[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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further refined.


                            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

                              ----------                              


                        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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \5\ 38 U.S.C. sec. 1706(b)(1).
    \6\ Ibid.
---------------------------------------------------------------------------
    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.''
---------------------------------------------------------------------------
    \8\ Ibid.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \3\ VA Medical Centers in Decatur, Georgia; Indianapolis, Indiana; 
Northampton, Massachusetts; Nashville and Murfreesboro, Tennessee; 
Salem, Virginia; Clarksburg, West Virginia.
---------------------------------------------------------------------------
    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.

                                 
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