our events, stay home from school and from
work, don't play ball with their kids, or live in chronic pain while
they wait for a new prosthesis. I have personal experience waiting for
prosthetics and know firsthand what it is like to live in pain while
waiting for a new limb and the frustration I felt when my daughter
asked my wife, ``Why can't daddy come on a walk with us?''
Wounded warriors need this Committee's help to ensure that they are
not forced to put their lives on hold any longer while federal
acquisition personnel process purchase orders. While we acknowledge
that prosthetic procurement in its current form is imperfect, VA's
prosthetics' procurement plan seems to take a meat cleaver to a
situation best addressed with a scalpel. Prosthetics are not light
bulbs or hammers. They are specialized medical equipment that should be
prescribed by a clinician and promptly delivered to the veteran.
Congress has long recognized the unique importance of prosthetics by
exempting them from burdensome federal purchasing requirements. \9\
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\9\ ``The Secretary may procure prosthetic appliances and necessary
services required in the fitting, supplying, and training and use of
prosthetic appliances by purchase, manufacture, contract, or in such
other manner as the Secretary may determine to be proper, without
regard to any provision of law.'' 38 USC sec. 8123. Given this specific
authority, there is no obvious rationale for changing current
prosthetics-service procurement practice.
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Given these concerns, we urge this Committee to direct VA to
suspend implementation of this major change in prosthetics procurement.
A change of this magnitude in a critical area of service-delivery to
wounded warriors - and particularly one that offers no promise of any
service-improvement--should not even be considered in the absence of a
detailed implementation plan. Minimally, such a plan should include
both (1) credible evidence that veterans would not encounter greater
resultant delay in receiving needed prosthetics and (2) meaningful
safeguards to protect clinical discretion. Should VHA wish to go
forward with this process, we urge the Committee to require it to
develop such a plan and to defer implementation until the Veterans
Affairs Committees have had sufficient time to review it thoroughly (we
would recommend a period of not less than 90 days).
Long term Challenges
While the proposed change in prosthetics procurement constitutes a
matter of immediate, acute concern, we see longer-term challenges as
well. War zone injuries that result in amputations are often complex
and can prove difficult for later prosthetic fitting because of length,
scarring, and additional related injuries such as burns. \10\ To its
credit, VA has instituted an amputation system of care and initiated
the development of amputee centers of excellence which can become
important components of needed change. But WWP's experience is that
much more progress is needed to realize the underlying vision. We are
pleased to hear that approval was recently given for the creation of a
VA Amputation System of Care registry/ repository. But we remain
concerned that VA prosthetics research - among VA's strengths in the
past and so important to serving wounded warriors tomorrow - has
lagged, even as the numbers of new veteran-amputees climb steadily. In
that regard, I had the honor of serving on a 27-member expert panel
that is to date the most comprehensive review of the status of
prosthetics-device issues facing wounded warriors, but that study is
now three years old and many of those recommendations have yet to be
implemented. VA must re-establish itself as a leader in prosthetic
research and commit to implementing the finds of such research so that
veterans can realize its benefits.
---------------------------------------------------------------------------
\10\ Ibid.
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Looking ahead, it is important to recognize that the Department of
Defense has far surpassed VA in providing state of the art
rehabilitation for this generation of combat injured amputee service
members and veterans. With OEF/OIF veterans being seen at VA medical
facilities across the country, any one particular medical center may
provide prosthetics care to only a few young veterans. The average age
of an OEF/OIF warrior at the time of injury leading to an amputation is
25. \11\ These veterans are young, computer-literate and inquisitive
about technology and the options available. Their active lifestyle
frequently requires specialized equipment with which VA staff at some
facilities - unable to keep uniform pace with technological advances -
often lacks familiarity. Today, some 39% of the OEF/OIF amputee
population returns to DoD to receive prosthetic care. While DoD is
currently able to shoulder that demand, WWP is concerned that as the
current conflicts draw down DoD facilities will ultimately scale back
their services and associated funding with the decline in combat
injuries. VA must be ready to meet this need; but it's not yet there.
There are pockets of excellence within VA's prosthetic system such as
the VISN 3 Manhattan prosthetic department, but that level of expertise
is not consistently available to veterans across the VA system.
---------------------------------------------------------------------------
\11\ VA Office of Inspector General. ``Health Care Inspection:
Prosthetic Limb Care in VA Facilities'' Report No. 11-02138-116, 8
March 2012. Accessed at: http://www.va.gov/oig/pubs/VAOIG-11-02138-
116.pdf
---------------------------------------------------------------------------
Wounded warriors advise WWP that the paradigm shift in amputee care
has yet to become evident at most VA medical centers. In fact, an
amputee being seen at a primary care clinic is seldom, if ever, asked
how the individual's prosthetic is working, and whether it is causing
pain. Prostheses should be prescribed on the basis of careful
evaluation, and joint patient-clinician decisionmaking that takes
account of best medical evidence and practice. \12\ But, as warriors
attest, VA clinicians themselves too often base decisions about
orthotic and prosthetic equipment on past practice and word of mouth,
rather than informed medical judgment, with the result that the choice
of equipment may or may not be appropriate. \13\ With wide variability
in providers' knowledge and expertise with new prosthetic technologies,
warriors report significant disparities from facility to facility in
the quality of care and the approval of specific durable medical
equipment. \14\ We are concerned, in that regard, that such disparities
may worsen over time, particularly if VA prosthetics service funding is
decentralized, as some have discussed.
---------------------------------------------------------------------------
\12\ Ibid.
\13\ Arrendondo, et al., ``Wounded Warriors' Perspectives; Helping
Others to Heal,'' J Rehabil Res Dev, 47(4): (2010) xxi-xxviii.
\14\ Ibid, xxvi.
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Centralized funding of prosthetics service has been vital to
ensuring that VA can meet wounded warriors' needs. While we are not
aware that any change in policy to decentralize prosthetics' funding is
imminent, we are not alone in holding deep concerns regarding such a
possibility. Candidly, the concern is closely related to a VHA
reorganization that occurred last year, which diminished the standing
of VA's Prosthetics and Sensory Aids Service relative to sister
services--and which, along with the planned change in prosthetics'
procurement raises red-flags of concern regarding the priority in which
VA currently holds prosthetics. Centralized funding is a means of
insuring that provision of prosthetic and orthotic equipment for
wounded warriors continues to be a national priority and that that
priority will not be compromised at the VISN level, such that there
develop 22 different levels of priority. Centralized funding of
prosthetics must be preserved.
As a bottom line, we have a real concern about the direction of
this program, which appears to have lost the kind of focused leadership
it once enjoyed, and has fallen victim to a bureaucratization that has
lost sight of its customer, the veteran.
Recommendations:
Let me re-emphasize the dangers inherent in VHA's proposed changes
in procuring prosthetics, and urge this Committee's intervention, as
discussed above. At the same time we are mindful that there are steps
VA can and should take to improve prosthetics care and service. In that
regard, WWP has long urged the need to improve system-wide coordination
and consistency, and - in the constructive spirit--offers the Committee
the following recommendations toward continued improvement of the
prosthetics program:
I Ensure through ongoing oversight that the vision of the Amputee
System of Care is realized;
I Press VA to establish a steering committee of experts composed
of academicians, clinicians, and researchers to oversee and provide
guidance to the Department on the direction and operation of its
prosthetics and orthotics program;
I Direct VA to develop guidance to assist clinicians in more
appropriately prescribing durable medical equipment (in particular,
expanding clinical practice recommendations through the use of
algorithms such as are commonly employed in other fields of medical
practice);
I Encourage VA to serve warriors more effectively through such
means as (1) creating an equipment-loan center or centers through which
warriors could borrow and test equipment before final issuance; (2)
providing veterans--in addition to any primary assistive device needed
for mobility or to perform ADL's--with functional spare equipment; and
(3) expanding efforts to develop informative materials for veterans and
caregivers on available devices; and
I Urge VA to assign additional VA prosthetics and sensory aids
staff at military amputee centers of excellence.
Continued congressional oversight to ensure both preservation of
the prosthetics' system strengths and progress in improving the quality
of VA's prosthetics and orthotics care (at least in part through VA
adoption of the above recommendations) would go a great distance toward
improving the lives of those who have lost limbs in our ongoing war,
and improving the care of veteran-amputees of all generations. After
more than eleven years of war and thousands of combat related
amputations, it is essential that VA re-establish itself as a leader in
prosthetic research and care and maintain that position as a commitment
to our severely wounded.
That concludes my testimony; I would be happy to answer any
questions you may have.
Prepared Statement of Alethea Predeoux
Chairwoman Buerkle, Ranking Member Michaud, and members of the
Subcommittee, thank you for allowing Paralyzed Veterans of America
(PVA) to testify today concerning prosthetic services of the Department
of Veterans Affairs (VA). Ensuring that our nation's injured veteran
population is able to receive state of the art prosthetic devices in a
timely manner is an extremely important issue for PVA. PVA has more
than 19,000 members who all utilize the services of PSAS on a regular
basis. Our National Service Officers work very closely with VA to
ensure timely delivery of quality prosthetic items needed by veterans.
In recent months, the VA Office of Inspector General (OIG) and the
OIG's Office of Audits and Evaluations have released numerous reports
on PSAS inventory management, the management of PSAS acquisition of
prosthetic limbs, and prosthetic limb care. PVA believes that these
internal audits and investigations have identified many areas in need
of improvement within PSAS, and PVA generally supports the spirit of
the recommendations provided by the OIG. The recommendations provide
not only an opportunity to improve upon the prosthetic services for
veterans with amputations, but for all veterans that utilize VA
prosthetic services.
The OIG's evaluations and assessments are taking place during a
critical turning point for PSAS. The Veterans Health Administration
(VHA) Office of Procurement and Logistics (P&LO) is currently
undergoing a structural reorganization. \1\ These changes include a
joint purchasing structure for prosthetic items that includes both PSAS
and P&LO making prosthetic purchases. Specifically, the division of
purchases will be based on the cost of items, the ``micro-purchase
threshold.'' \2\ Essentially, when an item costs a specific amount or
higher, it will be purchased by P&LO. While the VA reports that this
change will result in increased oversight and review of prosthetic
purchase orders, PVA is concerned that this dual purchasing track that
involves both PSAS and P&LO has the potential to create delays in the
delivery of items to veterans.
---------------------------------------------------------------------------
\1\ The Department of Veterans Affairs, Office of Inspector
General: Office of Audits and Evaluations; ``Veterans Health
Administration: Audit of the Management and Acquisition of Prosthetic
Limbs,'' March 8, 2012; 11-02254-102; http://www.va.gov/oig/pubs/VAOIG-
11-02254-102.pdf
\2\ Ibid, pg. 17
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PVA is further concerned that this new system will also lead to
less VA accountability for veterans during the ordering and delivery
processes. When an order for prosthetics is placed, at any point before
the item is delivered, veterans, or often times a National Service
Officer on behalf of a veteran, is able to contact a PSAS employee with
questions regarding the device or the status of delivery. With P&LO now
handling prosthetic purchases, it is unclear which office will serve as
a point of contact to provide veterans with timely assistance when
questions or concerns arise before the prosthetic item is delivered.
To ensure that the newly divided purchasing authority for
prosthetics does not lead to increased delays in delivery of items and
services, PVA recommends that PSAS leadership use a tracking system to
provide veterans, clinicians, and VSOs with timely updates, as well as
reasons for delays, when necessary. The VA has developed the eCMS
planning module to manage prosthetic orders. This system will serve as
a single point of entry for P&LO prosthetic purchases. PVA encourages
VA to notify veterans and their health care providers electronically
through the eCMS system to address issues that arise with prosthetic
orders such as delays in delivery. PVA also recommends the VA develop
guidelines that establish the length of time in which an order should
be completed.
PVA has reached out to PSAS leadership on several occasions to
identify the status of the reorganization and appreciates the
opportunity to provide our input. While we have been informed that the
dual purchasing system was piloted in three Veteran Integrated Service
Networks (VISNs) beginning in January 2012, and will be further
implemented in additional areas in July 2012, we are not aware of how
VA intends to make sure that veterans are aware of these changes.
Therefore, PVA encourages VA leadership to consult with veterans and
their families, as well as stakeholders who regularly work with PSAS to
provide input as they further develop the process for prosthetic
purchases through P&LO. Many veteran service organizations and veterans
have been working with PSAS for many years and could provide valuable
input that will help VA ensure that this change does not negatively
impact veterans. PVA would also encourage the VA to provide Congress
and veteran service organizations with updates and any findings that
are compiled as a result of the pilots that were implemented in January
2012, and future findings as the plans move forward.
As it relates to the impact of this procurement reform, dividing
the purchasing of prosthetics between PSAS and P&LO, PVA has concerns
regarding potential differences between the two departments' internal
policies, and how such differences may negatively impact the quality of
care and services provided to veterans. The P&LO office is governed by
policies of VA acquisition. Such policies are meant to address the
purchasing of various items for many different offices within the VA.
As such, PVA would like to make certain that the change to P&LO
managing the purchases of high cost prosthetics does not lead to the
standardization of prosthetics or increased limitations on ordering
devices. PVA strongly urges the VA to continue to abide by VA policy
that adheres to title 38, United States Code, Section 8123, which
states that:
The Secretary may procure the prosthetic appliances and necessary
services required in the fitting, supplying, and training and use of
prosthetic appliances by purchase, manufacture, contract, or in such
other manner as the Secretary may determine to be proper, with regard
to any other provision of law. \3\
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\3\ Title 38, United State Code, Section 8123; March 31, 2011.
---------------------------------------------------------------------------
This statute enables VA to meet the unique prosthetic needs of
veterans in a timely manner without the limitations of cost saving
measures such as standardization of items or contract bulk purchasing.
Veterans must have access to the prosthetics that best fit their
individual needs. For many years, PSAS has done a good job of ensuring
that the number one consideration when ordering prosthetics is
quality--the ability to meet the medical and personal needs of
veterans. The VA must make certain that the issuance and delivery of
prosthetics continues to be provided based on the unique needs of
veterans, and to help them maximize their quality of life. As VA
undergoes this procurement reform, and the reorganization of the
Veterans Health Administration, leadership must ensure that prosthetics
do not become subject to issuance restrictions based solely on cost or
internal pressures to control spending.
While PSAS has done a good job of providing veterans with the
prosthetics that they need, no health care system is perfect, and gaps
continue to exist in VA's delivery of prosthetics. As stated
previously, delays in delivery of prosthetics continue to exist. Often
these delays are due to inconsistent administration of prosthetic
policies between VISNs that ostensibly operate under the same guidance.
For instance, when a prescription for a prosthetic device is issued,
purchasing agents and administrators in one VISN often use an approval
process that may vastly differ from those used in the neighboring
VISNs. This becomes particularly problematic when a facility in one
VISN places an order for a veteran through its subsidiary facility, in
another VISN, and each uses different approval processes. When this
occurs, orders go back and forth between networks before they can be
authorized, placed, manufactured, and delivered to the veteran.
With established guidelines required for all staff handling
prosthetic orders, the back and forth during the approval process would
be eliminated. Ultimately, such inconsistencies in the administration
of PSAS policies lead to prolonged delivery of prosthetic items to
veterans. PSAS must require all VISNs to adopt consistent operational
standards in accordance with national prosthetics policies that provide
veterans with the best possible customer service.
Delays are also caused by an outdated filing system for veterans'
medical records. When veterans travel across the country or relocate,
should they need to seek services at a VA medical center for the first
time, they often have to wait for medical records to be emailed,
mailed, or even faxed. Urgent prosthetic care is delayed because there
is no system in place that allows veterans' records to be instantly
viewed by more than one medical center when necessary. This gap in care
must be addressed to make certain that veterans do not go without their
much needed prosthetic items.
Another example of administrative inconsistencies involves the
prosthetic purchasing agents and the clinicians that prescribe the
prosthetic. PVA has found that it is not uncommon for clinicians to
prescribe a prosthetic based on their medical expertise and the medical
needs of veterans, however, when the contracting officers receive the
order, the request for the device is modified or even denied due cost,
or the VA not having an established contract with the manufacturer of
the device. PVA understands that in the current fiscal environment the
VA must ensure that its employees are making smart and efficient
spending decisions. However, PVA believes that smart, efficient
decision making includes providing veterans with a quality prosthetic
device that meets their needs and provides them with quality of life
and independence.
Additionally, the quality of prosthetic devices is extremely
important to providing veterans with quality of life. When veterans are
issued prosthetics, it is VA policy to ensure that they have an
alternative device that is able to be used in the event that the
primary prosthetic is not available. The second prosthetic is commonly
referred to as the ``back-up'' device. While the VA issues back-up
devices to veterans with prosthetics, often the back-up prosthetic and
the primary prosthetic are not of equal quality. This poses significant
problems for veterans when their primary prosthetic is undergoing
repairs, or simply not available to them.
PSAS should work to provide veterans with quality prosthetic
devices as back-up options for veterans. Ordering quality prosthetics
for veterans has many benefits. While better quality items may not
always be the cheapest option, in the long-run it is cost efficient for
the VA. Providing veterans with quality prosthetics leads to longer
periods of use and less spending on replacement items, and also
prevents potential health hazards that may result from veterans using
equipment that is not durable or meant to meet their unique physical
needs.
There is a direct correlation between quality care and quality of
life. Prosthetics is one of the most important elements of providing
disabled veterans quality of life. VA prosthetics should give veterans
the opportunity to live with a disability without the concerns of
physical limitations that prevent them from being active, productive
individuals. Although PSAS could improve upon the management and
acquisition of prosthetic items such as limbs, for the past several
years PSAS has provided thousands of veterans with specialized, state
of the art, quality prosthetic devices. PVA believes that the only way
to continue this performance is to streamline the administrative
practices of the VA, and make certain that veterans are provided with
quality prosthetic devices that meet their needs in a timely manner.
Again, PVA thanks the Committee for their attention to this
important issue and encourages continued oversight of VA prosthetic
services. I am happy to answer any questions from the Committee.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$262,787.
Fiscal Year 2010
Court of Appeals for Veterans Claims, administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$287,992.
Prepared Statement of Linda Halliday
Madam Chairwoman, Ranking Member Michaud, and Members of the
Subcommittee, thank you for the opportunity to discuss the results of
recent Office of Inspector General (OIG) reports on prosthetic issues
dealing with the delivery of care, and contracting and supply issues
\1\. Based on the Committee's interest in VA's capabilities to deliver
state-of-the-art prosthetic limb care, we conducted one review of VA's
delivery of prosthetic limb care in its facilities and two audits
related to contracting and supply issues. The OIG is represented by Ms.
Linda A. Halliday, Assistant Inspector General for Audits and
Evaluations; Dr. John D. Daigh, Jr., Assistant Inspector General for
Healthcare Inspections; Dr. Robert Yang, Physician, Office of
Healthcare Inspections, OIG; Mr. Nicholas Dahl, Director of the OIG's
Bedford Office of Audits and Evaluations; and Mr. Kent Wrathall,
Director of the OIG's Atlanta Office of Audits and Evaluations. The
population analysis of veterans with prosthetic limbs was performed
under the direction of Limin Clegg, PhD.
---------------------------------------------------------------------------
\1\ Healthcare Inspection--Prosthetic Limb Care in VA Facilities,
March 8, 2012; Veterans Health Administration--Audit of the Management
and Acquisition of Prosthetic Limbs, March 8, 2012; Veterans Health
Administration--Audit of Prosthetics Supply Inventory Management, March
30, 2012.
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BACKGROUND
Prosthetics include limbs, sensory aids, durable medical equipment,
and orthotic appliances, parts or accessories required to replace,
support, or substitute an anatomical portion of the body. In addition
to artificial limbs, VA considers scooters, wheelchairs, telehealth
equipment, braces, watches, and implantable devices such as heart
valves and stents as prosthetics. From fiscal year (FY) 2007 through FY
2011, the Veterans Health Administration's (VHA) prosthetic costs
increased from $1.0 billion to $1.8 billion. VA maintains an inventory
for most prosthetics items. For some prosthetic items, such as
artificial limbs, VA Medical Centers (VAMC) do not maintain inventories
and instead order these items as needed for individual patients.
VA uses two automated inventory systems to manage prosthetic
inventories. Prosthetic and Sensory Aids Services (PSAS) uses the
Prosthetic Inventory Package (PIP) to manage the majority of prosthetic
inventories. Supply Processing and Distribution (SPD) Services uses the
Generic Inventory Package (GIP) to manage prosthetic supplies stored in
Surgery Service and medical supply inventories.
Three VA Central Office organizations have responsibilities related
to prosthetic inventory management. VHA's PSAS develops policies and
procedures for providing prosthetics to veterans. VHA's Procurement and
Logistics Office (P&LO) provides VAMCs logistics support and monitors
compliance with inventory management policies and procedures. VA's
Office of Acquisition, Logistics, and Construction supports VAMCs in
acquiring and managing supplies and offers training to VA's acquisition
professionals.
HEALTHCARE INSPECTION - PROSTHETIC LIMB CARE IN VA FACILITIES
While the majority of the amputations performed by VA are for older
patients with diabetes and poor circulation, we focused on those
veterans who had one or more major amputations as a result of injuries
sustained during Operation Enduring Freedom (OEF)/Operation Iraqi
Freedom (OIF)/Operation New Dawn (OND). This group of veterans is a
growing and considerably younger group that poses a different set of
challenges to VA with regards to prosthetic services.
In order to assess VA's capacity to deliver prosthetic care, we
reviewed VA credentialing requirements for prosthetists and orthotists;
the demand for health care services; and psychosocial adjustments and
activity limitations of OEF/OIF/OND veterans with amputations and their
satisfaction with VA prosthetics services. We found that VA prosthetics
staff were appropriately certified; that veterans with amputations are
a complex population who are significant users of VA health care
services including non-prosthetic services; and that veterans adjusted
to life with their artificial limbs as well as those in the civilian
population.
Demand for Health Care Services
Veterans with a major amputation differ significantly from their
peers. To identify how they differ, we examined the records of almost
500,000 veterans who separated from the military from July 1, 2005, to
September 30, 2006, for their experience transitioning to VA and using
VA health care and compensation benefits through September 30, 2011. We
compared frequency of diagnosis for veterans with traumatic major
amputations with their non-amputated counterparts in this veteran
population. In our analysis, we found that veterans with amputations
used significantly more health care services and that this difference
held true in every major disease category we examined, not just for
prosthetic-related services, traumatic brain injury, or post- traumatic
stress disorder (PTSD) issues. This group also had a higher frequency
of service-connected disability and higher service-connected disability
ratings. Veterans with amputations are more likely to receive medical
care at a VA facility than their counterparts.
Assessment of Veterans with a Major Amputation
With the assistance of the Department of Defense (DoD) Inspector
General, we acquired the DoD amputee list from TRICARE and Walter Reed
National Military Medical Center staff. This list contained 1,288
living service members who served in OEF/OIF/OND with major amputations
that occurred during active duty as of August 17, 2011. As of September
30, 2011, 838 (65 percent) of the 1,288 in the DoD OEF/OIF/OND amputee
population were discharged from active military service (veterans) and
were our population of interest.
Over 98 percent of this group of amputees were male. The average
(mean) age when the service member was injured was 25 years old.
Seventy-six percent of them served in the Army, and 20 percent in the
Marines. Ninety-three percent of all amputees were enlisted service
members. Seventeen percent had served in OEF while 84 percent served in
OIF/OND. Seventy-four percent lost one limb, 25 percent lost two limbs,
and 1 percent lost three or four limbs. Fifty-eight percent were
diagnosed with PTSD after their discharge from military service.
Thirty-five percent had a diagnosis of a mood disorder, and 15 percent
had a diagnosis of substance abuse.
Daily Living
To assess how well veterans were doing, we conducted in-person
visits to a statistically representative sample of the OIF/OEF/OND
veterans with at least one lower extremity amputation and as many
veterans with upper extremity amputations as we could. The responses of
many of the veterans were inspiring as many of them--80 percent of
those with upper extremity amputations and 90 percent of those with
lower extremity amputation--reported that their lives were full. Many
of the amputees also reported that they had adjusted to their
prosthetic limb and did not mind people asking them about it.
Most veterans were able to engage in their social relationships and
reported that visiting friends and maintaining friendships was not
limited at all. However, the majority also noted that they were more
dependent on others than they would like to be and that they were
limited in the kind of work that they could do. When asked about
activity limitations, most veterans reported limitations with vigorous
activities such as running, lifting heavy objects, and sports. Working
on hobbies was problematic for those with upper extremity amputations
while walking for a mile was difficult for those with lower extremity
amputations.
Among those veterans who were working, the ranges of limitation for
``going to work'' were similar between lower limb and upper limb only
amputees. Veterans also have adapted to living with pain. For veterans
with lower extremity amputations, many veterans expressed limitations
based on pain tolerance and complications, such as skin breakdown.
Satisfaction with the prosthetic was assessed by asking veterans to
report on the fit, appearance, and reliability of their prosthesis.
Over 90 percent of veterans with lower extremity prosthetics reported
satisfaction in all three areas as well as being satisfied overall.
Veterans with upper extremity amputations reported that their overall
satisfaction with their prosthetics was just below 70 percent. Upper
extremity prosthetic breakdown was reported by a greater proportion of
veterans and occurred more frequently.
While veterans with upper extremity amputations reported
limitations with individual activities, most veterans have adapted
their overall routine to minimize challenging activities as most report
no or mild difficulty with regular daily activities or normal social
activities. These veterans' loss of upper extremity function is similar
to the general public with unilateral upper extremity amputations.
Veteran Assessment of VA Prosthetic Care Delivery
We asked veterans open-ended questions about what the VA did well
and what they could improve on. While veterans praised their
experiences with VA, they also noted areas where the VA should improve
on the delivery of prosthetic services. Some of the veterans we
interviewed reported experiencing such poor service that they avoid
using VA care by using other health insurance, participating in
research studies, or discontinuing prosthetic use.
A common complaint by veterans using prosthetic limbs dealt with
the facility approval process for obtaining prosthetics through fee-
basis and contract care. Many felt that the VA process should be
simplified, streamlined, and require fewer visits to get approval for a
new prosthetic or major repair. Participants also expressed concerns
about the length of time and reliability of paperwork for processing
prosthetics requests, particularly between the VA and outside vendors.
Several veterans reported that they had to facilitate this paperwork to
obtain their prosthetics.
Veterans also reported difficulties with accessing prosthetic
services at VAMCs due to drive times, wait times, and unavailability of
prosthetic experts. Some veterans noted that their busy schedules made
any appointment a major inconvenience and were unsure whether the VA
was sensitive to this issue. Others reported that rescheduling a VA
appointment could be challenging as schedules could be full and the
appropriate clinic might be held infrequently.
Veterans also reported that VA personnel were unfamiliar with their
prosthetics or did not have access to or expertise with the latest
technologies. This was particularly reported by those with upper
extremity prosthetics. One veteran stated his frustration from having
to educate VA staff about his prosthetic and the overall needs of
veterans with amputations.
Recommendations
Our report contained three recommendations for the Under Secretary
for Health:
Consider the wide-ranging medical needs of traumatic
amputees beyond the prosthetic and mental health concerns identified in
this report; then adjust, if necessary, the provision and management of
health care services accordingly.
Consider that VHA evaluate the needs of veterans with
traumatic upper limb amputations to improve their satisfaction.
Consider veterans' concerns with the approval processes
for fee-basis and VA contract care for prosthetic services to meet the
needs of veterans with amputations.
The Under Secretary for Health agreed with our recommendations and
presented an action plan. We will follow-up as appropriate.
AUDIT OF THE MANAGEMENT AND ACQUISITION OF PROSTHETIC LIMBS
In this report, we evaluated VHA's management and acquisition
practices used to procure prosthetic limbs, and examined the costs paid
for prosthetic limbs. Overpayments for prosthetic limbs were a systemic
issue at all 21 Veterans Integrated Service Networks (VISNs). Overall,
we identified opportunities for VHA to: improve controls to avoid
overpaying for prosthetic limbs; improve contract negotiations to
obtain the best value for prosthetic limbs purchased from contract
vendors; and identify and assess the adequacy of in-house prosthetic
limb fabrication capabilities to be better positioned to make decisions
on the effectiveness of its labs.
Improved Internal Controls Needed
We reported VHA's PSAS needed to strengthen payment controls for
prosthetic limbs to minimize the risk of overpayments. We identified
overpayments in 23 percent of all the transactions paid in FY 2010. VHA
overpaid vendors about $2.2 million of the $49.3 million spent on
prosthetic limbs in FY 2010. VHA could continue to overpay for
prosthetic limbs by about $8.6 million over the next 4 years if it does
not take action to strengthen controls. On average, VHA overpaid about
$2,350 for each of these prosthetic limb payments. Overpayments
generally occurred because VHA paid vendor invoices that included
charges in excess of prices agreed to in the vendors' contracts with
VA. Strengthening controls to ensure invoices submitted by vendors are
consistent with contract terms should and can be accomplished without
compromising the quality of the prosthetic limbs provided to veterans.
At the four VISNs we visited (VISN 1, 8, 12, 15 \2\), we found that
Contracting Officer's Technical Representatives (COTRs) either did not
conduct reviews of prosthetic limb invoices or conducted only limited
reviews of invoices. Instead, Prosthetic Purchasing Agents were
reviewing vendor quotes, creating purchase orders, and reviewing
invoices prior to making final payments. This is contrary to the
Government Accountability Office's Standards for Internal Controls in
Federal Government that require key duties and responsibilities be
divided to reduce the risk of error or fraud.
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\2\ VISN 1--New England Healthcare System; VISN 8--VA Sunshine
Healthcare Network; VISN 12--VA Great Lakes Health Care System; VISN
15--VA Heartland Network.
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Actions Needed to Ensure the Best Value When Procuring Prosthetic Limbs
We found that VISN Contracting Officers were not always negotiating
to obtain better discount rates with vendors and some items were
purchased without specific pricing guidance from either the Procurement
and Logistics Office or PSAS. To illustrate, one VISN we reviewed had a
strategy to ensure that they received a discount on prosthetic related
contracts of at least 10 percent. Another VISN that was reviewed only
obtained an average discount of 8 percent; if they followed the other
VISN's lead in seeking a minimum of a 10 percent discount from vendors,
they could have saved about $58,000 in FY 2010. Without negotiating for
the best discount rates obtainable, VHA cannot be assured it receives
the best value for the funds it spends to procure prosthetic limbs. We
noted that while strengthening acquisition practices to ensure
contracting officers consistently negotiate better discount rates
should result in lower costs, it should in no way compromise the
quality of prosthetic limbs procured.
We also reported VA paid almost $800,000 for about 400 prosthetic
limb items using ``not otherwise classified'' (NOC) codes in FY 2010.
NOC codes are used by VA to classify items that have not yet been
classified or priced by Medicare. While this may not be a significant
amount in aggregate, the prices paid for individual items that have not
yet been classified can be significant. For example, absent pricing
guidance VA was paying about $13,700 for a type of Helix joint before
it was classified. Once the item was classified, the price dropped to
about $4,300. To avoid situations like this, we reported VHA needed to
develop guidance to help VISN staff determine reasonable prices for
items that Medicare has yet to classify and price.
Improved Prosthetic Limb Fabrication and Acquisition Practices Needed
We did not identify information that showed either how many limbs
specific VHA labs could fabricate or how many limbs they should be
fabricating. PSAS management did not know the current production
capabilities of their labs and could not ensure labs were operating
efficiently. VHA guidance states that PSAS should periodically conduct
an evaluation to ensure prosthetic labs are operating as effectively
and economically as possible. We found that PSAS suspended their review
of labs in January 2011 after reviewing only 9 of 21 VISNs. Because
reviews of all VISNs were not conducted, PSAS was unaware of its in-
house fabrication capabilities and management does not know if labs are
operating as effectively and efficiently as possible.
We also reported VISN prosthetic officials did not always identify
the appropriate number of contractors needed to provide prosthetic
limbs to veterans. VHA guidance recommends three to five vendors
receive contract awards depending on the geographic area and workload
volume. However, three of four VISN prosthetic managers interviewed
were under the assumption they were to award contracts to all vendors
who responded to their solicitation, provided those vendors met VA's
criteria to qualify as a contract vendor. The VHA guidance conflicted
with prosthetic limb contract guidance that states maximum flexibility
be given to individual medical centers to determine the number of
contracts required to meet their needs.
Due to the inconsistencies in guidance, differing procurement
practices existed among the four VISNs visited. Three of the four VISNs
did not identify an appropriate number of contract vendors and VISN
contracting officers made awards to nearly all vendors that submitted
proposals, many of which were located in the same general areas. As a
result, overlaps and gaps in service existed and VISN contracting staff
may have been performing unnecessary contract work. Additionally, VHA
could not be assured the decision to make contract awards was
effectively aligned with workload volume or with what individual
medical centers required to meet their needs in serving patients.
Use of VA's Electronic Contract Management System (eCMS) Needs to
Improve
Use of eCMS is mandatory for all procurement actions valued at
$25,000 or more. We found that contracting officers did not
consistently use eCMS to document contract awards to prosthetic limb
vendors. Nearly all of the eCMS contract files for awards made to
vendors at the four VISNs visited were missing key acquisition
documentation.
Missing documentation included evidence of required oversight
reviews and determinations of responsibility of the prospective
contractors through a check of the Excluded Parties List System.
Further, contract invoices were not included in eCMS. As a result, we
could not readily verify whether a COTR had reviewed vendor invoices
prior to certification to ensure they accurately reflected that goods
received were in accordance with contract requirements, including
prices charged.
Recommendations
We made eight recommendations to the Under Secretary of Health.
They include strengthening controls over the process for reviewing
vendor quotes, purchase orders, and verification of invoices and costs
charged by prosthetic limb vendors. In conjunction with this, we
recommended VHA take collection action to recover the $2.2 million
overpaid to vendors. We also made recommendations to ensure contracting
officers conduct price negotiations to obtain the best value for
prosthetic limb items. In addition, pricing standards need to be
established and an assessment of the capabilities of VHA's prosthetic
labs needs to be conducted. The Under Secretary for Health agreed with
our recommendations and presented an action plan. We will follow-up as
appropriate.
AUDIT OF VHA'S PROSTHETICS INVENTORY MANAGEMENT
This report provides a comprehensive perspective of the suitability
of VHA's prosthetic supply management policies. In assessing VAMC
prosthetic inventory management, VHA agreed that inventories maintained
above the 30-day level would be considered excessive unless there was
evidence VAMCs needed a higher inventory level to meet replenishment
and safety requirements. VHA also agreed prosthetic inventory levels of
7 days or less would create a risk of supply shortages.
We found VHA needs to strengthen VAMC management of prosthetic
supply inventories to avoid disruption to patients, to avoid spending
funds on excess supplies, and to minimize risks related to supply
shortages. Further, because of weak inventory management practices,
losses associated with diversion could go undetected. VHA needs to
improve the completeness of its inventory information and standardize
annual physical inventory requirements.
Inventory Systems Are Not Integrated
VAMC inventory managers need real-time information from VA's
Integrated Funds Distribution, Control Point Activity, Accounting and
Procurement System (IFCAP) and its Computerized Patient Record System
(CPRS) to keep PIP quantities accurate and manage prosthetic
inventories effectively. However, VHA's PIP does not integrate with
IFCAP and CPRS. As a result, when warehouse staff record received
supplies in IFCAP and when clinical staff record used supplies in CPRS,
PIP is not automatically updated. Consequently, staff must manually
record all supplies received and used in PIP. This work is labor-
intensive and reduces the time staff have to actively manage supply
inventories, and introduces errors into these systems.
Inefficiencies from Using Two Inventory Systems
VHA policies require VAMCs to use PIP to manage prosthetic supplies
and GIP to manage surgical device implants (SDIs). VAMCs use of two
inventory systems caused staff confusion about the responsibility for
managing SDI inventories and created inefficiencies in managing SDIs
stored in Surgery Service closets, crash carts, and operating rooms. As
a result, VAMCs did not use either PIP or GIP to manage about 7,000 (28
percent) of 25,000 SDIs. The estimated inventory value for these items
was almost $8 million. By replacing PIP and GIP with one automated
system, VHA can help VAMCs manage these inventories and avoid excess
prosthetic inventories and shortages.
Inadequate Staff Training
Inadequate training was a major cause of VAMCs accumulating excess
inventory and experiencing supply shortages. VHA's Inventory Management
Handbook requires staff to receive training from qualified instructors
on basic inventory management principles, practices, and techniques and
how to use PIP and GIP effectively. However, staff at the six VAMCs \3\
we visited had not received training from qualified instructors.
Because staff did not receive adequate training, they did not
consistently apply basic inventory management practices and techniques.
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\3\ VA Medical Centers in Decatur, Georgia; Indianapolis, Indiana;
Northampton, Massachusetts; Nashville and Murfreesboro, Tennessee;
Salem, Virginia; Clarksburg, West Virginia.
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VHA requires VAMCs to conduct annual wall-to-wall inventories of
quantities on hand with inventory accuracy rates of at least 90
percent. However, none of the six VAMCs we audited had the required
documentation of physical inventories. VAMCs' failure to consistently
conduct and document physical inventories was also a contributing cause
of reporting inaccurate quantities on hand. When VAMCs do not keep
quantities on hand current, the automated inventory systems cannot
accurately track item demand, which VAMCs must know in order to
establish reasonable stock levels.
Insufficient Oversight
Insufficient VHA Central Office and VISN oversight contributed to
VAMCs maintaining excess inventory and supply shortages. VHA's
Inventory Management Handbook states that GIP will be the source of
reported inventory data and lists seven performance metrics VAMCs must
report every month. However, because the Handbook does not specifically
require VAMCs to extract performance metric data from PIP, VAMCs did
not report the required performance metrics for prosthetic inventories.
In addition, VHA's Handbook does not sufficiently define the role
of VISN prosthetic representatives' (VPRs) inventory oversight
responsibilities. The VPRs, who had jurisdiction over the audited
VAMCs, stated they conducted VAMC site visits. However, the frequency
of the site visits varied from quarterly to annually and during the
site visits VPRs did not consistently perform a complete assessment of
prosthetic supply inventory management.
VHA Handbook Inadequacies
Although VHA's Inventory Management Handbook provided a reasonable
foundation for VAMC management of prosthetic supplies, the Handbook
needed more guidance to ensure VAMCs do not accumulate excess supplies
or experience supply shortages. We identified several Handbook
inadequacies VHA must improve to help ensure VAMCs maintain reasonable
inventory levels. For example, the Handbook did not have clear guidance
on establishing normal, reorder, and emergency stock levels or
timeliness standards for recording supplies received and used in PIP
and GIP. A comprehensive and clear Handbook is an essential VHA control
to ensure proper stewardship and accountability of VAMC prosthetic
inventories.
Recommendations
Our report included recommendations for VISN and VAMC directors to
eliminate excess prosthetic inventories and avoid prosthetic shortages,
develop a plan to implement a modern inventory system, and strengthen
management of prosthetic supply inventories. In addition, we
recommended VHA officials collaborate with the Executive Director,
Office of Acquisition, Logistics, and Construction, to develop a
training and certification program for prosthetic supply inventory
managers. The Under Secretary for Health agreed with our
recommendations and presented an action plan. We will follow-up as
appropriate.
CONCLUSION
Veterans with amputations are a complex group of patients with
specialized needs both medically and administratively. There are
opportunities to improve the prosthetic and medical care that VA
delivers to these individuals. While overall veterans with amputations
have had positive experience with VA, there is room for improvement in
the delivery of prosthetic services.
Administratively, until VHA strengthens management and acquisition
practices to procure and fabricate prosthetic limbs, VA will not have
assurances that its practices are as effective and economical as
possible. Furthermore, VHA must increase its inventory system
capabilities, provide staff training, implement sufficient oversight,
and establish adequate policies and procedures. By taking these
actions, VHA will reduce the risk of spending taxpayer dollars on
excess prosthetic supply inventories and disrupting patient care caused
by supply shortages.
Madam Chairman, thank you for the opportunity to discuss our work.
We would be pleased to answer any questions that you or other members
of the Subcommittee may have.
Prepared Statement of Lucille B. Beck, Ph.D.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee: thank you for the opportunity to speak about the
Department of Veterans Affairs' (VA) ability to deliver state-of-the-
art care to Veterans with amputations. I am accompanied today by Joseph
Webster, MD, Medical Director for VHA's Amputation System of Care;
Joseph Miller, Ph.D., National Program Director, Orthotic and
Prosthetic Services, and Norbert Doyle, MBA, VHA's Chief Procurement
and Logistics Officer.
VA continually strives to improve our programs and we appreciate
independent reviews that can validate our successes and offer
recommendations for improvement. On March 8, 2012, VA's Office of
Inspector General (OIG) published a report on Prosthetic Limb Care in
VA facilities. In this Report, OIG concluded that more than 99 percent
of Veterans with a traumatic amputation who were discharged from active
military duty had transitioned to VA care within 5 years of discharge.
OIG also found that Veterans reported receiving excellent care at VA
facilities, and that all required orthotic and prosthetic VA providers
were appropriately certified; however, Veterans did express concern
with the availability of care through fee basis or contract care. VHA
concurred with OIG's three recommendations: to consider the wide-
ranging medical needs of traumatic amputees and adjust, if necessary,
the delivery of appropriate health care services; to evaluate the needs
of Veterans with traumatic upper limb amputation and improve their
satisfaction; and to consider Veterans' concerns with VA approval
processes for fee basis and contract care for prosthetic services.
On the same day, OIG also published a report on the Management and
Acquisition of Prosthetic Limbs. In this Report, OIG found that
overpayment for prosthetic limbs was a systemic issue in each Veterans
Integrated Service Network (VISN), and that internal controls needed to
be strengthened to better control the process. VHA concurred with OIG's
recommendations in this report. OIG found that VA spent approximately
$54 million on artificial limbs in fiscal year (FY) 2010, including
total contracts to vendors valued at close to $49 million. VA
acknowledges it could have saved $2.2 million, and has adopted
practices to achieve greater savings.
Later that same month (March 30, 2012), OIG published a third
report, an Audit of Prosthetics Supply Inventory Management. In this
Report, OIG concluded that VA needs to strengthen management of
prosthetic supply inventories at its medical centers and make better
use of excess inventories. VHA concurred with OIG's recommendations in
this report, and has developed action plans to improve oversight and
management processes to better ensure VHA delivers the quality care
Veterans deserve while exercising responsible stewardship of
prosthetics supplies.
My testimony today will first cover the range of services available
to Veterans across our system of care, focusing specifically on demand
and utilization of health care services, quality of care, gaps in
service, and the ability for Veterans to access VA or contract care
that best meets their needs. I will then describe the impact of
procurement reform and suitability of acquisition and management
policies in support of our clinical care objectives.
Demand for Quality Amputation and Prosthetic Care
VA's Prosthetic and Sensory Aids Service is the largest and most
comprehensive provider of prosthetic devices and sensory aids in the
world. VA provides a full range of equipment and services, including
artificial limbs, durable medical equipment, hearing aids, eyeglasses,
ramps and vehicle modifications, and implantable devices, such as
replacement hips or biological tissues. All enrolled Veterans may
receive any prosthetic item prescribed by a VA clinician, without
regard to service-connection, when it is determined to promote,
preserve, or restore the health of the individual and is in accord with
generally accepted standards of medical practice.
VA's Prosthetic and Sensory Aids Service has a robust clinical
staff of orthotists and prosthetists at more than 75 locations, and
also partners with the private sector to provide custom fabrication and
fitting of state-of-the-art orthotic and prosthetic (O&P) devices.
Moreover, VA maintains local contracts with more than 600 accredited
O&P providers to help deliver care closer to home. Commercial partners
help fabricate and fit prosthetic limbs for Veterans across the
country. When utilizing the services of these community partners, VA
covers the full cost of the prescribed limb, as well as any repairs. In
FY 2011, VA spent more than $108 million to purchase devices or
services from more than 1,290 local business communities across the
country.
VA promotes the highest standards of professional expertise for its
workforce of more than 300 certified prosthetists, orthotists, and
fitters. Each VA lab that is eligible for accreditation is accredited
either by the American Board for Certification in Orthotics,
Prosthetics, and Pedorthics, Inc. (ABC), the Board of Certification/
Accreditation International (BOC), or both. This accreditation process
ensures quality care and services are provided by trained and educated
practitioners.
Since its creation in 2009, VA's Amputation System of Care (ASoC)
has expanded to deliver more accessible, high quality amputation care
and rehabilitation to Veterans across the country. The ASoC utilizes an
integrated system of VA physicians, therapists, and prosthetists
working together to provide the best devices and state-of-the-art care.
This System provides care through more than 375,000 clinical visits to
more than 30,000 Veterans with limb loss, including more than 1,000
Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn
(OEF/OIF/OND).
The ASoC consists of four levels of care. Seven (7) Regional
Amputation Centers provide comprehensive rehabilitation care through an
interdisciplinary team and serve as resources across the system through
the use of tele-rehabilitation technologies. These Centers provide the
highest level of specialized expertise in clinical care and technology
and provide rehabilitation and consultation to patients with the most
complex conditions. The seven locations include: Bronx, NY; Denver, CO;
Minneapolis, MN; Palo Alto, CA; Richmond, VA; Seattle, WA; and Tampa,
FL. Fifteen (15) Polytrauma Amputation Network Sites provide a full
range of clinical and ancillary services to Veterans closer to home.
One-hundred eleven (111) Amputation Rehabilitation Teams provide
specialized outpatient amputation care, and 22 Amputation Points of
Contact facilitate referrals and access to services. All sites in the
ASoC are fully operational.
To support the continued delivery of high quality care, VA has
developed a robust staff training program. We offer clinical education,
technical education, and business process and policy education, in
addition to specialty product training, to help our staff provide
better services to Veterans. Clinical education describes the nature of
the clinical environment and recommends ways to help maintain
productive and positive outcomes in the clinical setting. Technical
education trains providers in the nature of products, materials, and
supplies, explaining how a microprocessor in a knee may work or how to
harness advanced techniques for thermoforming plastics to improve the
fit and comfort of the prosthetic socket. Finally, business process and
policy education instructs providers how to help standardize processes
in the clinical and health care environment to ensure consistent,
quality care. Training is often available through facility-specific
courses, monthly video tele-conferences, manufacturer-offered courses,
educational seminars, curricula for independent study, and other
forums. Further, VA has one of the largest orthotics and prosthetics
residency programs in the Nation, with 18 paid residency positions at
11 locations across the country.
Research is another important element of VA's amputation care
program, with a number of research projects aimed at evaluating new
prosthetic devices and improving clinical care. VA's Office of Research
and Development spent more than $13 million in FY 2011 on prosthetics
and amputation health care research and is issuing Requests for
Applications for studies to investigate a variety of upper limb
amputation technologies and applications. VA also works with the
Department of Defense (DoD) to support joint research initiatives to
determine the efficacy and incorporation of new technological advances.
Recent examples of this collaboration include:
DEKA Arm, a robotic arm with fluid finger, wrist and
elbow movements that is currently being deployed for home trials with
29 research subjects to provide data on the usefulness of this device
in everyday life. This project began in April 2012.
i-Walk Foot, which became commercially available in 2011;
VA prosthetists have provided 57 units to date;
Genium/X-2 Knee, which became commercially available in
2010; VA and DoD have been involved in the research and development of
these products, which represent a significant advance in microprocessor
prosthetic knee technology. VA has promoted training in this new
technology, with more than 40 prosthetists, 25 physicians, and 35
physical therapists having completed training.
The partnership between VA and DoD extends further to provide a
combined, collaborative approach to amputation care by developing a
shared Amputation Rehabilitation Clinical Practice Guideline for care
following lower limb amputation. VA is supporting DoD by collaborating
on the establishment of the Extremity Trauma and Amputation Center of
Excellence (EACE). The mission of the EACE encompasses clinical care,
including outreach and clinical informatics, education, and research,
and is designed to be the lead organization for policy, direction, and
oversight in each of these areas. EACE is currently being implemented
and will obtain initial operating capacity by the end of FY 2012. VA
will provide four positions for the EACE, including the Deputy
Director, Deputy Clinical Program Director, and Deputy Research
Director.
Procurement Reform and Acquisition and Management Policies
Clinical care is an important part of our system to provide
prosthetic devices to Veterans. Procurement, acquisition, and
management policies reflect a complementary and essential piece of this
system as well. VA is reforming its procurement practices to extract
better prices and more competition in obtaining the devices and
supplies Veterans need where appropriate. Title 38, United States Code
(U.S.C.), section 8123, grants to VA broad authority to procure
prosthetic appliances and services in any manner ``the Secretary may
determine to be proper without regard to any other provision of law.''
When exercising this authority the Department may procure prosthetic
appliances and necessary services required in the fitting, supplying,
training, and use of prosthetic appliances by purchase, manufacture,
contract, or in other manners as appropriate. This flexibility was
granted to ensure that Veterans receive devices and supplies that are
suitable for them and that meet their clinical needs. Many of the
products VA purchases are either going to become a part of a Veteran or
will be a critical part of their daily lives, helping them walk, work,
and interact with their families. The Sec. 8123 authority permits VA to
limit competition when physicians require specific devices or equipment
to support patient care. Also, Federal Acquisition Regulation (FAR) and
VA Acquisition Regulation (VAAR) authorize limiting competition under
these circumstances. If the Secretary elects to use Sec. 8123 in this
manner, all applicable FAR and VAAR requirements must still be
followed.
When products are generally available and interchangeable,
competitive procurements may be more appropriate. VA must comply with
all applicable FAR and VAAR requirements in such procurements.
VHA is working to place appropriate limits on the use of the title
38 authority so that it secures fair and reasonable prices for products
while still delivering state-of-the-art care, and so we can improve
opportunities for Veteran-owned and small businesses. VHA is pursuing
three strategies to extract cost savings while preserving high quality,
patient-centered health care and appropriate clinical determinations.
First, we are transferring purchasing authority from prosthetics
purchasing agents to contracting specialists for any purchase above
$3,000 (the micro-purchase threshold). VHA has notified the field that
certified contracting specialists will be required to contract for
these items. For items less than $3,000, micro-purchase requirements
continue to apply. We conducted a pilot program to evaluate the impact
of this change from January until March in Veterans Integrated Service
Networks (VISN) 6, 11, and 20, and beginning this month, we are
transitioning to national implementation. Second, VHA is pursuing a
phased approach to standardize and define commodities for its products
where appropriate. When we can purchase products, devices, or supplies
that are generally available and interchangeable, we will comply with
the FAR to ensure we are obtaining the best price possible. In the long
term, VHA will develop a catalog of such items to facilitate better,
more cost effective purchasing decisions. Again, we must balance this
goal while still preserving clinical quality and patient care. Finally,
VHA is updating policies and directives to better guide clinical and
procurement staff on the proper use of Sec. 8123. These updates will
allow us to more accurately and timely provide services to the benefit
of Veterans.
VHA is also increasing its audits of purchases to identify best
practices and conduct better oversight. As we gather more data on how
these changes are working, we can continue to refine and enhance our
programs. We are using new templates, checklists, and justifications to
streamline and simplify our processes and improve communication between
staff and leadership so we have a comprehensive view of our procurement
activities. VHA will ensure proper controls are in place to review
vendor quotes, purchase orders, and verify invoices and costs by
developing a comprehensive database of all existing contracts. We will
correct non-compliant contracts as required and evaluate contractor
performance as required by the FAR, and institute collection activities
when warranted for VA overpayments. To improve the guidance provided to
certified prosthetists, we are developing contract templates, clearer
guidance, and notices that will be disseminated later this summer to
our VISN and facility contracting offices. VHA's Service Area
Organizations, which provide support, oversight, and guidance to our
facilities, will review the award of every new prosthetic limb base
contract to ensure price negotiations took place, and will review a
random sample of delivery orders between May and September 2012, to
ensure the base contracts include the correct prices. We will determine
if base prices can be established following a system-wide review of
non-Medicare classified limb items by the end of the fiscal year. In
some circumstances, VHA may be better suited to fabricate items in-
house. To better identify when we should pursue this approach, we will
be contracting for an external review to assess how expanded use of in-
house functions would impact patient satisfaction, capabilities,
staffing, and Veterans' needs.
Once VHA has procured devices and supplies, management of our
inventories and resources is also essential. In the recently published
OIG report auditing VHA's prosthetics and supply inventory management
practices, the OIG concluded VHA had made overpayments because of
inefficiencies in our system and inadequate training and guidance. We
appreciate OIG's efforts and recommendations, and in response, we are
better defining our policies and guidance to the field, improving our
information technology (IT) systems to better track supplies,
strengthening our training programs, and increasing oversight and audit
functions. We have directed our facilities to reconcile physical
inventories and take action to eliminate excess inventories without
creating supply shortages. We are revising our standards for facilities
to require at least one prosthetic supply inventory manager to become a
certified VA Supply Chain Manager. A new, comprehensive IT system will
be in place in 2015 to replace our existing inventory systems, but in
the interim, we have issued a patch that will enhance the ability of
the prosthetics package to interface with inventory management
software, facilitating better information sharing. Through these steps,
we will better utilize existing and available resources as we deliver
prosthetic and amputation services and products to Veterans.
Conclusion
VA supports high quality amputation and prosthetics care by
supporting ground-breaking research into new technologies, training a
highly qualified cadre of staff, and pursuing accreditation of all
eligible prosthetic laboratories in VA's Amputation System of Care. We
are improving our oversight and management of prosthetic purchasing and
inventory management to better utilize the resources we have been
appropriated by Congress as we serve America's Veterans. High quality
patient care is our top priority, but we understand we must pursue this
objective in balance with other aims. These aims include: supporting
Veteran-owned and service-disabled Veteran-owned small businesses,
ensuring responsible fiscal stewardship of the funding provided to VA
by Congress, and complying with all applicable laws and regulations in
this regard. We appreciate the opportunity to appear before you today
to discuss this important program. My colleagues and I are prepared to
answer your questions.
Statement For The Record
Christina M. Roof
[GRAPHIC] [TIFF OMITTED] T4587.001
`Chairwoman Buerkle, Ranking Member Michaud and distinguished
members of the subcommittee, I would like to extend my gratitude for
being given the opportunity to share with you my views and
recommendations at today's hearing regarding the Department of Veterans
Affairs Prosthetic and Sensory Aid Services, and how we can all work
together in Optimizing Care for Veterans with Prosthetics.
To fully understand the magnitude of what we are about to discuss,
we must start by examining the statistics of our returning
servicemembers, as well as forecasting what their needs will be. As the
face of warfare has so drastically changed during recent conflicts, so
have the injuries servicemembers are sustaining and thankfully
surviving. Injuries that would have been fatal 20 years ago are now
being treated and survived through advances in military field medicine.
In the decade since the Sept. 11, 2001 terrorist attacks, 2,333,972
American military personnel have been deployed to Iraq, Afghanistan or
both, as of Aug. 30, 2011 according to the Department of Defense (DOD).
Of that total, 1,353, 627 have since left the military and 711,986 have
used VA health care between fiscal year 2002 and the third-quarter
fiscal year 2011.
Currently, 58.2 percent of those still currently in uniform have
served a deployment or multiple deployments since 9/11. These are the
same men and women that will turn to VA after their service. These men
and women, approximately 800,000 servicemembers, will transition back
into civilian life over the next several years. It is of the utmost
importance that VA be prepared and equipped with only the finest
personnel, prosthetics and technology to care for these men and women.
As a nation, we must be able to ensure that when our wounded warriors
return from the battlefield, they will have access to the highest
quality of care possible.
As previously stated, recent conflicts have given way to a surge in
the survival of physical injuries such as, but not limited to,
amputations, hearing and sight loss, spinal cord injuries and brain
injuries; all conditions which will be treated by or provided resources
from the Veterans Health Administration (VHA), more specifically
Prosthetic and Sensory Aid Services (PSAS).
When someone thinks of prosthetics, they usually think of a
prosthetic arm or leg. Which is correct, however prosthetics
encompasses so much more. I believe the simplest way to describe the
care and services PSAS provides, is to say if something is in a veteran
(surgical), on the veteran, or for a veteran, it falls under the
responsibilities of the PSAS department. For example, items such as:
prosthetic limbs, surgically implanted devices, such as heart valves,
specialized footwear for diabetics, walking canes, eye glasses, wigs,
wheelchairs, hearing aids, Service and Guide Dogs and thousands of
other items or services needed to ensure only the highest quality of
care to our veteran community will be provided through PSAS.
Astoundingly, the number of veterans requiring the services and
care of PSAS has risen from 25 percent to nearly 50 percent over the
past five years. When compared to the total growth in the number of
veterans seeking care from every other VHA department, which is about
13 percent, PSAS has grown by more than 78 percent during the time same
period. PSAS also saw a huge growth of approximately 1,800 percent in
the number of Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) women veterans under their care from 2005-2009. This number
is projected to steadily rise with our continued involvement in
Afghanistan until 2024 and our presence in Iraq or Operation New Dawn
(OND).
It is a known fact that VA has long been a leader in the
development of new prosthetics and groundbreaking research. Over the
past several years, VA's prosthetic development has revolutionized the
way in which prosthetics work around the world. However, with these new
prosthetics and medical advances also come new challenges for VA and
PSAS, including ensuring that prosthetists, both inside the VA and
those with whom the Department contracts, have the skills and proper
training to service these new devices. If we are to optimize prosthetic
care, we must ensure the credentialing, training and abilities of the
PSAS personnel tasked with treating veterans.
That being said, I believe an issue hindering PSAS and veterans
equal access to care, is what I believe to be a broken qualification
standards and credentialing for prosthetic orthotic professionals. This
lapse in uniformed standards across the nation are hurting veterans'
access to quality and timely PSAS care and services. Currently, VHA has
established requirements for VA prosthetists and orthotists, and the
position requirements vary by General Schedule (GS) grade level.
Certification is required at the GS-12 grade level or above. However,
many times these prerequisites for credentialing are not properly
enforced. While OIG was able to verify that all required prosthetists
and orthotists staff in Regional Amputation Center (RACs) and
Polytrauma Amputation Network Sites (PANS) were certified according to
VA policy in their March 2012 report, I have serious concerns as to
whether or not all other PSAS departments around the country are
adhering to the same requirements for their prosthetists and orthotists
staff.
Furthermore, in regards to women veteran's care there is also a
distinct lack of certified mastectomy fitters in the VA. There is
actually a shortage of fitters and technicians throughout the system.
These broken qualification standards are the reason for this. They do
not allow medical centers to properly recruit and retain qualified
individuals into these roles. The government needs to maximize an
individual's function. Having a certified prosthetist orthotist fitting
shoes is not an efficient use of that clinical practitioner's time. VA
should have the ability to hire GS 5/6/7 fitters and technicians to
accomplish this work and free up certified prosthetists and orthotists
to do more direct patient care to maximize a Veteran's function and
independence.
I urge PSAS to immediately develop and implement uniformed
qualification standards that shall encompass all areas of orthopedic
and prosthetic care, beyond the GS level. I would further recommend
regular continuing education and credentialing verifications to
accurately verify that the prosthetists and orthotists treating our
severely disabled veterans are providing cutting edge, quality care to
every single veteran they care for.
Amputations are another injury PSAS serves as the primary care and
rehabilitation providers. According to the Defense Manpower Data
Center, the numbers below illustrate the number of amputations
sustained during service, as of November 2011.
There are 1,286 service members who are now amputees as a
result of the Iraq and Afghanistan wars.
In 2011, 240 deployed troops had to have at least an arm
or a leg amputated, compared with 205 in 2007, the height of the surge
in Iraq, according to data published by the Armed Forces Health
Surveillance Center.
The increase in 2011 coincides with the surge of troops
in Afghanistan, who often dismount on foot patrols in the country's
austere and rugged terrain.
Troops wounded in Iraq and Afghanistan also have suffered the loss
of multiple limbs--of the 187 service members with major limb loss in
2010, 72 of them lost more than one limb, according to the report from
the Army's Dismounted Complex Blast Injury Task Force.
While the number of veterans having sustained a battlefield
amputation has steadily risen, it is also very important to remember
that PSAS not only cares for those veterans having sustained
battlefield amputations. They also perform and care for thousands of
veterans every year who undergo amputations related to other medical
issues while already under VA care. This can be due to a number of
medical issues, such as diabetes or infection.
For example, in FY 2011, 6,026 veterans underwent an amputation,
with 2,248 having major amputations. Of the 6,026 veterans, 107 (1.8
percent) were female and 24 of the 107 women were veterans of OEF/OIF/
OND. The chart below provided by VA OIG in March 2012 shows the
distribution of amputations performed at all VA facilities in FY 2011.
[GRAPHIC] [TIFF OMITTED] T4587.002
Regardless of the cause, PSAS is tasked with providing and caring
for all amputees and that is why they must get it right for every
veteran amputee they care for.
This is another issue in which I believe PSAS could be more
effective and improve their care models, specifically speaking to
female amputees. The number of women veterans utilizing PSAS has
continued to rise over the past five years. From FY07 to FY11, the
number of items provided to female veterans rose 191% from 638,000 to
nearly 1.9 million. With that in mind, VHA decided to update VHA
Handbook 1330.01 in 2010 to reflect this change. VHA Handbook 1330.01
as amended states:
``Women Veterans Program Manager (WVPMs) need to work closely with
the Prosthetics Service and Supply, Purchase and Distribution
Department to ensure that supplies specific to women's health are
properly stocked, easily requested, and provided in a timely manner
(e.g., intra-uterine devices (IUDs), breast pumps, compression
stockings, etc.).''
While I absolutely agree with this part of the amended handbook, I
also believe that this handbook and several other internal publications
still fall short when outlining the policies and procedures that guide
the care of VA's female amputee population. I strongly recommend that
PSAS immediately adapt several policies, as well as the limb
prosthetics they purchase to better fit and meet the needs of women
veterans undergoing care for amputations.
While I can give my recommendations to this committee, I felt that
it would be more appropriate for an actual female double amputee to
share her concerns with you regarding this issue. A very close friend
of mine, Sue Downes, lost both of her legs in Afghanistan when multiple
Improvised Explosive Devices (IEDs) hit her convoy in the winter of
2008. Sue was the only survivor in her Humvee that day. Sue is the
first woman double amputee from the war in Afghanistan. She is
resilient to say the least and has a sense of dedication to country and
her fellow soldiers like I have never seen before. Sue survived her
grueling eight hour ordeal in Afghanistan and was transferred to
Germany to be stabilized and then to Walter Reed Medical Center where
she and her family would spend the next 20 months. Army doctors told
Sue, that she most likely would be confined to a wheel chair for the
rest of her life. However, Sue was a wife and is a mother of two young
children, thus she told the doctors, that was simply not an option and
she would walk. Given the fact that Sue was the first female soldier
double amputee the hospital and staff struggled to find prosthetics
legs that would correctly fit and support her female frame. Up until
this time, the Department of Defense (DOD), and most VA facilities, had
become accustomed to treating, individualizing and fitting male
amputees and thus only had the equipment and experience fitting our
male wounded warrior amputees. This was a milestone for both DOD and
VA. They now needed to be changed to meet the needs of America's new
returning wounded warrior amputees--women.
While, VA PSAS does provide the world's leading limb and
prosthetics care and equipment, many women amputees I have spoken with
strongly believe that their facilities in their VAMC's PSAS
departments, more specifically limb care and fitting, are still
designed to primarily meet the needs of their male counter parts.
Sue told me that when she was first being treated at Walter Reed
Army Hospital they made a statement to her, that it was very difficult
to work with her injuries since her body was so different from a male
when it came to prosthetics. Sue stated, ``Our bodies are totally
different than our male counterparts. So even though working with me
was a challenge, we got through and actually helped the physicians
start to master treating female double amputees.''
``I feel like that since I left Walter Reed I have had to fend for
myself within the VA system. I live in a rural area of Tennessee and
have to drive two hours each way for my prosthetics visits. Thus far,
VA has yet to meet my needs in fitting my two prosthetic legs properly.
While I have encountered several caring individuals from VACO PSAS
since Christina Roof has become involved in my case, I still feel like
I am not given the same care or respect as my male counterparts. I feel
as though I am often yelled at because of certain female issues beyond
my control. For example, I cannot help if I fluctuate in weight and
that I retain water certain times of the month, causing my sockets not
to fit properly. I feel like I always have to ``beg'' for new fittings
because I'm constantly changing in volume and water weight in my
legs.''
Sue continued, ``I can't shave what legs I have left either. It is
embarrassing and prevents me from wearing anything other than long
pants. I am not going to walk around with hairy legs. As a female
double amputee life is hard enough, the fact that I just want to feel
like a normal woman should not be too much to ask. So, if VA PSAS does
not want women amputees to shave their legs then maybe they could
provide us laser hair removal treatments. I am not asking for special
treatment, I am just asking to feel as normal as possible. As far as
the types of prosthetics go, yes I would like to look like I have
normal flesh colored legs, instead of two metal rods. Again, I just
want to look as normal as possible, so my kids do not have to answer
questions to schoolmates about why their mom has metal legs. I love my
country and would do it all again, but I, we, have sacrificed for our
country and would at least like somewhat of a normal life back. Is that
too much to ask? Yes, to women looks matter. My image and outer
appearance means a lot to me as a strong woman. While I have recently
received a pair of much better legs, I really just want a single pair
of cosmetic legs. However, every time I ask my VA PSAS department they
tell me that it will cost too much and to just ``make due'' with what
they have already given me.''
Sue is not alone in feeling as if not all of her needs as a woman
amputee are being met. I have spoken with several women who are
encountering the same types of issues. I cannot say whether these
problems are due to a lack of education at the individual VAMC level,
problems in credentialing or purchasing, or purely a funding problem.
Whatever the cause may be, I sincerely ask this committee to
immediately examine and take actions on what can be done to meet the
needs of our women amputee wounded warriors.
A problem I also believe to be hindering the optimization of every
veteran under PSAS for an amputation is the lack of ``Complete Patient
Centered Care''. What I mean by this is, that I believe veterans
receiving care for amputations are not treated as a ``whole'' person
needing assistance in multiple areas, but rather are treated in a more
reactionary way by individual departments who might not always share
information with each other. While I am aware of and applaud VA's
initiative called ``Patient Aligned Care Teams'' (PACT), however VA has
been very slow to implement this initiative even in their pilot sites,
and I also believe that this is a model of care that must be integrated
into the care of all veterans, not just amputees. That being said, I
will keep my comments focused on amputees today.
Amputees are a special population of veterans and usually have more
medical complex medical needs than other non-amputee veterans have.
This being said, the current broken system of often-reactionary care
has caused many problems and unnecessary stress for the veterans
already having to deal with the loss of a limb. While I understand that
several VAMCs are utilizing this team approach to a veterans care, I
strongly believe that all severely disabled veterans need to have the
option of receiving this team approach, regardless of location. If we
are truly to optimize a veterans quality of health care, we need to
ensure that veterans in all parts of the country have access to the
same care approaches, such as the team approach.
Veterans having sustained a single or multiple amputations will
need far more than simply ``limb'' care. This group of veterans will
have very complex medical needs that need to be addressed and treated
in conjunction with all other medical care they are receiving. For
example, an amputee will have most likely suffered a Polytraumatic
Injury and will need much more assistance and guidance than other
veterans will. This will range from medical care coordination between
an army of doctors, social workers and care providers. This may
include, but is in no way limited to, people such as a Neurologist for
the treatment for Traumatic Brain Injuries (TBI), Plastic Surgeons to
repair physical wounds and skin grafts for burns or limb re-
construction, Psychiatrists and Psychologists for mental health care,
Social and Case Workers to inform the veteran about their eligibility
for benefits such as clothing allowances, home adaptations and so much
more. This is why I believe it to be critical that VA PSAS, and VA as a
whole, start treating the entire veteran in a proactive manner, instead
of treating the veteran by individual symptoms and needs that may
arise. Each veteran receiving care for an amputation should be assigned
a dedicated ``Care Team'' that meets on regular basis to discuss the
veterans care and treatments by each of the individual physicians and
care providers assigned to the veterans ``Care Team.'' This is a very
simple and cost free way of ensuring every veteran undergoing care for
their amputations and related medical issues will receive the highest
quality of coordinated care VA has to provide.
This ``Care Team'' should be composed of the veterans PSAS
representative, social worker and every physician who regularly treats
the veteran. This will help ease the stress the veterans experience
trying to remember to tell their different doctors about something they
learned from another doctor, will greatly improve the quality and
safety of the care the veteran receives and will provide the highest
quality of coordinated care VA has to offer.
Another issue we must revisit, is the issue of timely access to
quality prosthetics care and services. I strongly believe that access
to PSAS care, services should be a top priority for VA, and that
overall PSAS has done an outstanding job developing several new methods
to meet the needs of today's veteran population, I also believe that
there are several factors actually hindering a veteran's access to
timely and quality PSAS care and internal hurdles PSAS staff must
overcome every day in order to meet the most basic of today's veteran's
needs. In order to optimize the PSAS system of care and internal issues
there must be several changes addressed immediately.
An issue hindering a veteran's timely access to PSAS care and
services is the fact that VHA has not established, nor does it maintain
any system of national patient records or the physician's original
corresponding request to PSAS. I believe this not only negatively
affects the veteran, but also poses a threat to the integrity of VA's
purchasing policies and procedures.
The lack of a centralized tracking and data exchange system
available to physicians and purchasing agents simply hinders a
veteran's timely access to care. Moreover, due to fragmented patient
records, veterans may not receive the care they need should they have
to visit any VA Medical Center (VAMC) or Community-based Outpatient
Clinic (CBOC) other than their home VAMC or CBOC. For example, if a
veteran utilizing a wheel chair is on vacation or on travel for their
job, and the wheel chair requires immediate assistance or service from
PSAS, the veteran will most likely encounter bureaucratic obstacles at
the nearest PSAS department as result of the missing PSAS data exchange
system. This same fragmentation puts veterans at a high risk in the
event of an emergency. Whether it is another Hurricane Katrina, or even
a snowstorm in Buffalo, VHA's lack of a national record and request
system means that a veteran's order cannot be processed if those local
employees that are unable to get to work. Moreover, if veterans are
displaced, there will be a substantial delay in replacing essential
equipment. This is a simple IT solution that VHA has no ability to
execute due to the centralization of VA's IT.
A recent OIG report found that Prosthetics was lacking some basic
inventory controls, but this too indicated a lack of appropriate IT
resources to have a modern inventory system to track and monitor stock
and reorder levels. This extends out to surgical implants where there
is a high risk of expiration- costing VA millions of dollars and
possibly veteran lives.
VA's issue, negatively affecting PSAS, associated with not having a
comprehensive modern inventory solution goes back to the calamity of
the Core Financial and Logistic System (Core FLS) programs, and more
recently the abandoning of Financial and Logistic Integrated Technology
Enterprise (FLITE) and Strategic Acquisition Management (SAM) programs.
Although VHA is trying to salvage some aspects of these programs, any
real implementation is several years away. I urge VA to act swiftly on
developing a data exchange system for the use of PSAS personnel to
avoid a potentially large backlog where veterans would be unable to
obtain the immediate resources and care provided to them by VHA PSAS.
Currently, VA has no way of tracking vital information on patients'
care and purchasing orders, thus opening themselves up to potential
fraud and abuse, and the inability to provide the highest quality care
to the veterans they serve. The inability to provide all veterans equal
access to care through centralized purchasing units--instead of the
current fragmented paper copy system--also prevents PSAS from
maximizing efficiencies.
Over the past couple years, VA has been moving to professionalize
the acquisition workforce and adhere to archaic federal acquisition
laws and regulations, none of which were written with an individual's
health care needs in mind. It is my understanding that VHA has
concluded a pilot to move procurements from the Prosthetic and Sensory
Aids Service to VHA Procurement for those items over the micro purchase
threshold.
I implore the committee to make it clear to VA that not only do
they have the authority to procure outside of Federal Acquisition
Regulations (FAR)- 38 USC 8123- they have a duty to do so to ensure
that our veterans are provided the most appropriate devices in the most
expeditious manner possible. We have slowly begun to hear rumors of
delays where veterans, even those most at risk such as amputees, spinal
cord injuries, and those with ALS (Amyotrophic Lateral Sclerosis) are
having their life critical devices held up in a bureaucratic nightmare.
Congress and VA must recognize a clinician's autonomy and ability to
prescribe what is best for that individual veteran.
While VA's Senior Procurement Executive has repeatedly touted a new
Strategic Acquisition Center, the fact remains that this is simply in
addition to the National Acquisition Center, the Denver Acquisition
Logistics Center, and the Technology Acquisition Center. At the
department level, VA seems to be building a substantial level of
duplication, all in an attempt to standardize prosthetics procurement
for veterans. Duplications of efforts are not the fiscally responsible
way to run any federal agencies, nor is it helpful in optimizing a
veterans care and access to PSAS services.
However, when this executive is asked, the Department will state
that this is not meant to reduce the ability to give veterans the most
appropriate items, their actions run contrary in that without these
contracts, VA is forcing these orders to be competed. Even within a
given contract award, there is a push for procurements to be
distributed amongst all awardees. This means there is still a complete
lack of respect for a veteran and their clinical team's decisions.
These inefficient practices must immediately be addressed and
corrected, if we wish to provide timely and quality access to PSAS
services for our veteran community.
Finally, a large problem that poses a hurdle to care to veterans
requiring PSAS resources is the location and availability of resources
to veterans living outside of major metropolitan cities. Over 4 million
of the veterans enrolled in the VA Healthcare System live in rural
areas. There is an overwhelming national misconception that all
veterans in need of PSAS have equal access to the comprehensive care
and other programs provided by VHA's PSAS. Unfortunately, this is not
true. Access to the most basic primary care is often difficult in rural
America, let alone the extensive individualized care that accompanies
amputations or other serious conditions in which PSAS would provide
care. Currently, PSAS does not have the necessary prosthetic or
orthotic professionals in-house needed to meet the demand for services
by the veterans' community. This is especially true for veterans living
in rural areas. Some veterans have to drive hours for something as
simple as getting their prosthetic limb adjusted or for physical
rehabilitation. PSAS has approximately 600 contracts with local vendors
across the nation to provide care closer to home for these rural
veterans. However, as VA moves to their new procurement model, I am
sincerely concerned that when a veteran has a unique situation, or
medical need, requiring the services of a vendor not on contract with
PSAS that this will no longer be an option under this new model of care
where PSAS procurements are accomplished through VHA's acquisition
service. I concur with the IG's recent report on limb procurement that
VA needs to assess its internal capabilities and determine the correct
number of contracted vendors to have in a particular area. This should
not preclude a Veteran from being able to utilize a vendor not on
contract when that Veteran has a unique medical need or lives in an
extremely remote area. I believe strongly in the authority granted PSAS
by Congress in 38 USC 8123.
Alarmingly, a 2006 study of the Carsey Institute reported that the
death rate for rural veterans is up to 60 percent higher than the death
rate of veterans residing in urban areas. Given the difficulties that
already accompany being an amputee then couple it with the multiple
obstacles rural veterans often face in their efforts to receive medical
and PSAS care is resulting in many veterans missing appointments or
foregoing care for a number of reasons beyond the long distances they
must travel. VA has stated that over 50 percent of the veterans they
treat live in areas of the country they consider to be ``remote'' or
``highly rural''. This statistic alone should be more than enough of a
reason to establish a better system of care of locations were that care
can be received.
I do however applaud several VAMCs PSAS departments who are
actively seeking out and treating rural veterans. For example, PSAS
teams from Colorado and Wyoming have established a Prosthetic Treatment
Center Mobile Laboratory. According to VA ``A certified Prosthetist-
Orthotist will travel to rural areas in Colorado and Wyoming in a van
equipped with a mini prosthetic-orthotic fabrication laboratory,
computer assisted design and manufacturing capabilities, and telehealth
equipment. This program will bring expertise in high end-orthotics and
in prosthetic fabrication and fitting to rural Veterans, and the van
will be used for tele-consultations with prosthetic and orthotic
rehabilitation specialists, the Amputation Rehabilitation Coordinator,
podiatrists, and wound care specialists from the Denver VAMC. This
mobile laboratory will provide rural Veterans with access to the
Regional Amputation System of Care (RAC) based in the VA Eastern
Colorado Health Care System. This mobile laboratory will provide a more
consistent standard of care for rural veterans than is currently
possible with community vendors.''
I would lastly like to note that PSAS has been under ``acting
leadership'' for nearly a year and a half. A department offering
services of this magnitude cannot hope to improve the services they
provide to to veterans as long as they are languishing without a leader
to provide the proper direction. Prosthetics needs to have a senior
leader appointed as soon as possible. I believe this leader should at
minimum be currently serving at the Chief Consultant level, if not
Chief Officer given the unique nature of the program and it's far
reaching, significant impact it has on all veterans, especially our
most vulnerable veterans with severe disabilities.
In closing, the current conflicts, along with an aging veteran
population and tighter budgets have placed VA PSAS under tremendous
strain. Congress and VA have both made an effort to ensure that the
budget for medically prescribed devices is substantial enough to ensure
that veterans receive the highest quality devices. Unfortunately, many
at VA seem to be devolving themselves into a bureaucracy where the
people who were successfully procuring prosthetic items are no longer
going to be involved. VA PSAS has IT systems that are woefully out of
date, placing veterans at risk for not receiving their required care,
while also putting VA at risk for increased fraud, waste and abuse.
High-risk populations, such as rural and women veterans, continue to be
the ones in danger of not receiving the care they have earned through
their selfless service. Congress has already recognized that federal
procurement laws and regulations do not always work for the
personalized health care many of our most severely disabled veterans
require. I beseech you to ensure VA respects the autonomy of their
physicians and the preferences of veterans by continuing to use 38 USC
8123 to provide medically prescribed devices to veterans in the most
efficient way possible. I also urge this subcommittee to have the
strictest of oversight to ensure VHA PSAS is provided with the
necessary resources to develop and implement a national prosthetics
record, a modern inventory system and the clinical and administrative
staff required to properly support our veterans and optimize their
prosthetics care.
Madam Chair, and distinguished members of the subcommittee, I would
like to again thank you for inviting me to share my views and
recommendations on this critical matter with the subcommittee today. I
stand ready to address any questions or concerns you may have for me.
Thank you.
May 11, 2012
The Honorable Ann Buerkle, Chairwoman
Subcommittee on Health
House Veterans Affairs Committee
335 Cannon House Office Building
Washington, D.C. 20510
Dear Chairwoman Buerkle:
Pursuant to Rule XI2(g)(4) of the US House of Representatives, I
have not received any federal grants in Fiscal Year 2012, nor have I
received any federal grants or contracts in the two previous Fiscal
Years relevant to the May 16, 2012, Subcommittee on Health hearing on
Optimizing Prosthetic Care for Veterans.
Very Respectfully,
Christina M. Roof
Question For The Record
Letter and Questions From: Hon. Michael H. Michaud, Ranking
Democratic Member, Subcommitte on Health - To: Ms. Lucille Beck, Ph.D.,
Acting Chief Consultant, Prosthetics and Sensory Aids Service, Veterans
Health Administration, U.S. Department of Veterans Affairs
May 23, 2012
Ms. Lucille Beck, Ph.D.
Acting Chief Consultant
Prosthetics and Sensory Aids Service
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue NW
Washington, DC 20420
Dear Dr. Beck:
In reference to our Subcommittee on Health Committee hearing
entitled ``Optimizing Care for Veterans with Prosthetics'' that took
place on May 16, 2012. I would appreciate it if you could answer the
enclosed hearing questions by the close of business on June 23, 2012.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Jian Zapata at [email protected], and fax your responses to
Jian at 202-225-2034. If you have any questions, please call 202-225-
9756.
Sincerely,
MICHAEL H. MICHAUD
Ranking Democratic Member
Subcommittee on Health
Enclosure
CW:jz
Questions for the Record from the House Committee on Veterans' Affairs
Subcommittee on Health
Hearing on Optimizing Care for Veterans with Prosthetics
1. Until the VA began upgrading its internal capacity to provide
prosthetic care, a senior VA PSAS official testified before Congress
that 97% of prosthetics for veterans were provided by contract
prosthetists. The OIG Report entitled, ``Healthcare Inventory,'' notes
that with respect to the prosthetic care received by recent veterans
with amputations, there are high satisfaction rates (90.9% for lower
limb amputees and 69.6% for upper limb amputees). Some of the most
positive feedback from individual veteran amputees in the OIG survey
involved praise for VA in permitting choice and location of contract
prosthetists (see p. 62):
a. QUESTION: Given the fact that veterans view choice and location
of contract prosthetists among the best aspects of the VA prosthetic
care system, and the fact that veterans have high satisfaction rates
with contract prosthetists, why would the VA not support passage of
H.R. 805, the Injured and Amputee Veterans Bill of Rights, as a step
toward addressing Recommendation No. 3 of the Healthcare Inventory
report, to improve the ``VA approval process for fee-basis and VA
contract care for prosthetic services to meet the needs of veterans
with amputations.''
2. The OIG Report on Prosthetic Limb Care in VA Facilities (Report
No. 11-02138-116) states that the VA has made a significant investment
in its capacity to serve veterans with amputations since 2009 through
its Amputee Systems of Care Program (ASoC), a comprehensive series of
settings in which amputee and prosthetic care is provided.
a. QUESTION: Can you tell the Subcommittee how much the VA has
invested in these upgrades to its internal capacity to serve veterans
with amputations since 2009?
3. The OIG Audit of the Management and Acquisition of Prosthetic
Limbs (Report No. 11-02254-102) states that of the $1.8 billion VA
spent on prosthetic items in FY 2010, only $54 million (3 percent) was
spent on prosthetic limbs.
a. QUESTION: Compared to the significant investment made to enhance
VA's internal capacity to fabricate prostheses, do you believe it is
cost-effective for the VA to consolidate prosthetic fabrication
internally in VA centers or would it be more cost-effective to continue
to rely on contract prosthetists located in the vicinity of the
veterans themselves, working in coordination with a VA rehabilitation
team?
4. The OIG report estimates that it costs the VA Prosthetic and
Sensory Aids Service (PSAS) approximately $12,000 on average to
purchase a prosthetic limb from a contract prosthetist but that it
costs the VA only $2,900 to fabricate a prosthetic limb from a VHA
prosthetic lab. This figure seems exceedingly low considering the
highly specialized services that go into the fabrication and fitting of
a prosthetic limb.
a. QUESTION: Can you tell the Subcommittee which costs specifically
were factored into this estimate of VA cost for the fabrication of a
prosthesis through its own prosthetic labs? For instance, were the
following costs included in the calculation:
i. Labor costs, including a portion of the salary and benefits
for the prosthetist and prosthetic technician to design, fabricate and
fit the limb as well as the administrative staff to process paperwork,
tend to the laboratory and clinical facility, etc.
ii. Facility costs, including a portion of overhead for the
clinical and laboratory facilities used in the fabrication of the
device, the storage of inventory and materials, and the housing of
machinery.
iii. Machinery and supplies, including the capital costs of
purchasing industrial ovens, laboratory work equipment, tools,
grinders, computer-assisted design/computer-assisted manufacture
devices and software, and other ancillary items that may not be
incorporated into a final prosthesis.
5. The OIG Report suggests that internal VA guidance suggests that
each VISN should contract with three to five (3 to 5) private
prosthetists to augment the capacity of the internal VA programs to
serve veteran amputees' prosthetic needs. Several VISNs have chosen to
contract with far more than this guidance suggests.
a. Does the fact that some VISNs have chosen to contract with many
more private practitioners than 3 to 5 suggest that there is veteran
demand for access to private practitioners? Is this not consistent with
maintaining veterans' choice and enhancing quality under the VA
prosthetic benefit?
Responses From: Veterans Health Administration, U.S. Department of
Veterans Affairs - To: Hon. Michael H. Michaud, Ranking Democratic
Member, Subcommitte on Health
1. Until the VA began upgrading its internal capacity to provide
prosthetic care, a senior VA PSAS official testified before Congress
that 97% of prosthetics for veterans were provided by contract
prosthetists. The OIG Report entitled, ``Healthcare Inventory,'' notes
that with respect to the prosthetic care received by recent veterans
with amputations, there are high satisfaction rates (90.9% for lower
limb amputees and 69.6% for upper limb amputees). Some of the most
positive feedback from individual veteran amputees in the OIG survey
involved praise for VA in permitting choice and location of contract
prosthetists (see p. 62):
a. Given the fact that veterans view choice and location of
contract prosthetists among the best aspects of the VA prosthetic care
system, and the fact that veterans have high satisfaction rates with
contract prosthetists, why would the VA not support passage of H.R.
805, the Injured and Amputee Veterans Bill of Rights, as a step toward
addressing Recommendation No. 3 of the Healthcare Inventory report, to
improve the ``VA approval process for fee-basis and VA contract care
for prosthetic services to meet the needs of veterans with
amputations.''
Response: The Department of Veterans Affairs (VA) acknowledges the
need to continually improve its approval processes for fee basis and
contracted services. Such improvements for contracted prosthetic
services require changes in administrative business practices as noted
in VA's response to the Office of the Inspector General report on
``Management and Acquisition of Prosthetic Limbs'' (March 8, 2012)
including: conducting quote reviews for services, certification of
invoices by contracting officers, and having clearly defined
performance measures stipulated in contracts.
VA recognizes the unique needs of injured and amputee Veterans,
which is why their care is managed by an interdisciplinary medical team
that provides high quality, comprehensive amputation rehabilitation
services. Fabrication of a prosthetic limb is one important element of
the rehabilitation care plan. A VA physician prescribes the necessary
prosthetic limb, VA or the contracted prosthetist fabricates that limb,
and the Veteran's care and ``medical rehabilitation'' (including
functional effectiveness of the fabricated limb) continues to be
managed and supervised by VA providers and the Veteran.
Veterans with severe injuries and amputation have unique needs that
set them apart from other patients at VA facilities--but they are not
set apart in their rights. The basic tenets of patient care should not
vary based either on the condition or injury experienced by a Veteran
or the type of medical services a Veteran receives. H.R. 805 would
confer unique rights upon a limited group of Veterans. Giving special
rights to injured and amputee patients that are not available to other
enrolled Veterans would result in inconsistent and inequitable
treatment among our Veteran patients.
VA adheres to strict standards of patient treatment. A VA
regulation requires that upon admission, patients or their
representatives must be informed that a list of patients' rights is
posted at each nursing station in all VA facilities. Patients who are
concerned about the quality of their care have a number of options
already available for addressing these issues. Every VA medical center
has a patient advocate dedicated to addressing the clinical and non-
clinical complaints and concerns of our Veterans and their families.
Many facilities also include a ``Letter to the Director'' drop box
where Veterans can communicate directly with the Director and raise
issues and concerns. In addition, VA's Prosthetic and Sensory Aids
Service maintains a Web site that offers Veterans and family members an
opportunity to ask questions or raise concerns directly with VA
officials. The Department also works closely with Veterans Service
Organizations to identify and respond to any concerns with quality and
access to care.
If extended to the entire patient population, the Department would
support the majority of ``rights'' that are included in this `Bill of
Rights' (e.g., the right to receive appropriate treatment, the right to
participate meaningfully in treatment decisions, etc). However, a few
of the ``rights'' raise serious concerns. Specifically, the Veteran's
``right to select the practitioner that best meets [his or her]
orthotic and prosthetic needs, [including] a private practitioner with
specialized expertise,'' is not sound from a medical perspective, as
the Veteran could select a person without the requisite qualifications
to provide quality care.
2. The OIG Report on Prosthetic Limb Care in VA Facilities (Report
No. 11-02138-116) states that the VA has made a significant investment
in its capacity to serve veterans with amputations since 2009 through
its Amputee Systems of Care Program (ASoC), a comprehensive series of
settings in which amputee and prosthetic care is provided.
a. Can you tell the Subcommittee how much the VA has invested in
these upgrades to its internal capacity to serve veterans with
amputations since 2009?
Response: In 2009, the Veterans Health Administration (VHA) began
the implementation of the Amputation System of Care (ASoC), which
provides specialized expertise in amputation rehabilitation
incorporating the latest practices in medical rehabilitation
management, rehabilitation therapies, and technological advances in
prosthetic components. From fiscal year (FY) 2009 to 2011, VHA invested
approximately $20 million in enhancement of amputation care. Of the $20
million, approximately $11 million was spent on dedicated staff; $7
million on prosthetic labs, rehabilitation and telehealth equipment;
and $2.4 million on education and training to maintain the skills and
competencies of the staff.
The ASoC is comprised of a tiered system of care of graded levels
of expertise and accessibility:
7 Regional Amputation Centers (RAC) provide comprehensive
rehabilitation care through an interdisciplinary team and serve as
resources for other facilities in the system through tele-
rehabilitation.
15 Polytrauma/Amputation Network Sites (PANS) provide the
full range of clinical and ancillary services to Veterans closer to
home.
Amputation Clinic Teams (ACT) provide limited inpatient
and prosthetic capabilities.
Amputation Points of Contact (APOC) include at least one
person at each facility identified as the point of contact for
consultation and assessment.
3. The OIG Audit of the Management and Acquisition of Prosthetic
Limbs (Report No. 11-02254-102) states that of the $1.8 billion VA
spent on prosthetic items in FY 2010, only $54 million (3 percent) was
spent on prosthetic limbs.
a. Compared to the significant investment made to enhance VA's
internal capacity to fabricate prostheses, do you believe it is cost-
effective for the VA to consolidate prosthetic fabrication internally
in VA centers or would it be more cost-effective to continue to rely on
contract prosthetists located in the vicinity of the veterans
themselves, working in coordination with a VA rehabilitation team?
Response: To meet the expectations of our Veterans to provide the
highest quality care and to provide devices closer to their homes, VA
continues to offer and develop in-house clinical presence in
partnership with community providers. When assessing the cost
effectiveness of providing prosthetic fabrication of an artificial
limb, VA considers more than just the price offered by contractors in
the private sector.
Reimbursement of care of amputees in the private sector generally
is measured by the number of prosthetic limbs provided because the
reimbursement structure is based on products, not clinical care
services. VA does not limit its care performance measure to examining
the number of limbs provided, but also recognizes the unique
professional nature, value, and role of orthotists and prosthetists in
the rehabilitation of Veterans. These specialists provide clinical
relevance and expertise, help educate professionals from other medical
disciplines, and support research.
When a Veteran is sent to the private sector for a prosthetic limb,
the private sector prosthetist or orthotist provides the ``product''
prescribed by the Veteran's VA health care provider(s). In the private
sector reimbursement is based on the product, not the services
provided. In such a system, the vendor receives the same payment
whether the patient is seen once or many times. Private sector
prosthetists and orthotists do not provide medical or rehabilitation
care, which remains the responsibility of the Veteran's VA health care
team.
In FY 2011, the VA Orthotics and Prosthetics (O&P) Service provided
420,427 patient visits in-house to 262,112 Veterans. The majority of
these visits were for clinical care outside of fabrication of
prosthetic devices. Looking only at fabrication, VA maintains a highly
skilled and trained team of professionals working in state-of-the-art
accredited facilities. However, VA's patient population is very
geographically diverse and demands a balance between in-house
fabrication, clinical expertise, and convenience resulting from local
vendors who fabricate the prescribed limb.
4. The OIG Report estimates that it costs the VA Prosthetic and
Sensory Aids Service (PSAS) approximately $12,000 on average to
purchase a prosthetic limb from a contract prosthetist but that it
costs VA only $2,900 to fabricate a prosthetic limb from a VHA
prosthetic lab. This figure seems exceedingly low considering the
highly specialized services that go into the fabrication and fitting of
a prosthetic limb.
a. Can you tell the Subcommittee which costs specifically were
factored into this estimate of VA cost for the fabrication of a
prosthesis through its own prosthetic labs? For instance, were the
following costs included in the calculation:
i. Labor costs, including a portion of the salary and benefits
for the prosthetist and prosthetic technician to design, fabricate and
fit the limb as well as the administrative staff to process paperwork,
tend to the laboratory and clinical facility, etc.
ii. Facility costs, including a portion of overhead for the
clinical and laboratory facilities used in the fabrication of the
device, the storage of inventory and materials, and the housing of
machinery.
iii. Machinery and supplies, including the capital costs of
purchasing industrial ovens, laboratory work equipment, tools,
grinders, computer-assisted design/computer-assisted manufacture
devices and software, and other ancillary items that may not be
incorporated into a final prosthesis.
Response: VHA Prosthetic and Sensory Aids Service reported these
data from VHA PSAS National Prosthetic Patient Database (NPPD), and
Orthotics Work Order Lab (OWL). The $12,000.00 average cost to purchase
a prosthetic limb from a contract prosthetist is based on data from the
NPPD for new limbs that are commercially purchased. There is reasonable
confidence in the commercial costs reported since these data follows
the same process as all Prosthetic purchase orders.
The reported $2900 VA costs for fabricating a prosthetic limb
within VA are based on data entered by VA clinicians from the
facilities providing cost estimates of labor and materials, only. The
reported costs entered by the clinician in OWL reflect only direct
labor costs for fabrication, and material costs for prosthetic
components. In summary:
i. Direct labor costs are only for Prosthetists, and does not
include administrative staff;
ii. No facility costs are included;
iii. Only costs of the actual device components and some
supplies are included. No machinery and overhead supply costs are
included (e.g., capital costs of purchasing industrial ovens,
laboratory work equipment, tools, grinders, computer-assisted design/
computer-assisted manufacture devices and software, and other ancillary
items that may not be incorporated into a final prosthesis).
5. The OIG Report suggests that internal VA guidance suggests that
each VISN should contract with three to five (3 to 5) private
prosthetists to augment the capacity of the internal VA programs to
serve veteran amputees prosthetic needs. Several VISNs have chosen to
contract with far more than this guidance suggests.
a. Does the fact that some VISNs have chosen to contract with many
more private practitioners than 3 to 5 suggest that there is veteran
demand for access to private practitioners? Is this not consistent with
maintaining veterans' choice and enhancing quality under the VA
prosthetic benefit?
Response: The OIG Report found multiple contract vendor awards in
some Veterans Integrated Service Networks (VISN) without balanced
consideration of geographic access and specialty demand for Veterans.
The large number of awardees did not increase Veteran access, as many
of these vendors were within walking distance of other providers. VA
concurred with the OIG recommendation to assess its internal
capabilities and to develop criteria to establish an appropriate number
of contracts. VA is committed to assessing these contracts and its
internal capabilities to generate a realistic number of awardees for
these contracts.
VA relies on these contract vendors to provide quality service that
is convenient to our Veteran population and will maintain Veterans'
choice, while balancing this duty with the fiscal responsibility to
secure the best value for taxpayers. VA must weigh several factors in
determining the appropriate number of awards. For example, VISNs with a
larger rural population may require more awards than a compact urban
VISN. VA is in the process of reviewing all of its contracts and
policies regarding the provision of prosthetic devices and services,
while ensuring that our top priority will always be quality care for
Veterans.