[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
VA SPECIALIZED SERVICES: LOWER EXTREMITY CONDITIONS
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HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, MAY 2, 2017
__________
Serial No. 115-13
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Printed for the use of the Committee on Veterans' Affairs
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Available via the World Wide Web: http://www.fdsys.gov
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
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C O N T E N T S
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Tuesday, May 2, 2017
Page
VA Specialized Services: Lower Extremity Conditions.............. 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable Julia Brownley, Ranking Member......................... 3
WITNESSES
Steven L. Goldman DPM, MBA, President, American Board of
Podiatric Medicine............................................. 3
Prepared Statement........................................... 26
Seth Rubenstein DPM, Treasurer, Board of Trustees, Immediate Past
Chairman, Legislative Committee, American Podiatric Medical
Association.................................................... 6
Prepared Statement........................................... 29
Col. James Ficke MD (ret.), Member, American Orthopaedic Foot and
Ankle Society, American Association of Orthopaedic Surgeons.... 8
Prepared Statement........................................... 32
Jeffrey M Brandt CPO, Member, American Orthotics and Prosthetics
Association.................................................... 9
Prepared Statement........................................... 33
Jeffrey Robbins DPM, Chief of Podiatry, Veterans Health
Administration, U.S. Department of Veterans Affairs............ 11
STATEMENTS FOR THE RECORD
Clifford James Buckley, M.D...................................... 38
Lawrence B. Harkless, DPM........................................ 39
Paralyzed Veterans of America (PVA).............................. 40
VA SPECIALIZED SERVICES: LOWER EXTREMITY CONDITIONS
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Tuesday, May 2, 2017
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 2:54 p.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup
[Chairman of the Subcommittee] presiding.
Present: Representatives Wenstrup, Dunn, Higgins, Brownley,
Takano, and Kuster.
Also Present: Representative Abraham.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. The Subcommittee will come to order. Good
afternoon, and thank you all for joining us.
Before I begin, I would like to ask unanimous consent for
my friend and colleague and former Committee Member, Dr. Ralph
Abraham, to sit on the dais and participate in today's
proceedings. Without objection, so ordered.
Today's hearing is the first of what I hope will be a
series of hearings to examine specialty care access and quality
in depth. Given the high rate of lower limb injuries and
conditions among veterans of all ages and the issues this
Subcommittee has been discussing since 2015 regarding
recruitment and retention among professionals trained to treat
foot and ankle issues in the Department of Veterans Affairs, I
thought it most appropriate to begin today with a discussion of
lower extremity injuries, conditions, and treatment.
Musculoskeletal injuries are the top concern among veterans
newly separated from service in the armed forces and are also a
primary concern among older generations of veterans with
conditions that may be exacerbated, not only by military
service, but also by aging and chronic illnesses like diabetes.
According to a February 2017 VA white paper, almost 2
million veterans in the VA health care system are at risk for
major foot wounds, infections, and amputations. And there is
increasing demand among VA patients, particularly those with
polytraumatic injuries, spinal cord injuries, and major limb
amputations, for primary and specialty podiatric services.
I ask unanimous consent to insert that white paper into the
record. Without objection, so ordered.
Mr. Wenstrup. Given increasing demand, it is imperative now
more than ever that the VA be equipped with the highly trained
workforce necessary to provide timely access to quality foot
and ankle care within VA medical facilities. The VA's ability
to do that, however, is hampered by antiquated statutory
requirements that have held podiatrists practicing within the
VA's walls back and, as a result, limited access to podiatry
care for veteran patients.
The podiatry profession has been transformed over the last
few decades, yet due to a law developed in 1976, 41 years ago,
the VA's podiatry practice has fallen far short of the private
sector in terms of pay and advancement opportunities. According
to the VA, this has led to an inability to recruit and retain
the most experienced podiatrists, the ones we want treating our
most vulnerable veterans, as well as recent graduates just
starting out. Needless to say, it has also led to lengthy
hiring delays, averaging 14 months for new podiatry positions.
At a time when veteran demand for foot and ankle care is
growing, this is unacceptable.
I have introduced a bill, H.R. 1058, the VA Provider Equity
Act, that would address this issue by including VA podiatrists
within the definition of VA physicians and, in turn, ensure
that podiatry pay is more in line with industry standard and
allow podiatrists to attain promotion and leadership positions
in the VA health care system. Similar language passed the House
last Congress, and for our veterans' sakes, I am hopeful it
will see the President's desk this Congress.
During today's hearing, I look forward to hearing our
witnesses' and Committee Members' thoughts on H.R. 1058 and on
what else this Subcommittee can do to guarantee timely access
to specialized foot and ankle care veterans have earned and
deserve.
I also want to discuss today how the VA can improve the
provision of both foot and ankle care and orthotic and
prosthetic care in the community for veteran patients. As the
American Orthotics and Prosthetics Association states in their
written testimony, 90 percent of the orthotic and prosthetic
care that our veterans receive is in the community. However,
there are persistent concerns about care coordination and
communication between VA and community providers treating
veterans with major amputations.
Unfortunately, this is not just an issue of concern for
prosthetics. During a Full Committee hearing earlier this year,
Dr. Dunn shared a story about a veteran constituent of his
whose delayed and disjointed experience seeking podiatry care
through the Choice Program led to an unnecessary lengthy and
burdensome episode of care.
I ask unanimous consent to insert that constituent's story
into the record for this hearing as well. Without objection, so
ordered.
Mr. Wenstrup. As we continue to move forward to develop the
next generation of VA care and community programs, we must take
those stories to heart and ensure that they are not repeated.
I appreciate our panelists and audience members for being
with us this afternoon, and I very much look forward to today's
discussion.
I will now yield to Ranking Member Brownley for any opening
statement that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman. And thank you for
holding today's hearing.
The ability of the VA to hire and retain skilled medical
professionals to treat veterans with lower extremity medical
conditions is vitally important. Many veterans who receive VA
care have lost limbs due to combat, others develop serious
medical conditions affecting the lower extremities later in
life due to their military service. These conditions and
injuries can significantly affect a veteran's quality of life.
I want to thank Chairman Wenstrup for being willing to work
in a bipartisan way to address this issue impacting the VHA and
the veterans it serves. I appreciate his insight into the issue
as a podiatrist and appreciate his leadership on this issue as
Chairman.
The number of veterans receiving amputations has tripled
since 2000, according to the VHA Amputation System of Care.
While many of these amputations were the result of injury, some
were the product of a preventable or treatable illness or
disease such as diabetes, hypertension, or obesity. Podiatrists
often act as the first line of defense against these types of
illnesses by providing preventative care that allows veteran
patients to improve their quality of life and avoid amputation.
I look forward to the discussion today. I hope that we may
use the testimony and information we receive to shape solutions
to these pressing problems. We cannot expect to solve the VHA's
access problems without the providers, supplies, and resources
that are urgently needed. I look forward to continuing the
bipartisan work on this issue in this Committee. And I yield
back.
Mr. Wenstrup. Thank you.
We are fortunate today to be joined this afternoon by
several distinguished witnesses. Joining us this morning on our
first and only panel is Dr. Steven Goldman, the President of
the American Board of Podiatric Medicine; Dr. Seth Rubenstein,
Treasurer of the Board of Trustees and Immediate Past Chairman
for the Legislative Committee for the American Podiatric
Medical Association; Dr. James Ficke, the Chairman of
Orthopedic Surgery at Johns Hopkins School of Medicine and a
member of the American Association of Orthopaedic Surgeons and
the American Orthopaedic Foot and Ankle Society; Jeffrey
Brandt, Chief Executive Officer and Founder of Ability
Prosthetics and Orthotics and a member of the American
Orthotics and Prosthetics Association; and Dr. Jeffrey Robbins,
the Department of Veterans Affairs Chief of the Podiatry
service.
I want to thank you all for being here today and taking
time from your schedules to join us.
Dr. Goldman, we will begin with you, if you will, and you
are now recognized for 5 minutes.
STATEMENT OF STEVEN L. GOLDMAN
Dr. Goldman. Dr. Chairman, Ranking Member, distinguished
Members of Congress, and guests, at the outset, I would like to
express my appreciation for the honor to address this Committee
today. In discussing this topic, I do so as a private citizen,
not as the chief of podiatry and the director of a podiatric
residency training program at a Veterans Administration medical
center; I do so not as the former interim chief of surgery or
the site director of surgical services at a second VA medical
center; and I do so not as a retired lieutenant colonel in the
United States Air Force, who served as a podiatrist and also as
a surgical operation squadron commander for the last 4 of my
20-year career in the Air Force.
I am testifying as a private citizen, one who graduated
almost 35 years ago and was an associate professor at the New
York College of Podiatric Medicine for nearly 15 of those
years, during which time I have witnessed firsthand the
metamorphosis of my profession.
I am currently the president of the American Board of
Podiatric Medicine, and in this position I represent thousands
of podiatrists across the country, many of whom are employed by
the Federal Government.
As a veteran myself, I am also now the consumer of the
medical services of the system about which you have invited me
here to testify.
I have witnessed the best of our profession as it has grown
over the past 35 years since I graduated in 1982. I am in awe
of how far we have come. Today, all graduating podiatrists are
3-year residency trained in podiatric medicine and surgery, and
we are an integral part to the collaborative health care
delivery system providing essential services alongside our
distinguished allopathic and osteopathic specialists.
Today's podiatrists manage the complex nature of foot and
ankle deformities and are a part of the multidisciplinary team
serving the needs of a seemingly ever-growing diabetic
population. We take call, provide inpatient and outpatient
care, respond to emergencies, prescribe medications, and
independently perform surgery of the foot and ankle.
Fundamentally, we perform a vital role in the continuum of
health care, equal to other physicians, often for a patient
population whose choice for health care is only the VA. More
often than not, those patients present with more multiple
comorbidities than the average population.
In the Veterans Administration, podiatry is often the first
specialty consulted for foot and ankle services, and we provide
more of these services than any other specialty.
Podiatrists in the private sector have witnessed salaries
commensurate with the profession's growing skills. By contrast,
salaries in the Veterans Health Administration, VHA, have not
kept pace, and the gap grows larger every day. Podiatrists in
42 percent of the regions across the country have reached
legislatively capped rates of pay under VHA. What that
practically means is that a podiatrist at the absolute top end
of the pay charts will earn exactly the same as much less
senior podiatrists, with no hope of ever being further
remunerated commensurate with the added time of service or
experience.
Podiatrists are defined as physicians under Title XVIII of
the Social Security Act, section 1861(r)(3). The VA definition
of podiatry is a vestige of a 41-year-old antiquated 1976 VA
Omnibus bill and is sorely outdated. Consequently, podiatry
salaries under the VA Health Administration are locked into
that same 41-year-old pay scale. As a result, it is becoming
increasingly harder to fill positions and keep people with the
vital skills under the VHA. I think we can all agree that all
of us, but particularly our veterans, deserve the very best of
care. When looking at the bell curve for salaries in podiatry
on salary.com, virtually no matter where you look by ZIP Code,
podiatry salaries in Federal services are in the lowest 10 to
15 percent of that curve.
Podiatrists in leadership positions within the
administration have been members of pay panels, making salary
decisions for their medical colleagues who enjoy salaries that
are at the very least 40 percent greater than the top end VHA
podiatry salaries.
Heretofore, the demographic for those seeking employment
under VHA used to be board certified, seasoned professionals
who came with many years of experience and who wanted to make
careers in Federal service. Podiatrists currently employed by
VHA remain in the system primarily for one of two reasons:
either they have a refined sense of purpose and wish to give of
themselves out of a sense of commitment to our veterans, or
they do so because they themselves are veterans and they are
compelled by a continued sense of mission tending to the
medical needs of their comrades in arms.
I have said many times the VA hospital system is the only
health care system that I have ever known where you will see a
patient with one leg being pushed to his appointment in a
wheelchair by a patient or volunteer with one arm, and they
don't know each other. Veterans get this.
These good-hearted providers are getting harder to find and
even harder to keep. Podiatrists with less than 10 years of
experience make up 60 percent of the new hires at VHA. The VHA
podiatry workforce has effectively become the private sector's
farm team now being filled by younger, often nonboard certified
providers who seek to acquire the required case volume and
diversity to qualify to sit for their board certification
examinations, and after passing, take those skills to the
private sector where they can manage--where they can make a
fair wage in order to repay a student debt burden that often
averages and exceeds $194,000.
Specifically in 2016, only 30 percent of new hires were
board certified. Until then--until we can offer better
compensation, this has and will continue to trickle down to
affect patient access, because skilled, board certified,
experienced practitioners can manage larger patient populations
more efficiently than inexperienced, younger professionals.
To make matters even worse, in 2016, the VA's average delay
in hiring a podiatrist to fill a vacant position was 14 months.
That means 14 months of patients having to seek care elsewhere
or forego necessary foot and ankle care all together.
Based on the salary.com data mentioned earlier, the
takeaway message is that the VA's top performing podiatrists,
those making the highest possible salaries in the VA, are paid
about 25 percent less than the median salaries of their non-VA
counterparts, and in most cases, only about half of what the
top non-VA performers earn.
In hospital leadership positions, both in the public and
private sectors, podiatrists have had the oversight of numerous
surgical and medical subspecialties, utilizing an insight of
core and fundamental medical and surgical principles. These
principles, coupled with consultation and input from the chiefs
of the respective medical and surgical colleagues that they
oversee, provide for an effective leadership model.
Should a podiatrist be the chief of a subspecialty like
neurosurgery or orthopedists, should--or orthopedics? The
answer has to be, no more than a neurosurgeon or orthopedist
should be the chief of podiatry. But that does not mean a
podiatrist who is the overall chief of all the surgical
subspecialties can't work with and oversee and provide
effective administrative leadership of those departments with
collaborative input from the subspecialties with whom they
work.
In conclusion, Dr. Chairman, Ranking Member, and Members of
the Committee, I thank you again for inviting me here to share
my thoughts with you all and for your efforts and your desire
to discuss this topic to hopefully right this inequity. I am
available to address any questions you may have for me.
[The prepared statement of Steven L. Goldman appears in the
Appendix]
Mr. Wenstrup. Thank you, Dr. Goldman.
Dr. Rubenstein, you are now recognized for 5 minutes.
STATEMENT OF SETH RUBENSTEIN
Dr. Rubenstein. Chairman Wenstrup, Ranking Member Brownley,
and Members of the Subcommittee, I welcome and appreciate the
opportunity to testify before you today on behalf of the
American Podiatric Medical Association. I commend the
Subcommittee for its focus to assist and direct the Veterans
Administration to effectively and efficiently recruit and
retain qualified medical professionals to treat veteran
patients and improve access to quality health care in the VA.
I am Dr. Seth Rubenstein, member and trustee of the
American Podiatric Medical Association. I am before you today
representing the APMA, the podiatric medical profession, and
specifically our members currently employed and those seeking
to be employed by the VA. I do not represent the Veterans
Administration in my capacity today, though I bring with me
knowledge of widespread disparity between podiatric physicians
and other VA physicians.
Dr. Chairman, the VA's qualification standards for podiatry
were written and adopted in 1976. Podiatry starkly contrasted
with other physician providers at the time and, for that
matter, with what podiatry is today. Unlike 41 years ago,
current podiatric medical school curriculum is vastly expanded
in medicine, surgery, and patient experiences and encounters,
including whole body history and physical exams. Back then,
residencies were few and not required for licensure. Today,
there are mandated standardized, comprehensive 3-year medicine
and surgery residency positions of sufficient number to satisfy
the full number of our graduates, with 63 positions housed
within the VA, each requiring completion of a broad curriculum
comparable with medical and osteopathic residency training.
Today's podiatrists are appointed as medical staff at the
vast majority of hospitals and they serve in leadership roles
within those institutions, including but not limited to chief
of staff and chief of surgery. Podiatric physicians also serve
as members of their State medical licensing board. Many of my
colleagues have full admitting privileges and are responsible
for emergency and trauma call.
The competency, skill, and scope of today's podiatric
physicians has vastly improved since 1976. Because of this, CMS
recognizes today's podiatrists as physicians and TRICARE
recognizes us as licensed independent practitioners.
The veteran patients we treat, often plagued by
socioeconomic and psychosocial issues, are ailing, have more
comorbid disease and disproportionately poor health status
compared with their nonveteran counterparts. Such patients
suffer from a greater burden of diabetic foot ulcers,
amputations, and associated complications. As documented in my
written testimony, almost 2 million veterans are at risk of
amputation secondary to diabetes, sensory neuropathy, and
nonhealing foot ulcers.
Dr. Chairman, the veteran population is far more complex to
treat than patients in the private sector. One of the major
missions of podiatrists as providers of lower extremity care is
amputation prevention and limb salvage, which provides a cost
savings to the VA and plays an integral role in a veteran's
quality of life.
As part of an interdisciplinary team, podiatrists
independently manage dermatologic, rheumatologic, and
orthopedic pathology and trauma within our relative scope of
practice. We assume the same clinical, surgical, and
administrative responsibilities as any other unsupervised
medical or surgical specialty. Despite this equality in work
responsibility, there exists a marked disparity in the
recognition and pay of podiatrists as physicians within the VA.
The majority of new podiatrists recently hired within the
VA have less than 10 years of experience and lack board
certification. The majority of these individuals will separate
from the VA within 5 years.
Seven years ago, APMA leadership made VA recruitment and
retention a top priority. Since then, we have alerted the VA to
our concerns, and in response, former Under Secretary Petzel
created a working group, with whom we participated in several
meetings and from whom we received support for a legislative
solution to address this issue.
I come before this Committee today to respectfully request
that Congress help the VA and its patients by passing
legislation to recognize podiatric physicians and surgeons as
physicians in the physician and dentist authority. We believe
that changing the law to recognize podiatry, both for the
advancements we have made to our profession and for the
continuing contributions we make in the delivery of lower
extremity care for the veteran population, will resolve
recruitment and retention problems for the VA and for veterans.
Dr. Chairman and Members of the Subcommittee, thank you
again for this opportunity. This concludes my testimony. I am
available to answer your questions.
[The prepared statement of Seth Rubenstein appears in the
Appendix]
Mr. Wenstrup. Thank you, Doctor.
Dr. Ficke, you are now recognized for 5 minutes.
STATEMENT OF COLONEL JAMES FICKE
Dr. Ficke. Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee, on behalf of the American
Association of Orthopaedic Surgeons, which represents over
18,000 board certified orthopedic surgeons, and the American
Orthopaedic Foot and Ankle Society, which represents over 2,200
orthopedic surgeons specializing in foot and ankle disorders, I
thank you for the opportunity to speak to you today about lower
extremity care for veterans.
My name is Colonel James Ficke, retired, and I am an
orthopedic surgeon specializing in foot and ankle care. I am
currently the chairman of orthopedic surgery at Johns Hopkins
School of Medicine. I served in the United States Army for 30
years, deploying to Iraq from 2004 to 2005 as a deputy
commander and chief medical officer for the 228th Combat
Support Hospital in Mosul. I have led the Extremity War
Injuries Project Team for 12 years, an effort focused upon
improving care of warriors who have sustained battlefield
injuries. This effort has identified the gaps in knowledge as
well as research needs that have shaped the generous
congressional funding of over $330 million for veterans with
limb injuries commonly sustained in combat.
There are many orthopedic surgeons serving the veterans
proudly through the VA and many others caring for veterans
through the Choice Program. Orthopedic surgeons play a role in
saving limbs, reconstructing function, and returning veterans
to a healthy, active lifestyle. The AAOS was honored to receive
a Joint Warfighter Program award in collaboration with the
Major Extremity Trauma Research Consortium, the purpose of
which was to determine the best evidence for treatment of
injuries to our warriors, including lower extremity injuries.
We are honored to receive that support with your effort--
through your effort, Dr. Chairman, and we appreciate your many
years of support for orthopedics and our patients.
We acknowledge the significant need for access and for care
of veterans through the VA with lower extremity conditions.
Current statistics are staggering regarding the burden of
injury and the disability. My own teams have reported and
published literature showing that up to 92 percent of warriors
with battlefield injuries will have permanent disability of the
musculoskeletal system. As of April 2017, 6,920 men and women
have given their lives in the defense of our Constitution, and
52,540 men and women have sustained wounds in action, of which
as many as 80 percent involved a limb injury, and many of these
are lower extremity.
We absolutely agree that musculoskeletal care for veterans
is imperative. We will only meet these needs with a strong
force of well-trained providers of all backgrounds, including
podiatric surgeons and physicians and orthopedic surgeons.
Concerning H.R. 1058, the VA Provider Equity Act, the
orthopedic surgeons of the AAOS strongly agree and support that
high quality podiatric surgeons should be more equitably
compensated to support their recruitment and their retention.
Podiatrists are an essential part of the care team at the VA
and provide excellent service to veterans. During my service in
the Army, I practiced alongside podiatrists in many military
bases and had a podiatric surgeon on my staff at Mosul, who
served in a nonclinical leadership role, Lieutenant Colonel
John Gouin, Doctor of Podiatric Medicine.
The American Association of Orthopaedic Surgeons and the
Orthopaedic Foot and Ankle Society are concerned with two
aspects of the legislation that are not essential to the goal
of paying podiatrists what they are worth at the VA. Firstly,
this legislation would label podiatrists who have the Doctor of
Podiatric Medicine, or DPM, within the VA as physicians,
including them in a category currently reserved for doctors of
medicine and doctors of osteopathy. Secondly, the bill would
allow DPMs to attain clinical leadership positions over MDs and
DOs.
Podiatrists and orthopedic surgeons are trained
differently. The lower extremity is one of the more complex
areas of the human musculoskeletal system, and an orthopedic
surgeon will attend 4 years of medical school, serve a 5-year
orthopedic surgery residency, and then typically take an
additional year of subspecialty fellowship training. All MDs
and DOs are trained in multisystem clinical care and disease
management, which is not the case for all podiatrists, and it
is a prerequisite for peer review of physicians.
While recent changes have improved podiatric education, it
is not the same as the multisystem medical education required
to become a DO or an MD, nor is it the same accreditation
process. Podiatry does not participate in the United States
Medical Licensing Examination, which is the standard for all
advanced medical care and essential to practice as a physician.
We believe that the title of physician should be attained
through the accreditation process and not the legislative
process.
The AAOS and the AOFAS stand ready to work with the
Subcommittee in good faith to improve this legislation and to
improve the care of veterans provided by both orthopedic
surgeons and podiatric surgeons.
Thank you for the opportunity to appear before the
Subcommittee and for your work on behalf of our Nation's
veterans. I look forward to answering any questions you may
have.
[The prepared statement of James Ficke appears in the
Appendix]
Mr. Wenstrup. Thank you very much, Dr. Ficke.
Mr. Brandt, you are now recognized for 5 minutes.
STATEMENT OF JEFFREY M. BRANDT
Mr. Brandt. Chairman Wenstrup, Ranking Member Brownley, and
Members of the Committee, thank you for inviting AOPA's
insights regarding lower extremity care for veterans. My name
is Jeffrey Brandt, and I am the CEO of Ability Prosthetics and
Orthotics. We work with seven VAMCs to provide prosthetic and
orthotic services to veterans across VISNs 4, 5, and 6.
Nationally, 80 to 90 percent of veterans' orthotic and
prosthetic care, known as O&P, is provided within the
community. The private sector's procurement relationship with
the VA and its workforce must be a part of any discussion of
care for veterans with limb impairment or loss.
TBI and amputation are signature injuries of Iraq and
Afghanistan. As of June 2015, more than 327,000 servicemembers
had suffered a TBI, which can require orthotic management. More
than 1,600 amputations had been performed for wounded warriors,
with 80 percent affecting one or both limbs. But most
amputations are a result of diabetes or cardiovascular disease.
In 2016, the VA served 89,921 veterans with amputations.
Seventy-eight percent of veterans undergoing amputation last
year were diabetic.
AOPA commends the VA for its leadership granting access to
advanced prosthetic technology, often before Medicare or
private insurance. AOPA is also deeply grateful to the VA for
rejecting a devastating prosthetics proposal put forward by the
Centers for Medicare and Medicaid Services in 2015.
When it comes to O&P care for individual veterans, in my
experience, it is very uneven. Some VAMCs have excellent
clinicians, embrace innovation, and maintain cordial working
relationships with the private-sector providers providing the
majority of care to veterans. In other places, VA staff appear
not to be very knowledgeable about O&P. Some treat private
providers as though we are competing for patients, or we are
just in it to take advantage of the taxpayer.
There are many advantages to veterans from the private-
sector partnership in O&P. Veterans receive the care they need
more quickly. Care can be provided closer to the veterans'
homes or workplaces. We often adopt cutting-edge practices and
implement innovations earlier than our Federal agency
colleagues. For example, at Ability, every new patient receives
three objective evaluations to establish their K-level, or
capacity for activity, and determine what technology is
appropriate given that classification. But the VA very often
does not use such tests or even a consistent approach in
determining those K-levels.
Frequently, the VA won't accept our evaluation, even if we
have more O&P expertise and are using a more rigorous
evaluation. If we call or write the VA to say our evaluation
shows that the patient is, for example, a K2 and wouldn't
benefit from microprocessor control technology, we often hear
comments like, ``to be on the safe side, all my patients get
that technology.''
Conversely, when our evaluation shows the veteran needs
more advanced technology than the VA perhaps recommended, we
find ourselves accused of lining our own pockets. At that
point, I have a choice: I can continue to advocate for my
patient at the expense of my relationship with the VA, or I can
fill a prescription my assessment tells me is not best for my
patient. If the veteran comes back 10 times in the next 6 weeks
because the prosthesis wasn't fit properly, then the veteran
hasn't been served, and our reputation is damaged.
All of this could be averted by use of proper clinical
protocols by the VA, and better collaboration with outside
providers.
Sometimes patients come to us having heard about new
technology. It is hard to tell a patient he or she doesn't need
the device that was featured on a magazine cover. Our tests and
data help patients understand and accept those difficult
determinations. The VA, with its concerns of fraud and abuse,
should welcome an approach that objectively determines
patients' needs.
I do see some things changing, though slowly, in some parts
of the VA. Some recent RFPs have more emphasis on outcomes,
data, and objective evaluations. But that change is uneven and
slow, and it is the veterans who suffer the most with those
delays.
Now I would like to turn to a challenge facing both the VA
and private-sector providers, and that is maintaining a highly
qualified workforce. Demand for O&P is increasing, experienced
clinicians are retiring, and we have got a shortage. Already in
California and Florida, an advertised opening can take longer
than 12 months to fill. Currently, 13 universities offer O&P
master's degrees, graduating fewer than 250 students annually.
These positions pay good wages and can't be outsourced
overseas, but master's programs are costly to expand.
The Wounded Warrior Workforce Enhancement Act, introduced
with bipartisan support by Representative Cartwright in the
last Congress would help. This bill is a limited, cost-
effective approach to assisting universities in creating or
expanding accredited O&P master's degree programs. Priority is
given to the programs that have a partnership with the VA or
DoD facilities, so students learn to respond to the unique
needs of servicemembers and veterans. We need this bill, and I
ask for your support.
AOPA looks forward to working with you to meet the needs of
veterans with limb loss and limb impairment. No veteran should
suffer from decreased mobility or independence because of lack
of access to high quality care, regardless of where it is
provided.
Thank you for considering my comments today. I would be
happy to answer any of your questions.
[The prepared statement of Jeffrey Brandt appears in the
Appendix]
Mr. Wenstrup. Thank you, Mr. Brandt.
Dr. Robbins, you are now recognized for 5 minutes.
STATEMENT OF JEFFREY ROBBINS
Dr. Robbins. Thank you.
Good afternoon, Chairman Wenstrup, Ranking Member Brownley,
and Members of the Subcommittee. My name is Jeffrey M. Robbins,
and I am the national program director for podiatry services
for the VA's central office. Thank you for the opportunity to
discuss lower extremity injuries and conditions among veteran
patients and the ability of VA to recruit and retain high
quality providers.
The VA's podiatry service is dedicated to the mission of
providing high quality foot and ankle health care to veterans.
In fiscal year 2016, the podiatry service cared for some
577,000 unique patients in over 1.4 million encounters. This is
a 12 percent increase over fiscal year 2014.
Podiatrists treat a wide variety of conditions, including
major foot deformities from both battle and other service-
related injuries, to wound and amputation care for those with
traumatic and chronic disease-related amputations. Podiatry
service performed almost 16,000 operating room procedures in
fiscal year 2016 alone.
In addition to my role as national program director for
podiatry services, I am also the national chairman for the VA's
Amputation Prevention Program, currently called Prevention of
Amputation in Veterans Everywhere, or PAVE.
The VA has been engaged in amputation prevention since
1993, after Public Law 102-405 in 1992 established the
importance of high quality amputee, and identified veterans
with amputations as a special disability group.
In 2006, the VA Oversight Committee recognized that we
needed to address new traumatic amputees from Operation Iraqi
Freedom and Operation Enduring Freedom. In order to determine
those needs and write effective policy, I have visited Walter
Reed to speak with veteran amputees, their families, and their
caregivers. As a result of those conversations, the 2006
directive on this matter added a mandatory offer of a mental
health consultation to any veteran who had or was about to
undergo an amputation. This consultation was aimed to address
the adjustment disorder common in those who have lost a limb,
regardless of cause.
In 2012, the VA's Amputation Prevention Program was
identified as an innovation by the Amputation Coalition of
America, not only for its evidence-based program, but also for
its continuous quality improvement. In fact, the latest
directive was signed on March 17, 2017.
The VA cares for 1.7 million veterans at risk for
amputation, of which 1.5 million suffer from diabetes, 46,000
suffer from end-stage renal disease, and 617,000 have
peripheral vascular disease. Overall, the VA treats over 66,000
patients yearly who have suffered an amputation, with more than
6,000 veterans having undergone an amputation in fiscal year
2016.
Podiatry services are provided in 134 medical centers and
many VA community-based outpatient clinics, and VA podiatry is
an extremely hardworking service. However, our compensation
system has fallen behind the times, as the current pay
authority is over 41 years old and was established when
podiatric medicine was a very different profession. As a
result, it has been increasingly difficult in the past several
years to recruit and retain experienced providers.
To illustrate this point, in fiscal year 2015 and 2016, we
brought in 142 new hires, for a net gain of 54. What this means
is that 88 providers left the system, or almost 62 percent of
medical centers had to replace providers, disrupting patient
continuity. Additionally, in 2016 alone, the national podiatry
standards review board processed 53 new hires. Of those 53 new
hires, 66 percent had less than 10 years of experience and only
30 percent were board certified.
The pattern that has emerged that in the past several years
is one of young providers coming into the system, gaining
experience, as well as their cases for board certification,
becoming board certified, and then leaving for the private
sector, where the average compensation, the average
compensation is $30,000 higher than the highest compensation in
the VA. In fact, 58 percent of our pay regions have reached the
legislative cap established in 1976, making it extremely
difficult to recruit and retain staff.
The podiatrists that make up the VA's podiatry services are
all proud to provide the best care they can to Americans'
veterans. We are also proud that this includes many veterans
within our ranks. As a service, we are dedicated to continuous
improvement and continue to look for ways to improve how we
care for veterans. As such, the Department of Veterans Affairs
supports H.R. 1058, the VA Provider Equity Act.
Thank you for this opportunity to address this Committee,
and I look forward to your questions.
Mr. Wenstrup. Thank you, Dr. Robbins.
I thank all of you. I am going to now yield myself time for
questions and comment.
First of all, Mr. Brandt, I want to thank you very much for
your testimony today, and I look forward to working with you
and your profession on how we can increase capabilities and
fulfill the needs of so many of our veterans. And those
numbers, as you know, are growing and the need for your
profession is greatly needed.
On the podiatry issue, it first came to my attention, not
really because I am a podiatrist, but because I serve on this
Committee, and it was brought to our attention by Secretary
McDonald during the last term that there was a tremendous
shortage of podiatry, there was a reason for the shortage, and
the need was tremendous. And at that time, the Secretary and
his staff put together a paper on the idea of being able to fix
this problem by moving podiatric physicians and surgeons into
the category of physicians and surgeons, which they are under
Medicare and throughout the States. And that would solve the
problem, increase the pay, and the problem would be solved. We
ran into some roadblocks in the Senate, as we did get a bill to
do that through the House of Representatives.
You know, first of all, I want to say that this is not
about the provider as much as it is about the patient. This is
about the veteran in need of care. And you are going to hear of
situations and the long waits, and you have heard about it
today, for so many that seek the expertise of podiatry. And
this is about recruitment, retention, and, therefore, access
for our veteran patients.
We say, do no harm. Right now, those that are being harmed
are our veterans that do not have access to podiatric care
because of the inability of the VA to recruit and retain in the
way that they could if this problem was corrected. So I thank
the Secretary and the current Secretary for their VA paper,
which is now in the record.
I want to be clear. This is not a scope of practice issue.
This is not about expanding the realm of credentialing that a
podiatrist has or has had. It is about access, access that is
stymied by a classification, by a limited career path for
podiatrists, and opposition that has come against the notion of
moving podiatrists into the category of physicians and
surgeons.
We talk about education. Podiatry is a medical school
curriculum, 4 years after 4 years of college. During that
medical school curriculum, there are 2 years of lower extremity
biomechanics that is unique to the profession. There is a 3-
year surgical residency. When completed, podiatrists have a
full prescribing license, and they are licensed to do complete
body history and physical examinations. Now, that isn't because
it was just granted; it is because it is part of the training.
Just for some comparison, because I am listening to some of
the things that were said, so I have a question for Dr. Ficke.
You have, within the American Academy of Orthopaedic Surgeons,
a foot and ankle society. Is that correct?
Dr. Ficke. Yes, there is a foot and ankle society.
Mr. Wenstrup. And you are a member of that?
Dr. Ficke. That is correct.
Mr. Wenstrup. Okay. Is there a board that you need to take
to become a member, like there is for hand, say, within
orthopedic surgery?
Dr. Ficke. There is a board of orthopedic surgery, and I
sit on that board. I write questions for that board as a foot
and ankle surgeon.
When one is in the process for which you are asking, the
person is eligible at the completion of 5 years of orthopedic
surgery residency. They sit for a written examination. I am one
of the question writing task force for the written questions.
After 2 years of case collections, those cases are collected
and submitted. Those cases are peer reviewed. When a person is,
as a specialty of foot and ankle, like hand, they sit for their
ABOS, the American Board of Orthopaedic Surgeons, on a panel of
fellowship-trained, board certified orthopedic foot and ankle
surgeons, at the end of 2 years of collection. When they are--
they succeed in the oral boards, which is, again, 2 years after
a 5-year residency, they are qualified as American Board of
Orthopaedic Surgeons. There is not a certificate of additional
qualification for foot and ankle surgeons.
Mr. Wenstrup. So when you--do you need--there are 1-year
fellowships after the 5-year residency in foot and ankle that
are available?
Dr. Ficke. That is correct.
Mr. Wenstrup. Does everyone in the society, are they
required to complete that fellowship?
Dr. Ficke. Everyone in the--which society? The Foot--
Mr. Wenstrup. The foot and ankle.
Dr. Ficke [continued].--and Ankle Society? No. The Foot and
Ankle Society is, by its constitution, embraced for anyone who
has a practice or has an interest in foot and ankle surgery
after they have completed--
Mr. Wenstrup. But not specifically the fellowship--
Dr. Ficke [continued].--a foot and ankle--
Mr. Wenstrup [continued].--like you have completed and--
Dr. Ficke [continued]. That is not a requirement for the
Foot and Ankle Society.
Mr. Wenstrup. Okay. And I hope things have changed, because
I am looking at a study--you are familiar with Foot and Ankle
International? Is that an orthopedic journal?
Now, this is a while ago, so maybe things have changed. And
your process for foot and ankle sounds like it is up to the
same measure that exists for podiatry, as far as oral exam,
written exam, and case presentation. But this abstract from
this article, ``Foot and ankle experience in orthopedic
residency,'' says: Current residency training in the United
States does not universally require commitment to foot and
ankle education. A large number of residency programs do not
have a faculty member committed to foot and ankle education,
and almost one-third have no time specifically allocated to
foot and ankle education.
Has that changed in orthopedic residencies?
Dr. Ficke. Dr. Chairman, could you tell me the date of that
publication?
Mr. Wenstrup. Yeah. It was a while ago. It was 2003.
Dr. Ficke. 2003? Yes, I am familiar with that study.
As a result of the 2003 paper, which is, you know, 14 years
ago, there has been a radical change in education. The Foot and
Ankle Society as an organization has put out a series of
lectures, has--and, really, everyone who is board certified in
orthopedic surgery is required to do a series of milestones,
and the milestones project is accredited--the ACGME, the
American Council on Graduate Medical Education, is really the
entity that reviews the milestones. And the milestones,
including foot and ankle surgery, require a rotation, require a
certain number of minimums.
Mr. Wenstrup. So since that time--
Dr. Ficke. Radically changed, similar to the podiatry
residency that we all agree have changed.
Mr. Wenstrup. Requirements.
Okay. One of the things that--I guess for Dr. Goldman, and
I want to know if you agree with this statement or not from Dr.
Ficke, it says: MDs or DOs participate in active clinical care
and multisystem trauma and disease management, which is not the
case for all podiatrists, and is a prerequisite for peer review
oversight.
Would you agree that is not the case for all podiatrists
today?
Dr. Goldman. If you could repeat the question, sir. I am
sorry.
Mr. Wenstrup. Yeah. Well, the comment was that--do
podiatrists basically actively participate in multisystem
trauma and disease management in their training?
Dr. Goldman. I would say we do, along with our medical
colleagues. Certainly, we have scopes of practice that we all
work within, and with that, certainly there is a collaborative
effort with any system condition that we may experience,
whether it be infectious disease, primary care, internal
medicine, vascular surgery, that we will collaborate that
effort.
Mr. Wenstrup. And participate actively in the care of that
patient--
Dr. Goldman. Yes, sir.
Mr. Wenstrup [continued].--correct, especially in residency
training?
Dr. Ficke, you had a concern, I believe, when we talked
before and today about the administration roles of podiatrists.
And I think your concern predominantly was clinical oversight,
podiatrists over orthopedists or, for that matter, any other
specialty.
Dr. Robbins, could you clarify for me, can a podiatrist
have clinical oversight over an orthopedic surgeon in the VA?
Dr. Robbins. No, not clinical oversight. That is actually a
joint commission requirement that peers evaluate peers. So, for
example, if a urologist was a chief of surgery, they couldn't
do an ongoing professional practice evaluation on an
orthopedist, or a psychiatrist couldn't do it, and so on. That
has to be peer to peer.
Mr. Wenstrup. And that makes sense to me. You know, you
should be able to be within your own section. So as far as that
concern, it sounds like you can't do it anyway, so hopefully
that is clarified. And I would agree with that 100 percent with
you, Dr. Ficke.
I want to applaud you for your 30 years, I believe, of
military service, your deployments, and all that you have done
for our troops. And I have enjoyed working with you on many
issues and hope to continue to do that. We may have a little
disagreement here on some things today, but I do extend that
and truly mean that.
One of the things--you talked about your roles in theater
as deputy commander. I also served as a deputy commander of
clinical services. I was the assistant to the DCCS, but for 3
months, I was the DCCS, and served at the same time as chief of
surgery in that role, and things went well. And I think it is a
small world story to be able to say that I was appointed to
those positions by your medical school roommate, Jim Terrio.
So I just wanted to clear some things up. And I want to
give other people a chance to ask their questions. And with
that, Ms. Brownley, you are now recognized.
Ms. Brownley. Thank you, Mr. Chairman. And I would agree
with all of your arguments around the need for more services to
our veterans. The only thing I would take objection to is when
the problem arise that you weren't sought out because you were
a podiatrist but because you were a Member of the Committee. I
think it has to be both.
Mr. Wenstrup. Well--
Ms. Brownley [continued]. Anyway, I wanted to ask Dr.
Robbins, you gave some statistics about the rise of podiatric
need within the VA. Can you just give me a quick explanation
why that increase has occurred? It is pretty significant.
Dr. Robbins. It is quite significant, and partially due to
returning vets from the three theaters now, Operation Iraqi
Freedom, Operation Enduring Freedom, and Operation New Dawn,
with new problems, these are young people, very complex
problems, they want to stay active, and they require,
especially if they have lower extremity injuries, they require
good podiatric biomechanical care.
We also have a significant aging population that are coming
to us with diabetes, end-stage renal disease, peripheral
vascular disease, that are at extremely high risk for an
amputation.
The VA also takes a much more enlightened approach about
what kind of basic foot care we provide. So veterans who are
blind can't get podiatric care in the private sector, patients
who have dementia cannot get podiatric services in the private
sector, patients who have movement disorders, like Parkinson's,
anticoagulation therapy, severe debilitating arthritis.
We expanded that scope of eligibility for veterans back in
2002 as we saw that, especially with the aging population
coming down the pike, that they were also at risk for
amputation, and, more importantly, for quality of life. When
you lose the ability to walk, your life expectancy goes down
significantly. So we expanded that, and that is the reason that
we are seeing increasing numbers of veterans seeking podiatric
care.
Ms. Brownley. Thank you very much. And in terms of the
salary schedules within the VA, it is my understanding that
they have been in effect since 1976. Is that correct?
Dr. Robbins. Yes, ma'am.
Ms. Brownley. And as someone responsible for these services
to veterans, why is it that this hasn't been revisited in terms
of salary schedules?
Dr. Robbins. I have actually revisited for the last 11
years writing legislative proposals to move podiatry into the
same pay authority as other physicians and dentists. What has
occurred is that we have gotten full support through VHA, but
when it got up to VA and OMB, because it had a price tag on it
of any sort, it was kicked back.
In addition to that, the OMB looked at it and said, well,
it looks like you can hire new podiatrists. We don't really
care about their experience. It appears you can hire
podiatrists. So that also when--I made the argument that we
can't hire highly experienced providers, that we were getting
inexperienced providers or older providers without board
certification, that sort of fell on deaf ears, and here we are
11 years later.
Ms. Brownley. Thank you for that. It seems like it has been
an ongoing issue.
So, Dr. Ficke, if you could talk a little bit about--I
think you mentioned it in your testimony, but--and I only have
a minute left, but if you could talk a little bit about, going
back to the accreditation requirements and, you know, comparing
the two, but could you kind of explain the barriers, from your
vantage point, barriers a podiatrist may have in providing
administrative oversight and leadership as a medical director?
Dr. Ficke. Yes, ma'am. I am seeing 30 seconds to try to
answer this. We will do our best.
The question, first of all--
Ms. Brownley. The Chairman is giving us a little more time.
Mr. Wenstrup. You can have more time.
Dr. Ficke. Thank you, Dr. Chairman.
And to attribute this, Dr. Chairman mentioned that he
served as the assistant deputy commander for clinical services.
And I will attest that at that time, Lieutenant Colonel and now
Colonel--congratulations, sir--Wenstrup did a fantastic job,
and by our mutual friendship with Jim Terrio, who was the
deputy commander, said he was exceptional.
There is no question that leadership is a character
quality. Congressman Wenstrup demonstrates that, we all would
agree. Leadership as a character quality has nothing to do with
orthopedic surgeons, podiatric surgeons, or any other training.
It is a character quality, bar none.
So that the obstacles to these really have to do with
administrative leadership, which is, as I have said--and we all
agree, chief of staff, commander of a hospital, president of a
hospital, those are roles that offer leadership enticement. And
we completely agree that those are roles that if they provide
incentives that are nonmonetary but job satisfaction for any
provider, especially in this situation, podiatric surgeons, who
we need in the VA, we completely endorse that. I hope that
answers your question.
Ms. Brownley. It does. Thank you.
And I yield back.
Mr. Wenstrup. Dr. Dunn, you are now recognized for 5
minutes.
Mr. Dunn. Thank you, Mr. Chairman. And thank you also to
the members of our expert panel here for devoting your time and
your expertise to our veterans.
Colonel Ficke, I am impressed by the vast--I too am
impressed by the vast body of your military service and
accomplishments. I served in the U.S. Army Medical Corps the
same time as you did. I am sure I--we didn't--I don't recall
crossing paths with you, but it is a big army. I think it would
be fun for us to get together sometime and swap social stories.
I want to ask you a couple of questions, and please don't
take any umbrage if it appears that I am disagreeing with your
conclusions. I am just trying to understand how you arrived at
those conclusions and how important you think your conclusions
are to the questions that we are addressing here today.
So the first one was, you evinced a concern that the term
``physician'' would be used to refer to podiatrists. I have
been a civilian for over the last 20 years, and in the civilian
world, the term ``physician'' has long since left the barn. It
has migrated to a wide variety of health care practitioners. As
a matter of law in Florida, chiropractors can use the term
``acupuncturists.''
So I wonder how important is it to our veterans, our
patients, the ones that we treat in the VA that we continue to
hue to the classic use of the term ``physician'' only to refer
to MDs and DOs? And I will wait for your answer on that.
Dr. Ficke. Thank you for your question. I certainly take no
umbrage, Mr. Congressman.
The statement that I made was that the definition by
Merriam's dictionary and several other organizations for
``physician'' is that they have passed the U.S. Medical
Licensing Examination. There are many doctors, there are
doctors of chiropracty, there are doctors of physical therapy.
That is by no implication lesser or more, superior or inferior.
It is a definition.
I don't think that--and so I would--you asked how important
that is. I think it is the least important aspect of this
testimony or this bill.
The American Academy of Orthopaedic Surgeons, the Foot and
Ankle Society, both agree that the VA desperately needs foot
and ankle care. So we have more in common, I believe, than we
do differences.
Let me ask--let me make one clear point. The difference is
there are six core competencies recognized by the double AMC,
the American Association of Medical Colleges. Those six core
competencies, one critical of those is systems-based practice.
That creates the education, the basis for care of all systems.
We are not trying to make something of this that it isn't.
That is not one of the core competencies of the APMA or the
podiatric education process. They have six core competencies,
but they don't have systems-based practices. I don't--I
really--
Mr. Dunn. So the actual term ``physician'' isn't--
Dr. Ficke [continued]. I think the most important aspect of
this is that we are--that our public and our veterans need to
understand that there are differences in training, make the
decision.
Mr. Dunn. All right. Let me go to the second question,
then, also for you, Dr. Ficke. So you have evinced a concern
about, and we have began to address this, right, just before, a
podiatrist's clinical leadership. And certainly in academia,
such as Johns Hopkins, it would be unheard of to have a
podiatrist be the chief of orthopedics. But in the military,
when I was a surgeon, I had commanding officers and leaders in
the hospital who were medical service corps officers, there was
hospital administrators for the nonmilitary, and nurses and
whatever, and I never felt that that was a problem for me or my
patients in terms of how we applied our clinical judgment or
our surgical practices.
And I think that you mentioned, Dr. Robbins, that in the
VA, the rough--you know, we wouldn't have a urologist
overseeing an orthopedic surgeon, even though that sounds
pretty good to me as a urologist, but anyway.
So what was your concern about the clinical leadership as
it were? So is it okay to have a chief of surgery in a VA
hospital who is not an MD or a DO?
Dr. Ficke. Yeah. So--yes, sir. I had addressed that concern
as far as the leadership opportunities. We agree completely.
There was a point in my career not far--long ago that I had no
single physician in supervisory roles over myself.
Mr. Dunn. I am running out of time, so just let me say,
Colonel, thank you very much again for being here, and thank
you for the time you devote to our veterans. And I would
seriously enjoy a chance to spend time with you in a smaller
group and exchange ideas.
I yield back, Mr. Chairman. Thank you.
Mr. Wenstrup. Ms. Kuster, you are now recognized for 5
minutes.
Ms. Kuster. Thank you, Mr. Chairman.
I wanted to direct my questions to Dr. Robbins. Moving on
from the credentialing issue, we have had a great deal of
discussion, most recently, with regard to the Washington, D.C.,
VA, but I know this has been an issue all around the system
about the delays for veterans needing prosthetics. We had a
conversation just this week with our colleague, Tammy
Duckworth, in the Senate about her own experience after her
injuries and getting prosthetics and prosthetics that fit and
prosthetics that worked and the delays.
So could you comment about describing our national
procedures currently and what we could be doing to make sure
that our veterans who are in need of prosthetics can get those
devices in a timely way, that they fit well, that they are
effective for their quality of life, any other suggestions that
we should be focused on in this regard?
Dr. Robbins. Well, I can't answer the question from the
prosthetics side since I am not a prosthetist or have any
authority over prosthetics. I can address it from the provider
side.
Ms. Kuster. Okay.
Dr. Robbins. So we will oftentimes need to work with
prosthetics to provide a shoe with a special insert for a
partial amputation in order to have that veteran ambulate
properly. And so we will work very, very closely with
prosthetics to provide that care.
The variation in the prosthetic departments throughout the
VA is quite significant. So we have some services that are
outstanding, some prosthetic services, that work with podiatry
get what they need when they need it; others that don't have
the same resources in order to provide that care.
And this is not something that is not something that we are
aware of. This is something that we work on year after year to
improve the work with the prosthetics folks. But, again, I
don't run prosthetics, so I can't respond specifically to that
portion of your question.
Ms. Kuster. Who at the VHA would be in charge of that? Is
that the Chief Logistics Officer? Or who works with the
prosthetic companies to make sure that--I am not so concerned
about the companies; I want to know at the VA--to make sure
that these devices are available for your patients?
Dr. Robbins. We have a department of prosthetics and
rehabilitative care services.
Ms. Kuster. And do you have any suggestions for us about
improvements to that department?
Dr. Robbins. If they are asking for more resources, they
can absolutely use resources. Because, as we just heard, the VA
is also having some issues getting well-qualified folks in
prosthetics and orthotics that have the kinds of credentials
that we now expect from those folks, and getting those people
into the VA in order to provide that care.
And also--and I think that the new Choice bill addresses
some of this, if I am not mistaken, from my brief review of
that--it also strengthens that relationship between the private
sector, so that if we can't do it, we should be able to
outsource it to someone who can in time. Just-in-time care.
Ms. Kuster. Anybody else on the panel?
And adding that dimension to it, should we be going the
private route with prosthetics? Do you think we have the
expertise in-house? Can we get it? What recommendations do you
have for your patients to get the prosthetics that they need
for their quality of life in a timely way?
Mr. Brandt. Yes. Thank you.
So, as I testified, 90 percent of prosthetics are provided
from private providers outside of the VA. If there is an
initiative to decrease that, then, you know, the VA would have
to look at how are they going to increase the qualified
providers on staff. And then you have a similar type
conversation in the O&P realm that we are having about
podiatry; how are you going to attract, retain highly qualified
CPOs, or certified prosthetists/orthotists, within the VA
system.
If the VA believes that it still wishes to have 90 percent
of that service provided through private contractors or outside
contractors, then, at least through my own experience, where I
start to see some of those gaps is the facilitation of those
cases as a need is determined by the VA and a veteran chooses a
provider.
My recommendation for veterans to get quality care is
largely related to the clinical protocol or the outcomes
measures, those aspects of the care that is being provided. Our
field, too, has sanctified over the years our educational
requirements as prosthetists/orthotists, we are now master's-
degree-holding practitioners with 1 year of residency in each,
orthotics and prosthetics, and pass board exams.
We are also seeing--with the advent of the quicker movement
of technology, we are seeing patients that want to come out of
the VA, to a private facility. Most of our private
practitioners at this point have biomedical engineering
backgrounds. And we have to interface with the VA system, where
qualifications, skill levels, protocols are a bit hit or miss.
Patient evaluations may be a bit more anecdotal. That VA
determination can, many times, come down to prior experience or
what has worked in the past, not objective tests and
assessments.
We are sitting in the private sector with protocols,
saying, all we need to do is follow these. It is not the be-all
and end-all of quality care, but it is a start. Because all of
us, whether private sector or VA, we all should be looking at
evidence-based outcomes and supporting why we do what we do.
Ms. Kuster. Thank you very much.
Mr. Wenstrup. Mr. Higgins, you are now recognized for 5
minutes.
Mr. Higgins. Thank you, Mr. Chairman.
Dr. Goldman, from your posture as president of your board,
is a podiatrist capable of making an accurate diagnosis of
diabetes based on if it is an initial examination where a
veteran has been sent to that?
Dr. Goldman. Certainly, using the entire scope of what is
available to us as laboratory data, clinical evaluation, we can
certainly make that diagnosis. I mean, it is, unfortunately,
too easy to diagnose, as we can all speak to.
Mr. Higgins. All right. I ask that because, in speaking
with veterans--and I represent a district with one of the
highest densities of veteran populations anywhere, certainly in
my State. I represent 133,000 veterans, and some of them, that
their initial symptoms that they noticed were foot pain and
problems with their feet. And that led them eventually to a
diagnosis of diabetes.
So nontreatment of diabetes leads to cholesterol and blood
pressure problems, loss of vision or vision impairment. It
doubles the risk of heart attack, kidney failure, neurological
complications, and leads me to my next question, which will be
for Mr. Brandt. Failure to treat diabetes also can lead to loss
of lower limbs and amputations. People with diabetes have
undergone 73,000 lower-limb amputations, on average, each year,
or roughly 60 percent of total amputations.
And you stated, Dr. Brandt--we have just heard Dr. Goldman
say that a podiatrist, a modern podiatrist, can make an
accurate diagnosis of diabetes. If you disagree with that,
please tell me.
But, in your written statement, you stated that ``the VA
staff making decisions, in some cases, affecting lower-
extremity care appear not to be particularly knowledgeable
about prosthetics and orthotics. Some VA prosthetic and
orthotic clinicians welcome the partnership with private
providers, while other VA staff seem to believe that some
private-sector providers are in competition with them for
patients.''
So my question, Dr. Brandt, is: How would you suggest the
VA improve coordination and communication with community
prosthetic and orthotic providers? And what are the costs to
veteran patients if effective coordination and communication is
not in place?
Mr. Brandt. Thank you for your question. And to clarify for
the record, I am not a doctor. I am just, for the record, Mr.
Brandt.
Thank you for that--
Mr. Higgins. Did I call you ``Dr. Brandt''?
Mr. Brandt. You did.
Mr. Higgins. Well, congratulations. You have been promoted.
Mr. Brandt. So, number one, the first part of your
question--I am sorry.
Mr. Higgins. I am asking regarding the coordination with
private--
Mr. Brandt. Right. So--
Mr. Higgins [continued]. Regarding prosthetics and
orthotics.
Mr. Brandt. I am sure the association could put a detailed
position forward on what could be done in the VA to facilitate
more collaboration and coordination of care.
As for me, my personal experience, that is a big topic. It
ranges from the qualifications of those certified prosthetists/
orthotists or their credentials, to continuing education, to--
Mr. Higgins. But you believe your organization could
provide for this Committee a specific recommendation regarding
that?
Mr. Brandt. Correct.
Mr. Higgins. Could you get that to us down the line? I have
one more question for you.
Mr. Brandt. Yes, I can. Thank you.
Mr. Higgins. Okay.
Your testimony indicates that, in an effort to reduce costs
and eliminate fraud and abuse, the VA dismisses clinical
recommendations made by community partners. However, you also
state, ``The VA often will make unnecessary purchases for
prosthetics which wouldn't benefit the patient.''
Could you speak more on that a little bit for us, please?
Mr. Brandt. Right. I think the easiest way to describe it
is we see instances of overprescription and underprescription.
Correcting this fits very nicely into outcomes measures, or
attempting to baseline patients. There are ways to score
patients regarding their functional levels, and then you can
track that through the treatment of a veteran with limb loss,
or any patient with limb loss. So, once you apply those
measures, it is not a silver bullet, so to speak, but it can
contribute to your overall determination of matching
componentry to functional level.
So there are methods--and this is a big topic in our
profession right now, which is advancing outcomes measures so
that we can qualify and quantify why we are doing what we are
doing. And it is not just based on things that we can't base
decisions on that we might have in the past.
Mr. Higgins. Yes, sir. Thank you.
And I will ask, if possible, regarding both of my
questions, that your organization perhaps provide to this
Committee within a reasonable timeframe some specific
recommendations that we may perhaps move forward to address
both of these concerns.
Thank you, Mr. Chairman. I yield back.
Mr. Wenstrup. Dr. Abraham, you are now recognized.
Mr. Abraham. Thank you, Mr. Chairman.
For the panel, I am an M.D. by training. I graduated from
the LSU School of Medicine in Shreveport. I have been very
fortunate to practice medicine, family medicine, in the
Louisiana and Mississippi Delta, treating thousands of veterans
and certainly tens of thousands of civilian patients.
And when I need a higher level of care, certainly in the
lower extremity, I don't look at the initials after the name; I
look at the name before the initials.
And, Dr. Ficke, you alluded to that when you referenced
character. And whether you are an M.D., a medical doctor, a
D.O., a doctor of osteopathic medicine, or a DPM, a doctor of
podiatric medicine, the patients and the veterans--to your
statement earlier, Dr. Ficke, about educating that veteran as
to the different standards, the different educational training
of those three different specialties--the veterans and the VA,
they know, but, again, the initials don't mean anything to
them. These are all physicians in their mind and certainly in
the mind of myself. Again, they want to be healed, and the
definition of ``physician'' is one of a healer.
We all, when we--and Dr. Wenstrup alluded to this--when we
applied to our respective medical schools, whether it was M.D.,
D.O., DPM, we had to write out an essay, and if we were
fortunate enough to get past the essay part, we got before an
admission board. And the question was always: Why do you wish
to become a physician? And I assure you, for every one of us in
here that are physicians, the answer was: to take care of
patients. That is what we do, as physicians.
So I think it is tragic that we are arguing over semantics
for our veterans when we have such a disparity of economy in
the VA system between what podiatrists and other physicians get
paid.
Dr. Ficke, Dr. Wenstrup, you guys practiced your profession
in what I imagine is the most trying conditions, where
artillery shells were literally going off around you. In some
cases, you were probably dodging bullets. But you did your job,
and you saved lives, and you saved limbs.
We heard today where podiatrists, D.O.s, M.D.s, we can all
do physical exams. We all understand, certainly you guys, your
specialties, in your specialties, you know bones, ligaments,
tendons, nerves, blood vessels, and how they all are
interrelated through the whole body.
So, you know, I think it is unfortunate and, in fact, silly
that we are arguing over this definition of ``physician''
between these three specialty groups of providers here. Whether
it is a DPM, a D.O., or an M.D., we are all physicians. And the
only thing that should matter here, especially for our veterans
since 9/11--you guys have been under the most trying
conditions, hundreds of thousands of patients, unfortunately
hundreds of thousands of new veterans feeding into the VA
system because of these ongoing wars that we have continuously.
I think we actually need to come together instead of trying to
fight each other here.
And I understand, Dr. Ficke, that the USMLE doesn't
recognize their board, but they have their board, and I am sure
it is as good as the USMLE board that you took.
You know, I think we are better than this. I think we need
to--I think we forget that, as physicians, our job, but not
only that, our passion is to do thing in this world, take care
of the patient, and that is our priority.
So, semantics aside, you know, let's get this behind us.
Let's get the podiatric profession and the VA up on the salary
schedule, up on the respect schedule, and let's take care of
these veterans.
And I appreciate it, Mr. Chairman. That is all I wanted to
say.
Mr. Wenstrup. Thank you, Doctor. And I appreciate that.
I am going to take another question here. And the statement
was made about systems-based care. And I am not sure where you
think that is missing in podiatry. You know, as a podiatrist, I
sometimes am the first one to find someone's hypertension,
congestive heart failure, vascular disease, neuropathy due to
diabetes or alcohol, take a skin lesion, find a melanoma, all
those things. All those things, I can tell you, I have seen and
been the first to suspect, do the proper tests, and make the
appropriate referral to the specialist. That is what we do.
I don't know why you are saying systems-based care is
missing there. Yes, we have a scope of practice surgically that
pertains to the foot and ankle, but it doesn't mean that the
systems-based care and ability to diagnose or suspect or to
order the appropriate tests, make the proper referral--that is
what we do. That is what you do. That is what you do. If you
took off a lesion on a foot and it was malignant melanoma, you
are going to refer that, I would assume.
And so I think we really need to take a look at this. And
as far as the definition of ``physician,'' I have, you know,
Webster's right here: ``a person skilled in the art of healing;
specifically: one educated, clinically experienced, and
licensed to practice medicine as usually distinguished from
surgery.'' And, in this case, we do both. Some of the
definitions I looked at, it gave the example of M.D., but it
didn't limit it to that.
And so for us to be hung up on this word, at the expense of
veterans having a large pool of physicians able to take care of
them, I think it is a shame. And I hope we can get beyond this
as we move forward with this bill. And I know we will have
continued discussions.
And I just want to finish by saying I appreciate each and
every one of you being here today, because I do know that it is
on behalf of veterans that you are all here. And we will move
on from here. And I want to thank you again for attending
today.
And Ms. Brownley?
Ms. Brownley. I just have one quick question. And my
question really, I think, doesn't directly relate to the
essence of what we are talking about here relative to the
specific bill.
But, Dr. Robbins, I just wanted to ask you--I wanted to go
back to the salary schedule again. And if you could tell me how
the VA determines the minimum and maximum allowable salaries
for physicians, for dentists? And then how do they do the same
determination for minimum and maximum allowable for
podiatrists? Are they different, or are they the same?
Dr. Robbins. Yes, they are different as of 2006 when the
physicians' and dentists' pay bill was passed. The physicians
and dentists moved into different tables and tiers, and the
podiatrists stayed in the same GS-12, -13, -14, and -15
categories as they had been, again, since 1976.
Within that process, the physicians and dentists are
boarded locally, where in podiatry we are boarded nationally--
and I am actually the chairman of the National Podiatry Board--
and qualification standards are issued. And the ones in
podiatry are from 1976, in VA Handbook 5005. And it is scary
that I know that, but that is the directive that that
information comes from.
So we are obligated to use those qualification standards in
order for us to provide a grade and rank for podiatrists, so
much so that, in the past 3 years, we have had to go through
there and write equivalencies to bring it up to 2017, because a
lot of the stuff written in 1976 doesn't really apply. So we
had to determine equivalencies, which is a document that we use
as the qualification standards now.
Ms. Brownley. Thank you. I guess my question was relevant
to the essence of what we are talking about today.
And just, you know, one final question quickly is, you
know, how many podiatrists are really expected to retire from
the VA in the next 10 years? And do we have a succession plan
in place to fulfill those jobs for current and future needs?
Dr. Robbins. We have a significant number--I don't have the
exact number, but we have a significant number of people I call
``less young'' that are approaching retirement age and that are
going to retire. And many of those folks are the mentors and
the residency directors. And someone talked a little bit about
access a little bit earlier. That has a profound potential
negative effect on access, as the more experienced providers,
who can deal with more complex problems see patients more
effectively and efficiently, are leaving the system, and
younger providers, who don't have the same experiences, can't
see patients as effectively and efficiently as those providers.
The best system, of course, is when you have mentor and
mentee and develop that kind of succession plan. What we are
hoping from this legislation is to give us the opportunity to
start recruiting some of those mid-career folks who have board
certification, have those experiences, to act as those mentors
for our younger folks. That will provide us with that
succession planning that veterans deserve.
Ms. Brownley. Thank you.
And, Mr. Chairman, I yield back.
Mr. Wenstrup. Any other questions?
Okay.
To the panel, I want to thank you all once again for good
conversation today. If there are no further questions, the
panel is now excused. Again, I thank you all for coming.
And I ask unanimous consent and all Members have 5
legislative days to advise and extend their remarks and include
extraneous material.
Without objection, so ordered.
The hearing is now adjourned. Thank you.
[Whereupon, at 4:18 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Steven L. Goldman
Dr. Chairman, Ranking member, Distinguished Members of Congress and
Guests;
At the outset I would like to express my appreciation for the honor
to address this committee today. In discussing this topic, I do so as a
private citizen and not as the Chief of Podiatry and Director of a
Podiatry Residency training program at a Veterans Affairs Medical
Center. I do so not as the former interim Chief of Surgery or the Site
Director for Surgical Services at a second VA facility, and I do so not
as a retired Lt Colonel in the United States Air Force Reserve who
served as a podiatrist and also as Surgical Operations Squadron
Commander for the last four years of my 20 year Air Force career. I am
testifying as a private citizen, one who graduated almost 35 years ago
and was an Associate Professor at the New York College of Podiatric
Medicine for nearly 15 years, during which time I witnessed firsthand
the metamorphosis of my profession. I am currently the President of the
American Board of Podiatric Medicine and in this position I represent
thousands of podiatrists around the country, many of whom are employed
by the Federal Government. As a veteran, I am now also a consumer of
the medical services of the system about which you have invited me here
today to testify.
I have witnessed the best of our profession as it has grown over
the past 35 years since I graduated in 1982. I am in awe of how far we
have come. Today, all graduating podiatrists are three-year residency
trained in podiatric medicine and surgery, and we are integral parts of
the collaborative health care delivery system, providing essential
services alongside our distinguished allopathic and osteopathic
specialists. Today's podiatrists manage the complex nature of foot and
ankle deformities and are part of the multidisciplinary team serving
the needs of a seemingly ever-growing diabetic population. We take
call, provide inpatient and outpatient care, respond to emergencies,
prescribe medications, and independently perform surgery of the foot
and ankle. Fundamentally, we perform a vital role in the continuum of
health care equal to other physicians, often for a patient population
whose only choice for healthcare is the VA. More often than not, those
patients present with more multiple comorbidities than the average
population. In the Veterans' Administration, podiatry is often the
first specialty consulted for foot and ankle care services, and we
provide more of these services than any other specialty.
Podiatrists in the private sector have witnessed salaries
commensurate with the profession's growing skills. By contrast,
salaries in the Veteran's Health Administration (VHA) have not kept
pace, and the gap grows larger every day. Podiatrists in 42 percent of
the regions across the country have reached legislatively capped rates
of pay under VHA. What that practically means is that a podiatrist at
the absolute top end of the pay charts will earn exactly the same as
much less senior podiatrist, and with no hope of ever being further
remunerated commensurate with the added time of service or experience.
Podiatrists are defined as physicians under Title XVIII of the Social
Security Act 1861(r)(3) [42 U.S.C. 1395x] *. The VA definition
of podiatry is a vestige of a 41-year-old, antiquated, 1976 VA Omnibus
Bill, and is sorely outdated. Consequently, podiatry salaries under the
Veterans Health Administration are locked into the same 41-year-old pay
scale. As a result, it is becoming increasingly harder to fill
positions and keep people with vital skills under VHA. I think we can
all agree that all of us, but particularly our veterans, deserve the
very best of care. When looking at the bell curve for salaries in
podiatry on salary.com, virtually no matter where you look by zip code,
podiatry salaries in federal services are in the lowest 10-15 percent
of that curve.
Podiatrists in leadership positions within the administration have
been members of pay panels, making salary decisions for their medical
colleagues who enjoy salaries that are, at the very least, 40 percent
greater than the top-end of VHA podiatry salaries.
Heretofore, the demographic for those seeking employment under VHA
used to be Board Certified, seasoned professionals who came with many
years of experience and who wanted to make careers in federal services.
Podiatrists currently employed by VHA remain in the system primarily
for one of two reasons; either they have a refined sense of purpose and
wish to give of themselves out of a sense of commitment to our
veterans, or they do so because they themselves are veterans and they
are compelled by a continued service mission, tending to the medical
needs of their comrades in arms. I have said many times, the Veterans'
Administration hospital system is the only healthcare system that I
have ever known where you will see a patient with one leg being pushed
to his or her appointment in a wheelchair by a patient or volunteer
with one arm, and they don't know each other. Veterans truly get this.
These goodhearted providers are getting harder to find and even harder
to keep.
Podiatrists with less than 10 years of experience make up 66
percent of the new hires at VHA. The VHA podiatry workforce has
effectively become the private sector's farm team now being filled by
younger, often non-Board Certified providers who seek to acquire the
required case volume and diversity to qualify to sit for their Board
Certification examinations and, after passing, take those skills to the
private sector where they can make a fair wage in order to repay a
student debt burden that averages, and often exceeds, $194,000.
Specifically, in 2016, only 30 percent of new hires were Board
Certified. Until we can offer better compensation, this has, and will
continue to trickle down to affect patient access because skilled,
Board certified, experienced practitioners can manage larger patient
populations more efficiently than inexperienced, younger professionals.
To make matters even worse, in 2016, the VA's average delay in hiring a
podiatrist to fill a vacant position was 14 months - that means 14
months of patients having to seek care elsewhere, or forgo necessary
foot and ankle care altogether.
Based on the salary.com data mentioned earlier, the take-away
message is that the VA's top performing podiatrists, those making the
highest possible salaries in the VA, are paid about 25 percent less
than the MEDIAN salaries of their non-VA counterparts, and in most
cases, only about half of what the top non-VA performers earn.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]1
In hospital leadership positions, both in the public and private
sector, podiatrists have had oversight of numerous surgical and medical
subspecialties, utilizing an insight of core and fundamental medical
and surgical principles. These principles, coupled with consultation
and input from the Chiefs of the respective medical and surgical
colleagues that they oversee, provide for an effective leadership
model. Should a podiatrist be the Chief of a subspecialty like
neurosurgery or orthopedics? The answer has to be, ``no more than a
neurosurgeon or orthopedist should be the Chief of Podiatry.'' But that
does not mean that a podiatrist, who is the overall Chief of all of the
surgical subspecialties, can't work with and oversee and provide
effective administrative leadership of those departments with
collaborative input from the subspecialists with whom they work.
In conclusion, Dr. Chairman, Ranking Member, and members of the
Committee, I thank you again for inviting me here to share my thoughts
with you all, and for your efforts and your desire to discuss this
topic to hopefully right this inequity. I am available to address any
questions you may have for me.
Prepared Statement of Dr. Seth A. Rubenstein
Chairman Wenstrup, Ranking Member Brownley and members of the
Subcommittee, I welcome and appreciate the opportunity to testify
before you today on behalf of the American Podiatric Medical
Association (APMA). I commend this Subcommittee for its focus to assist
and direct the Veterans Administration (VA) to effectively and
efficiently recruit and retain qualified medical professionals to treat
veteran patients and improve access to quality health care in the VA.
I am Dr. Seth Rubenstein, member and trustee of the American
Podiatric Medical Association (APMA). I am before you today
representing APMA and the podiatric medical profession, and
specifically our members currently employed, and those seeking to be
employed, by VA. I do not represent VA in my capacity today, though I
bring with me knowledge of the widespread disparity between podiatric
physicians and other VA physicians.
APMA is the premier professional organization representing
America's Doctors of Podiatric Medicine who provide the majority of
lower extremity care, both to the public and veteran patient
populations. APMA's mission is to advocate for the profession of
podiatric medicine and surgery for the benefit of its members and the
patients we serve.
Dr. Chairman, the Veterans Health Administration (VHA)
qualification standards for podiatry were written and adopted in 1976.
Podiatric education, training and practices in 1976 starkly contrasted
with those of other physician providers of the time, and with podiatric
medicine as it is today. Unlike 41 years ago, the current podiatric
medical school curriculum is vastly expanded in medicine, surgery and
patient experiences and encounters, including whole body history and
physical examinations. In 1976, residency training was not required by
state scope of practice laws. Today, every state in the nation, with
the exception of two, requires post-graduate residency training for
podiatric physicians and surgeons. In 1976, podiatric residency
programs were available for less than 40 percent of graduates. Today
there are 613 standardized, comprehensive, three-year medicine and
surgery residency positions to satisfy the full number of our
graduates, with 64 positions (or 10 percent) of those residency
position housed within the VA. In contrast to 1976, today's residency
programs mandate completion of a broad curriculum with a variety of
experiences and offer a direct pathway to board certification with both
the American Board of Podiatric Medicine (ABPM) and the American Board
of Foot and Ankle Surgery (ABFAS). These certifying bodies are the only
certifying organizations to be recognized by the Council on Podiatric
Medical Education (CPME) and VA. These bodies not only issue time-
limited certificates, but they participate in the Centers for Medicare
and Medicaid Services (CMS) Maintenance of Certification (MOC)
reimbursement incentive program. Unlike the residency curricula in 1976
(which were not standardized, nor comprehensive), today's residency
curriculum is equitable to MD and DO residency training and includes
general medicine; medical specialties such as rheumatology,
dermatology, and infectious disease; general surgery; and surgical
specialties such as orthopedic surgery, vascular surgery, and plastic
surgery. CPME-approved fellowship programs did not exist in 1976, but
since their creation in 2000, they offer our graduates opportunities
for additional training and sub-specialization. Today, podiatric
physicians are appointed as medical staff at the vast majority of
hospitals in the United States, and many serve in leadership roles
within those institutions, including but not limited to chief of staff,
chief of surgery, and state medical boards. Many of my colleagues have
full admitting privileges and are responsible for emergency room call
as trauma and emergency medicine are now also incorporated into post-
graduate training. The competency, skill and scope of today's podiatric
physicians are vastly expanded and truly differ from the podiatrist who
practiced when the statue was originally adopted. Because of this, CMS
recognizes today's podiatrists as physicians, and Tricare recognizes us
as licensed, independent practitioners.
The total number of VA enrollees has increased from 6.8 million in
2002 to 8.9 million in 2013(1). While we are slowly losing our Vietnam
veteran population, we are gaining a solid base of Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) patients, returning
from war with their unique lower extremity issues. The projected
patient population of Gulf War Era veterans is expected to increase
from 30 percent in 2013 to approximately 55 percent in 2043(1). The
number of service-connected disabled veterans has increased from
approximately 2.2 million in 1986 to 3.7 million in 2013(1). More than
90 percent of disabled veterans were enrolled in VHA in 2012(1). The
likelihood of service-connected disabled veterans seeking VA health
care generally increases with the veteran's disability rating(1). The
majority of male veterans who are currently seeking care from VA served
during the Vietnam era(1).
As a matter of fact, veteran patients are ailing and have more
comorbid disease processes than do age-matched Americans(2, 3, 4, 5,
6). This includes major amputation, where age-specific rates are
greater in the VHA compared to the US rates of major amputation(7).
Elderly enrolled veterans have substantial disease burden with
disproportionately poor health status compared to the same age enrolled
in Medicare(8). The prevalence of diabetes is substantially greater
among veteran patients compared to the general population, and
unfortunately, the data reflect that the prevalence is trending up(6).
While diabetes affects 8 percent of the US population, 20 percent of
veteran patients carry this diagnosis(9).The aging veteran population
combined with these increased rates of diabetes has increased the
burden of diabetic foot ulcers and amputations(10). Veteran patients
with one or more chronic diseases account for 96.5 percent of total VHA
health care(9). In addition to diabetes, some of the most common
chronic conditions documented in veteran patients manifest in the lower
extremity such as hyperlipidemia, coronary artery disease; chronic
obstructive pulmonary disease; and heart failure(9).
Socioeconomic and psychosocial issues often plague our veterans and
further complicate disease management. Veteran patients statistically
have lower household incomes than non-veteran patients(1). Sadly, many
of our nation's veterans are homeless and suffer from comorbid
conditions such as diabetic foot ulcers, sometimes with a level of
amputation, so management of this patient population can be extremely
challenging. Health care expenses combined with disability and
compensation coverage account for the majority of VA utilization and
have demonstrated significant growth since 2005(1).
This is the VA patient population. Patients who are statistically
comorbid with psychosocial and socioeconomic issues, all of which play
a role in the delivery of care and final outcome. The veteran
population is far more complex to treat than patients in the private
sector, as a whole. Greater than 90 percent of the veteran podiatric
patient population is 44 years and older, with the majority of patients
of the Vietnam era, who are plagued by the long-term effects of Agent
Orange. Because of this and because of the increasing number of OEF,
OIF, and Operation New Dawn (OND) veterans with lower extremity
conditions, one of the major missions as providers of lower extremity
care is amputation prevention and limb salvage.
Dr. Chairman, the value of podiatric care is recognized in at-risk
patient populations. Care provided by podiatrists, as part of an
interdisciplinary team approach, reduces the disease and economic
burdens of diabetes. In a study of 316,527 patients with commercial
insurance (64 years of age and younger) and 157,529 patients with
Medicare and an employer sponsored secondary insurance, there was noted
a savings of $19,686 per patient with commercial insurance and a
savings of $4,271 per Medicare-insured patient, when the patients had
at least one visit to a podiatric physician in the year preceding their
ulceration(11). Nearly 45,000 veterans with major limb loss use VA
services each year. Another 1.8 million veterans within the VA
Healthcare Network are at-risk of amputation. These at-risk veterans
include 1.5 million with diabetes, 400,000 with sensory neuropathy, and
70,000 with non-healing foot ulcers(12). Despite having a large at-risk
patient population from the Vietnam era, VA podiatric physicians are
seeing increasing numbers of OEF, OIF and OND patients who are at-risk
for amputation. From FY 2001 to 2014, the number of foot ulcers
increased in the OEF, OIF, and OND populations from 17 documented cases
to 612(12). Despite these statistics for at-risk patients, lower
extremity amputation rates among all veteran patients decreased from
approximately 11,600 to 4,300 between fiscal year 2000 and 2014(12).
Given the magnitude of amputation reductions, podiatric physicians not
only provide a cost-savings to VA, but we also play an integral role in
the veteran quality of life(12).
While limb salvage is a critical mission of the podiatry service in
the VA, the care delivered by the podiatric physician is of much
broader scope. As the specialist of the lower extremity, we diagnose
and treat problems ranging from dermatological issues, to peripheral
vascular disease. We perform falls prevention and orthopedic surgery.
As one of the top five busiest services in VA, podiatry provides a
significant amount of care to veteran patients, and the bulk of foot
and ankle care, specifically. In fiscal year 2014, the foot and ankle
surgical procedures rendered by the podiatry services totaled 4,794,
while foot and ankle surgical procedures performed by the orthopedic
surgery service was a sum total of 72.
The mission of VA health providers is to maintain patient
independence and keep the patient mobile by managing disease processes
and reducing amputation rates. Podiatric physicians employed by VA
assume essentially the same clinical, surgical, and administrative
responsibilities as any other unsupervised medical and surgical
specialty. Podiatrists independently manage patients medically and
surgically within our respective state scope of practice, including
examination, diagnosis, treatment plan and follow-up. In addition to
their VA practice, many VA podiatrists assume uncompensated leadership
positions such as residency director, committee positions, clinical
manager, etc. Examples include:
Steve Goldman, DPM, Chief of Podiatry and Residency
Director, Department of Veterans Affairs - Northport Health Care System
- Former Site Director for Surgical Service, Department of Veterans
Affairs - New York Harbor Health Care System;
William Chagares, DPM, Research Institutional Review
Board Co-Chair, Chair of Research Safety Committee and Research
Integrity Officer at the James A. Lovell Federal Heath Care Center;
Aksone Nouvong, DPM, Research Institutional Review Board
Co-Chair at the West Los Angeles VA;
Lester Jones, DPM the former Associate Chief of Staff for
Quality at the VA Greater Los Angeles Health Care System for eight
years, and podiatric medical community representative while serving on
the VA Special Medical Advisory Group.
Despite this equality in work responsibility and expectations,
there exists a marked disparity in recognition and pay of podiatrists
as physicians in the VA. These discrepancies have directly resulted in
a severe recruitment issue of experienced podiatrists into the VA, and
unfortunately have also been the direct cause of retention issues. The
majority of new podiatrists hired within the VA have less than 10 years
of experience and are not board certified. As a result of the disparity
the VA is attracting less experienced podiatric physicians. The
majority of these new podiatrists hired into the VA will separate
within the first five years.
Compounding the recruitment and retention issues, there exist
lengthy employment vacancies when a podiatrist leaves a station. The
gap between a staff departure to the time of filling the position is in
excess of one year. Because of employment gaps as a consequence of the
inherent and chronic recruitment and retention challenges, wait times
within the VA for lower extremity care are unacceptably long. Since
October 2014, 22,601 of the 191,501 (11.8 percent) established patients
suffered a wait time of greater than 15 days, with some greater than
120 days. During this same time period, 23,543 of the 25,245 (93
percent) new patients suffered a wait time of the same magnitude. The
prolonged vacancy exists partly because the VA is not capable of
attracting experienced candidates, but also because the credentialing
process is ineffectively burdensome.
It is precisely because of the aforementioned issues that
legislative proposals to amend Title 38 to include podiatric physicians
and surgeons in the Physician and Dentist pay band have been submitted
by the Director of Podiatry Services annually for more than 10 years
now. These proposals have been denied every single year. Additionally,
several requests for an internal fix have been denied, despite written
letters of support for this movement from former Under Secretary of
Health, Robert Petzel, MD.
Seven years ago, the APMA's House of Delegates passed a resolution
making this issue a top priority. Since then we have alerted the VA to
our knowledge of this issue. In response, former Under Secretary Petzel
created a working group composed of Dr. Rajiv Jain, former Assistant
Deputy Under Secretary for Health for Patient Care Services; Dr.
Margaret Hammond, former Acting Chief Officer for Patient Care
Services; and Dr. Jeffrey Robbins, Chief of Podiatry Service. We
participated in several meetings with members of the working group and
received written support of Patient Care Services and Podiatry Service
for a legislative solution to address this issue.
Occam's razor is a problem solving principle whereby the simplest
solution is often the best. I come before this committee today to
respectfully request that Congress help the VA and its patients by
passing legislation to recognize podiatric physicians and surgeons as
physicians in the physician and dentist authority. We believe that
simply changing the law to recognize podiatry, both for the
advancements we have made to our profession and for the contributions
we make in the delivery of lower extremity care for the veteran
population, will resolve recruitment and retention problems for VA and
for veterans. Dr. Chairman and members of the Subcommittee, thank you
again for this opportunity. This concludes my testimony and I am
available to answer your questions.
1. National Center for Veterans Analysis and Statistics, Department
of Veterans Affairs, http://www.va.gov/vetdata/index.asp
2. Singh JA. Accuracy of Veterans Affairs databases for diagnoses
of chronic diseases. Prev Chronic Dis. 2009 Oct;6(4):A126.
3. Olson JM, Hogan MT, Pogach LM, Rajan M, Raugi GJ, Reiber GE.
Foot care education and self management behaviors in diverse veterans
with diabetes. Patient Prefer Adherence. 2009 Nov 3;3:45-50.
4. Powers BJ, Grambow SC, Crowley MJ, Edelman DE, Oddone EZ.
Comparison of medicine resident diabetes care between Veterans Affairs
and academic health care systems. J Gen Intern Med. 2009 Aug;24(8):950-
5.
5. Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at
Veterans Affairs medical centers sicker? A comparative analysis of
health status and medical resource use. Arch Intern Med. 2000 Nov
27;160(21):3252-7.
6. Miller DR, Safford MM, Pogach LM. Who has diabetes? Best
estimates of diabetes prevalence in the Department of Veterans Affairs
based on computerized patient data. Diabetes Care. 2004 May;27 Suppl
2:B10-21.
7. Mayfield JA, Reiber GE, Maynard C, Czerniecki JM, Caps MT,
Sangeorzan BJ. Trends in lower limb amputation in the Veterans Health
Administration, 1989-1998. J Rehabil Res Dev. 2000 Jan-Feb;37(1):23-30.
8. Selim AJ, Berlowitz DR, Fincke G, Cong Z, Rogers W, Haffer SC,
Ren XS, Lee A, Qian SX, Miller DR, Spiro A 3rd, Selim BJ, Kazis LE. The
health status of elderly veteran enrollees in the Veterans Health
Administration. J Am Geriatr Soc. 2004 Aug;52(8):1271-6.
9. Neugaard BI, Priest JL, Burch SP, Cantrell CR, Foulis PR.
Quality of care for veterans with chronic diseases: performance on
quality indicators, medication use and adherence, and health care
utilization. Popul Health Manag. 2011 Apr;14(2):99-106.
10. Johnston MV, Pogach L, Rajan M, Mitchinson A, Krein SL,
Bonacker K, Reiber G. Personal and treatment factors associated with
foot self-care among veterans with diabetes. J Rehabil Res Dev. 2006
Mar-Apr;43(2):227-38.
11. Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG,
Defrancis RR, Wang S, Bagalman JE, Christina JR. The economic value of
specialized lower-extremity medical care by podiatric physicians in the
treatment of diabetic foot ulcers. J Am Podiatr Med Assoc. 2011 Mar-
Apr;101(2):93-115.
12. Preventing Amputation in Veterans Everywhere (PAVE) Program
Prepared Statement of Colonel (ret) James Ficke, MD
Chairman Wenstrup, Ranking Member Brownley, and members of the
Subcommittee,
On behalf of the American Association of Orthopaedic Surgeons
(AAOS), which represents over 18,000 board-certified orthopaedic
surgeons, and the American Orthopaedic Foot and Ankle Society (AOFAS),
which represents over 2,200 orthopaedic surgeons specializing in foot
and ankle disorders, I thank you for the opportunity to speak to you
today about lower extremity care for Veterans.
My name is Colonel (retired) James Ficke, and I'm an Orthopaedic
Surgeon specializing in foot and ankle care. I'm currently the Chairman
of Orthopaedic Surgery at Johns Hopkins School of Medicine. I served in
the United States Army for 30 years, deploying to Iraq from 2004-2005
as the Deputy Commander and Chief Medical Officer for the 228th Combat
Support Hospital in Mosul. I have led the Extremity War Injuries
Project Team for 12 years, an effort laser-focused upon improving care
from injury to final resolution of battlefield injuries. This effort
has identified the gaps in knowledge, as well as research needs, that
have shaped the generous Congressional funding of over $330 Million
dollars for Veterans with limb-injuries commonly sustained in combat.
There are many orthopaedic surgeons serving Veterans proudly at the
VA, and many others caring for Veterans through the Choice program.
Orthopaedic surgeons play a role in saving limbs, reconstructing
function, and returning Veterans to a healthy, active lifestyle. AAOS
was honored to receive a Joint Warfighter Program award in
collaboration with the Major Extremity Trauma Research Consortium, the
purpose of which was to determine the best evidence for treatment of
injuries to our Warriors. We were honored to receive your support for
this effort, Mr. Chairman, and we appreciate your many years of support
for orthopaedics and our patients.
We acknowledge the significant access to care challenges at the VA
in lower extremity conditions. Current statistics are staggering
regarding the burden of injury and disability. My own teams have
reported and published literature showing that up to 92% of Warriors
with battlefield injuries will have permanent disability in the
musculoskeletal system. As of 27 April 2017, 6,921 men and women have
given their lives in defense of the Constitution, and 52,540 have
sustained wounds in action, of which as many as 80% include a limb
injury - the vast majority in the lower limb. We absolutely agree that
musculoskeletal care for Veterans is imperative, and we will only meet
their needs with a strong force of well-trained providers of all
backgrounds.
Concerning H.R. 1058, the VA Provider Equity Act, AAOS strongly
agrees that high quality podiatrists should be more equitably
compensated to support their recruitment and retention. Podiatrists are
an essential part of the care team at the VA and provide excellent
service to Veterans. During my service in the Army, I practiced
alongside podiatrists in many military bases and had a podiatrist on my
staff in Mosul, who served in a non-clinical leadership role, LTC John
Gouin DPM.
AAOS and AOFAS are concerned with two aspects of the legislation
that are not essential to the goal of paying podiatrists what they're
worth at the VA. Firstly, this legislation would label podiatrists
within the VA as ``physicians,'' elevating them to the category
currently reserved for doctors of medicine and doctors of osteopathy.
Secondly, the bill would allow podiatrists to attain clinical
leadership positions over MDs and DOs.
Podiatrists and orthopaedic surgeons are trained differently. The
lower extremity is one of the more complex areas of the human
musculoskeletal system, and an orthopaedic surgeon will attend four
years of medical school, serve a five year orthopaedic surgery
residency, and typically take an additional year of subspecialty
fellowship training. MDs or DOs participate in active clinical care in
multi system trauma and disease management, which is not the case for
all podiatrists, and is a prerequisite for peer-review oversight.
While recent changes have improved podiatric education, it is not
the same as the multi-system medical education required to become a MD
or DO, nor is it the same accreditation process. They do not
participate in the United States Medical Licensing Examination, which
is the standard for all advanced medical care and essential to the
degree of MD and DO. We believe that the title of physician should be
attained through the accreditation process, and not the legislative
process.
AAOS and AOFAS stand ready to work with the subcommittee in good
faith to improve this legislation and increase Veteran access to the
care provided by both orthopaedic surgeons and podiatrists.
Thank you for the opportunity to appear before the subcommittee and
for your work on behalf of our nation's Veterans. I look forward to
answering any questions you may have.
Prepared Statement of Brandt
Ensuring High Quality Lower Extremity Care for Veterans
Testimony by the
American Orthotics and Prosthetics Association
Chairman Wenstrup, Ranking Member Brownley, and Members of the
Committee,
Thank you for inviting the American Orthotic and Prosthetic
Association to offer insights and recommendations regarding the
Department of Veterans' Affairs ability to meet the need for high
quality clinical care and procurement of prosthetic and orthotic
devices for Wounded Warriors and Veterans with limb loss and limb
impairment. My name is Jeffrey Brandt, and I am a Certified
Prosthetist/Orthotist as well as the Founder and CEO of Ability
Prosthetics and Orthotics. Since I founded the company in 2004, we have
grown to ten clinics in the states of Pennsylvania, Maryland and North
Carolina. As part of our work, we work with seven VA Medical Centers to
provide prosthetic and orthotic services to Veterans. We have active
contracts with four VAMCs across VISNs 4, 5 and 6.
I am pleased to be here today representing the Association. AOPA,
as we call it, represents over 2,000 orthotic and prosthetic patient
care facilities and suppliers that evaluate patients for and design,
fabricate, fit, adjust and supervise the use of orthoses and
prostheses. Still, sadly, fewer than half of all amputees in the United
States ever receive a prescription for a replacement limb. The
likelihood of receiving a prosthesis declines by 50% with every 10
years of advancing age. That results in percentages of US patients who
are untreated that are much higher than several European countries. Our
members serve Veterans and civilians in the communities where they
live, and our goal is to ensure that every patient has access to the
highest standard of O&P care from a well-trained clinician. It is not
widely known that 80-90% of prosthetic/orthotic care delivered to
Veterans is provided in a community-based setting, outside the walls of
a VA Medical Center. The vast majority of your constituents who are
Veterans and who need a prosthesis or orthosis received a device that
was provided and maintained by an AOPA member.
The VA contracts with community-based providers to offer Veterans
timely, convenient and high quality prosthetic and orthotic care near
the locations where they live and work. Because such a high percentage
of care is delivered by community-based providers, the private sector
workforce and procurement relationships with the VA must be a part of
any discussion of lower extremity prosthetic and orthotic care for
Veterans.
Caring for Wounded Warriors
Traumatic Brain Injury (TBI) and amputation are the signature
injuries of the wars in Iraq and Afghanistan. Traumatic Brain Injury
often manifests in the same way as stroke, with orthotic intervention
needed to address drop foot and other challenges balancing, standing
and walking. The Department of Defense Surgeon General reported to the
Congressional Research Service that from the start of 2000 through June
2015, more than 327,000 service members had suffered a TBI.
Although the death rate from conflicts in Iraq and Afghanistan is
much lower than in previous wars, the amputation rate has doubled. The
Department of Defense and the Department of Veterans' Affairs have
reported that in past wars, 3% of service members injured required
amputations; of those wounded in Iraq, 6% have required amputations.
The DoD Surgeon General reported to CRS more than 1,600 service-related
amputations from October 2001-June 2015. More than 80% of amputees lost
one or both legs. Concussion blasts, multiple amputations, and other
conditions of war have resulted in injuries that are medically more
complex than in previous conflicts. The majority of these amputees are
young men and women who should be able to live long, active,
independent lives if they receive timely, high quality, and consistent
prosthetic care.
Caring for Senior Veterans
Most Americans are unaware that the majority of Veterans with
amputations undergo the procedure as a result of diabetes or
cardiovascular disease. According to VA statistics, one out of every
four Veterans receiving care has diabetes; 52% have hypertension; 36%
are obese. These conditions are associated with higher risk for stroke,
neuropathy, and amputation.
These underlying health conditions are the reason that the number
of Veterans undergoing amputation is increasing dramatically, and is
expected to increase at an even more rapid pace in the future. VHA
Amputation System of Care figures show that, in the year 2000, 25,000
Veterans with amputations were served by the VA. By 2016, that number
had more than tripled to 89,921. Between 2008-2013, an average of 7,669
new amputations were performed for Veterans every year; in 2016, 11,879
amputation surgeries were performed. 78% of the Veterans undergoing
amputation last year were diabetics. 42% had a service-connected
amputation condition.
AOPA commends the VA for its historical leadership in ensuring that
Veterans who have undergone amputations have access to appropriate,
advanced prosthetic technology, often before the same technology is
made available to patients in the private sector. For example, when the
first microprocessor-controlled knee came to market, it was initially
considered beneficial for the fittest, most active amputees. The late
Fred Downs, then National Director of the Prosthetic and Sensory Aids
Service, was himself a Vietnam Veteran who lost an arm in combat. He
had the idea that the greater stability offered by microprocessor
control might actually be equally or more beneficial to older, less
active Veterans with limb loss who were less steady on their feet.
After testing the computer-controlled knees with older Veterans
undertaking activities such as walking in the community and riding
Metro escalators, the VA became the first payer to approve
microprocessor-controlled knees for older and less active patients.
Today, following the VA, Medicare and private insurance companies
widely accept that microprocessor-controlled knees improve safety and
increase activity levels for patients with limb loss across a wide
spectrum of activity levels.
AOPA also wishes to express its deep gratitude to the Veterans'
Administration for its feedback to the Centers for Medicare and
Medicaid Services in response to a devastating proposed policy
regarding eligibility for prosthetics. In 2015, CMS issued a draft
Local Coverage Determination (LCD) that, if enacted, would have denied
access to prosthetic technology to large groups of seniors with limb
loss, and potentially carried implications for denial of care to
Veterans as well. The guidelines in the LCD were arbitrary, were not
supported by clinical research or practice, and included provisions
such as disqualifying amputees for advanced prosthetic devices if,
during any part of the day or night, they used a cane, walker, or
wheelchair. The VA's leadership, combined with outcry by patients and
advocacy by the O&P field, resulted in the suspension of implementation
of this ignorant, unscientific and inappropriate policy.
Partnering with the Private Sector to Provide Timely, Quality Care
O&P care is unusual in that for decades, about 90% of care provided
to Veterans has been through contracts with private sector providers -
often small businesses, such as my own.
My experience with the VA, and that of my colleague AOPA members
and the Veterans we serve, is that the quality of care, the
implementation of policies, and the approaches taken by the VA to
prosthetic and orthotic services, are extremely uneven, variable, and
in many circumstances, dependent upon personalities. Unquestionably,
some VA medical centers have excellent clinicians, embrace innovation
and best practices to the extent the bureaucracy allows, and maintain
strong and cordial working relationships with private sector providers
who are responsible for the majority of care for the Veterans that
Medical Center serves.
In other places, VA staff making decisions affecting lower
extremity care appear not to be particularly knowledgeable about
prosthetics and orthotics. Some VA prosthetic and orthotic clinicians
welcome the partnership with private providers as a needed resource to
meet the growing demand for care. Other VA staff seem to believe that
some private sector providers are in competition with them for
patients, and are out to take advantage of the taxpayer with more
expensive, unwarranted components. Some VAs have begun a practice of
excluding community providers from the VA prosthetic clinic where
patients are referred to providers, or to make attendance at those
clinics dysfunctional. Contentiousness in relationships between the VA
and the clinicians actually providing the prosthesis does not serve
Veterans well. The best care is supported by a genuine rehab team
approach.
There are multiple advantages to the VA, and to Veterans, from this
long-time public-private partnership in O&P.
We are all familiar with stories about wait lists, delays in care,
and the VA's struggle to provide timely care to its patients. With a
private sector network of O&P clinics supplementing care available from
VA employees, wait times are reduced and Veterans receive the care they
need more quickly than if they were relying solely on overburdened VA
facilities and federal employees.
Community-based providers, such as myself, are often closer to
Veterans' homes or workplaces. Frequently, we offer Veterans more
convenient care, with less travel time and expense, less time away from
work, and less interruption to their daily lives.
Another significant advantage is that, in my experience, community-
based providers are often more nimble in adopting cutting-edge
practices, collecting data, and implementing innovations than our
colleagues operating in a large federal agency.
For example, at Ability, our practitioners work with every new
patient to complete a series of questionnaires and three objective
baseline outcome evaluations, to establish the patient's physical
capacity for activity. That capacity determination, called a
``functional level,'' indicates what kind of technology will best
facilitate mobility for that patient.
But the VA very often does not use such objective, validated tests,
or even an observably consistent approach, to evaluating functional
levels.
Regardless of the VA evaluation, when a Veteran comes to us with a
VA doctor's prescription for a prosthesis, we give that Vet the same
expert care that we give all our patients. Before we start work on the
prosthesis, Ability uses our own assessment process to evaluate what
will best suit the Veteran's needs. Sometimes, our evaluation confirms
the prescription provided by the VA.
When our evaluation differs from the VA's - maybe the VA evaluated
the Veteran at a K3 but we put the Veteran at a K2 - we call the VA
clinic, and ask to talk with the staff there. We ask for additional
information, including the prosthetic evaluation notes, so we can
understand why the VA recommended something different. Most of the
time, the VA staff don't welcome our call. It can take two weeks to get
a call back - two weeks when the Veteran is waiting for the medical
device that makes it possible to walk. Then the Veteran has to become
the squeaky wheel, calling the VA on our behalf to try to open the
lines of communication. When the VA staff calls us back, they're often
annoyed. They tell us that they can't share the evaluation notes with
us. They tell us that the VA's electronic medical record has no way to
extract and send information. They treat us like a vendor, instead of a
professional. They accuse us of making them look bad.
Here's the irony: in an effort to reduce costs, supposed fraud and
abuse initiated by community-based providers, the VA often won't accept
our expert professional recommendations. If we call to say our
evaluation shows that the patient is a K2 and wouldn't benefit from a
microprocessor-controlled ankle, we hear comments like ``I don't want
the Veteran to complain'' or ``to be on the safe side, all my patients
get that ankle.'' When our evaluation methodology shows that the
Veteran needs more advanced technology than was recommended by the VA's
subjective exam, we can find ourselves accused of trying to line our
own pockets by providing more advanced devices.
At that point, I have a choice. I can continue to advocate for my
patient, at the expense of my relationship with my VA client. Or, I can
proceed to fill a prescription my evaluation assessment tools tell me
is not necessarily best for my patient. If the Veteran comes back ten
times in the next six weeks because the prosthesis isn't appropriate,
then the Veteran hasn't been served, and my reputation is damaged. I
have to sit down with the patient and explain what the problem is. The
Veteran often has to go back to the VA and do his or her best to
articulate why a change in componentry might be appropriate. The VA
staff may become defensive, and accuse the outside provider of not just
providing what was initially discussed, looking for more money, and
putting the Veteran up to asking for something different. All of this
could be averted with proper clinic protocol, use of outcome metrics
and better communication.
All of us - patients, clinicians, and taxpayers - would benefit
from a more consistent, and more data-driven system. Sometimes,
patients come to our office having seen or heard about more expensive,
advanced new devices. Maybe a buddy with a similar injury received one.
Sometimes, that device is absolutely appropriate for our patient.
Sometimes, it would help the Veteran reach his highest activity
potential, and engage in activities he used to do before losing a leg.
But sometimes we find, when we go through our assessment, that that
Veteran can't really take advantage of that advanced technology, and
probably shouldn't get it. It's always hard to tell a patient that he
or she really doesn't need the new device that was featured on a
magazine cover, generated buzz in a Veterans' chat room, or that a
buddy received. We find that our process, with its objective tests and
data, is valuable in helping Veterans and other patients understand and
accept those difficult determinations. We tell them that, as time goes
on, we can always re-evaluate them by giving them the tests again, and
upgrading the technology as the data warrants. And sometimes the
opposite is true - our data helps us work with private insurance
companies to get more advanced technology for our private patients. You
might think that the VA, with its concerns about fraud and abuse, would
welcome an approach that objectively documents advanced technology for
their patients. In our experience, that's rarely the case.
There are multiple other challenges that can make it difficult for
a community-based provider, and particularly for a small business, to
work with the VA to provide care to Veterans. In brief, these include,
but are not limited to:
Contracts that expire and take more than a year to renew
Contracts that are not awarded until 12-18 months after
the bid process closes
VISNs that allow contracts to expire, and then permit any
provider to offer care, regardless of the quality of that provider
Outdated methodologies for evaluating the quality and
capacity of private sector bidders (ie, how many band saws do you have
on site?)
Accelerated approval processes for technology when
provided by an in-house VA clinician, creating incentives for patients
to shift care from a community provider to a federal employee.
Before I close on this point, I would like to make one additional
observation. Often, as Veterans, AOPA members and representatives
discuss these issues with Members of Congress and their staff,
policymakers are surprised that these problems were not solved by the
Veterans' Access, Choice and Accountability Act of 2014. O&P is not
covered by the Veterans' Choice Act. Inconsistencies in the recent VA
reforms only got part way to the target. Veterans located a distance
from a VAMC can exercise the option to see a doctor in the community
with the VA's guarantee of payment at Medicare rates. But Veteran
amputees are not accorded that option or guarantee. Nobody seems to be
able to explain why. AOPA looks forward to working with you, and with
the new Administration, to find solutions to these challenges.
As you know, the VA is a large ship, and it is difficult to turn
quickly. I do see some things changing, slowly, in some places. There
does seem to be a heightened emphasis on outcomes in some of the recent
RFPs that have been released. There are more questions being asked of
private sector providers about data and objective, rather than
subjective, evaluations of patients. But, from a small business
perspective, that change is uneven, and it's not coming quickly enough.
And, unfortunately, it's the Veterans who suffer the most.
Demand for High Quality Care is Growing While Provider Population
Shrinks
I'd like to turn now from procurement issues to a different kind of
challenge facing both the VA and private sector providers: maintaining
and growing a highly qualified workforce.
From the battlefield to the homeland, medical conditions requiring
prosthetic and orthotic care have become more complex and more
challenging to treat. New prosthetic and orthotic technology is more
sophisticated. To ensure professional, high quality care that could
respond to these shifts, earlier this decade the entry-level
qualifications for prosthetists and orthotists were elevated from a
bachelor's degree to a master's degree.
Veterans need and deserve clinicians who can successfully respond
to their battlefield injuries with appropriate, advanced technologies.
As the population of amputees grows, many experienced professionals who
were inspired to enter the field to care for Vietnam Veterans retiring.
Providing high quality care to our Wounded Warriors, Veterans, seniors,
and civilian amputees is going to require more master's degree
graduates from American universities to be the next generation of
practitioners.
The National Commission on Orthotics and Prosthetics Education
(NCOPE) commissioned a study of the O&P field, which was completed in
May of 2015. The study found that in 2014, there were 6,675 licensed
and/or certified orthotists and prosthetists in the United States. It
concluded that, by 2025, ``overall supply of credentialed O&P providers
would need to increase by about 60 percent to meet the growing
demand.'' Subsequent analysis conducted by NCOPE and AOPA suggests that
the current number of providers is closer to 5,500, an even more
significant shortage than than previously predicted. Already, my
colleagues in states including Florida, California, and Texas tell AOPA
that an advertised opening for a licensed prosthetist or orthotist can
take more than twelve months to fill.
Currently, there are thirteen schools in the US that offer master's
degrees in orthotics and prosthetics. The largest program,
Northwestern, accepts 48 students. The majority of programs have
classes of 20 or fewer students per year. Nation-wide, fewer than 250
students are anticipated to graduate with master's degrees in orthotics
or prosthetics this year.
Current accredited schools will barely graduate enough entry-level
students with master's degrees to replace the clinicians who will be
retiring in coming years. Class sizes simply aren't adequate to meet
the growing demand for O&P care created by an aging population and
rising incidence of chronic disease.
Positions as licensed, certified prosthetists and orthotists are
good jobs. Nationally, the average wage exceeds $65,000. These jobs pay
good wages, support a family, and can't be outsourced overseas. Most
importantly, they help improve the health and quality of life for our
fellow citizens - including Veterans. I am proud of my profession, and
of the work we do. Veterans, and civilian amputees, need care.
Companies need high quality employees. People want fulfilling careers.
Schools are getting more applicants for O&P programs than they can
accept. Why is this so hard?
The Wounded Warrior Workforce Enhancement Act
O&P master's programs are costly and challenging to expand. The
need for lab space and sophisticated equipment, and the scarcity of
qualified faculty with PhDs in related fields, contribute to the
barriers to expanding existing accredited programs. There are currently
no federal resources available to schools to help create or expand
advanced education programs in O&P. Funding is available for
scholarships to help students attend O&P programs, but do not assist in
expanding the number of students those programs can accept.
One way to address this problem is by passing The Wounded Warrior
Workforce Enhancement Act, introduced in the House last Congress by
Representative Cartwright with bipartisan support. This bill is a
limited, cost-effective approach to assisting universities in creating
or expanding accredited master's degree programs in orthotics and
prosthetics. It authorizes $5 million per year for three years to
provide one-time competitive grants of $1-1.5 million to qualified
universities to create or expand accredited advanced education programs
in prosthetics and orthotics. Priority is given to programs that have a
partnership with Veterans' or Department of Defense facilities,
including opportunities for clinical training, to ensure that students
become familiar with and can respond to the unique needs of service
members and Veterans. The bill was endorsed by Vietnam Veterans of
America and VetsFirst, which recognized the need for additional highly
qualified practitioners to care for wounded warriors.
In May of 2013, the Senate Committee on Veterans Affairs held a
hearing to consider the Wounded Warrior Workforce Enhancement Act and
other Veterans' health legislation. The VA testified that the grants to
schools were not necessary because it did not anticipate any difficulty
filling its seven open internal positions in prosthetics and orthotics.
The VA testified that its O&P fellowship program, which accepted
nineteen students that year, was a sufficient pipeline to meet its need
for internal staff. The VA offered similar testimony at a House
Veterans Affairs Health Subcommittee hearing in November 2015.
The Senate rejected the VA's argument. Acknowledging that more than
80% of prosthetic and orthotic care to Veterans is provided by
community-based facilities, the Committee concluded that nineteen
students could not meet the system-wide need. Committee members also
agreed that Veteransand the VA would benefit from a larger pool of
clinicians with master's degrees, whether those graduates were hired
internally at the VA, or by community-based providers. The Committee
included provisions of the Wounded Warrior Workforce Enhancement Act in
S. 1950, which passed Senate VA Committee unanimously in 2013. Due to
factors unrelated to O&P, the omnibus bill did not advance. Related
provisions were included in the Senate's omnibus package Veterans'
legislation in 2016, but were not included in final legislation passed
late last year.
AOPA looks forward to working with you to expand the number of
highly qualified prosthetists and orthotists who can meet the needs of
Veterans with limb loss and limb impairment, and to reducing the
barriers to timely, appropriate lower extremity care. No Veteran should
suffer from decreased mobility or independence because of lack of
access to high quality care, regardless of where it is provided.
I am the principal in a private sector company with my foot on the
gas pretty much all the time. I've got a good facility, and good
practitioners ready to serve Veterans. I want to give back to the folks
who have suffered in the service of our country. It just shouldn't be
this hard.
Thank you for considering my comments today, and for your
commitment to providing the highest level of O&P care for our Veterans.
If you have any questions or would like more information, please do not
hesitate to contact AOPA.
Statements For The Record
CLIFFORD J. BUCKLEY, M.D., F.A.C.S.
Commentary in Support of Improved Compensation Package for
Podiatrists Employed in the Veterans Administration
My name is Clifford J. Buckley, M.D., F.A.C.S. and I am providing a
voluntary statement in support of efforts to improve compensation for
podiatric physicians and surgeons that are employed by the Veterans
Health Administration. I feel qualified to comment on this issue
because I have relied heavily on the support provided by appropriately
qualified podiatrists in caring for patients who have problems related
to their lower extremities and especially their feet. By way of
background, I am a Board Certified Vascular Surgeon and hold the rank
of Professor of Surgery (unmodified title) Texas A&M University College
of Medicine. I have spent 15 years on active duty with the United
States Military, 15 years in the private practice of medicine and 24
years in academic medicine - nearly half of that time in association
with Veterans Health Administration. Specifically, my work with the VA
has been as Associate Chief of Staff Surgical Services, CTVHCS, Chief
Surgical Consultant VISN 17 VHA and former chair and member of the
Vascular Surgery Advisory Board to the National Director of Surgery.
Throughout my entire time working with the Veterans Health
Administration, it is my personal judgment that podiatric physicians
and surgeons have been under compensated and undervalued with respect
to their peers and to their overall role in providing comprehensive
care for the feet and lower extremities of our Veterans. This
observation spans a time frame of at least 15 years or more. In CTVHCS,
it would be impossible for me to recruit and retain Board Certified and
clinically well-qualified podiatrists if I did not have supplemental
salary assistance for our podiatric faculty provided by our University
Affiliate. Currently, VA Podiatrists appear to be compensated at a
level substantially lower than their civilian counterparts. In fact,
when I attempt to recruit new podiatric faculty, my choices are usually
limited to physicians with either medical/legal or substance abuse
problems or new training graduates who have social reasons requiring
them to remain in our local area. The primary driving factor for a
young podiatrists seeking employment with the VA and who have a desire
for some degree of academic affiliation in their practice has been
access to VA research support - financial and administrative.
Unfortunately, these young podiatrists often leave for a more lucrative
and generally professionally satisfying practice environment once they
have established at least their local reputation.
I have been extremely fortunate to have had faculty staffing our
podiatry section who are extremely well qualified, clinically
experienced and for the most part, are rear foot and ankle surgery
qualified through additional training and certification. My recent
Chiefs of the Podiatry Section have earned promotion to the rank of
Professor of Surgery because of their academic productivity, clinical
outcomes, and their regional and national reputations. Podiatrists of
this quality could not be retained at our institution without the
disproportionate supplemental salary support provided by our university
affiliate.
Podiatrists are the main stay for appropriately managing problems
related to the feet. Their knowledge and skills in wound management
identifying sources for pain and soft tissue injury and recognizing the
complications of systemic illnesses like diabetes mellitus, chronic
venous insufficiency and renal failure have saved the extremities of
countless Veterans from amputation. P.A.V.E program, which is generally
managed by podiatrists across the VA, is a shining example of their
success at quality improvement for all forms of foot care but
especially in the elderly Veteran. The ability of the podiatrists to
recognize and manage problems related to the foot is not duplicated by
any other group of health care providers. Their perspective in this
field is exceptional. Their critics have often said that ``all the VA
needs to do is hire some health technicians who can be trained to
provide nail care, orthopedic surgeons are capable of providing care
for the remaining foot issues as they occur''. Nothing can really be
farther from the truth. Podiatrists understand the biomechanics of the
foot and all of the various factors, which can produce local tissue
injury. Their ability to manage each of these issues by directly
attacking the source of the problem rather than treating sequellae is
invaluable.
I hope my comments in the above text show the strong support that
myself and my Vascular Surgery colleagues have for improving the
compensation package for VA Podiatrists. If I can be of any further
assistance in their behalf, please do not hesitate to contact me.
Clifford J. Buckley, MD, FACS
254-931-0818
LAWRENCE B. HARKLESS, DPM
RE: Commentary on HR 1058, VA PROVIDER EQUITY ACT
My name is Lawrence B. Harkless, DPM, FACFS and I am providing a
voluntary statement in support of efforts to improve compensation for
podiatric physicians and surgeons that are employed by the Veterans
Health Administration. I am qualified to comment on this issue because
of my personal experience and observations on the role provided by
qualified podiatrists in caring for patients who have problems related
to the lower extremities, and especially their feet.
By way of background, I am a Board certified foot and ankle surgeon
and have been serving for the past ten years as the Founding Dean and
Professor of Podiatric Medicine and Surgery at Western University of
Health Sciences in Pomona, California. For my over thirty-year career I
have served as a professor in the Department of Orthopedics and
Podiatry Division Chief, and Director of Residency for Podiatric
Medicine at the University of Texas Health Science Center, San Antonio,
Texas. This also included staff privileges at the Audie Murphy VA
Hospital where I was an attending physician during my thirty-year
career. I have had the unique opportunity to serve the county hospital
population in addition to the veteran's population of the San Antonio
community and beyond. I also served on a Special Medical Advisory Group
(SMAG) that advises the Secretary of the VA from 1995-2001.
During my entire career of working at UT and Audie Murphy VA it IS
my own opinion that podiatric physicians and surgeons have been
undercompensated and undervalued in comparison to their peers, and to
their role in providing comprehensive care for the feet and lower
extremities of veterans. The VA continues to have trouble recruiting
and retaining experienced podiatric providers due to low compensation.
The VA can recruit young providers out of residency but once they
become Board certified and more experienced, they leave the VA for the
private sector. Several of my former residents, who were destined for
academic careers, have not taken VA positions due to this low
compensation. Our veterans deserve better.
The ability to attract and retain experienced podiatric providers
has affected access. With a projected increase of over 400,000
additional veterans coming into the system, the VA will continue to
struggle with access unless the VA can offer better compensation for
podiatric physicians. Legislatively capped VA clinical podiatrists in
nearly 58% of the regions receiving locality pay have reached the
legislatively capped rate of pay for the executive schedule which has
resulted in significant reduction in pay over the past decade for many
of highly productive and experienced providers.
The Center for Medicare and Medicaid Services (CMMS) is already
defining podiatrists as physicians under Title XVIII. The VA's
definition is from the 1976 Title XXXVIII Omnibus Bill, and it is an
outdated thirty-year old law. Podiatrists share the same inpatient/
outpatient on call and rounding responsibilities as any other
physician's profession.
The VA is central to residency education and training for
podiatrists. It trains more podiatric medical residents than any health
system. It's important to attract the best and brightest as they will
provide leadership in education, research and service to the next
generation of podiatrists who will care for the veterans. Moreover they
will have an impact with interprofessional teams in improving foot
health for the veteran population.
Podiatry has the most important role in keeping America walking.
Their knowledge and skills in the management in foot problems in the
areas of diabetes, aging and arthritis are noteworthy. Congress now
finds itself with the opportunity to make long needed improvements in
the VA health care delivery system, and I hope my testimony will
encourage the House to do the right thing for our veterans and America.
Sincerely,
Lawrence B. Harkless, DPM
LBH:mb
PVA
PARALYZED VETERANS OF AMERICA (PVA)
Chairman Wenstrup, Ranking Member Brownley, and members of the
subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to offer our views on VA specialized services
for lower extremity conditions. PVA represents the voice of
approximately 60,000 veterans in the U.S. who live with paralysis of
the lower extremities due to spinal cord trauma, multiple sclerosis,
amyotrophic lateral sclerosis, and other dysfunctions. We are grateful
to be part of this discussion.
Loss of lower extremity function related to the spinal cord often
includes loss of other functions, such as genitourinary, digestive, and
reproductive. It may also be accompanied by chronic nerve pain, muscle
spasticity, muscle atrophy, and skin breakdown. For this reason,
medical professionals who are trained in spinal cord injury medicine
are best equipped to provide medical care for this population of
mobility-impaired veterans. Paralyzed veterans are the largest cohort
of veterans who rely of specialized services in VA and have the fewest
alternative choices for care and long term institutionalization. The
overwhelming majority of paralyzed veterans suffer lower extremity loss
of use (exceptions include central spinal cord, which only affects the
upper extremities, and some veterans with regressive MS). They rely on
prosthetic devices such as wheelchairs, power chairs, power-assist
chairs, patient lifts, auto adaptive equipment, home adaptive
equipment, and other mobility solutions.
No one is more affected by provider shortages than those veterans
with complex injuries who rely on VA to treat their specialized needs.
Unfortunately, VA has not maintained its capacity to provide for the
unique health care needs of severely disabled veterans-veterans with
spinal cord injury/disorder, blindness, amputations, and mental
illness-as mandated by P.L. 104-262, the ``Veterans' Health Care
Eligibility Reform Act of 1996.'' As a result of this law, VA developed
policy that required the baseline of capacity for Spinal Cord Injury/
Disease System of Care to be measured by the number of available beds
and the number of full-time equivalent employees assigned to provide
care.VA was also required to provide Congress with an annual
``capacity'' report to be reviewed by the Office of the Inspector
General. This reporting requirement expired in 2008, and was reinstated
in last year's ``Continuing Appropriations and Military Construction
and Veterans Affairs Appropriations Act for FY 2017.'' This report, a
critical tool of oversight, should be made available to Congress by
September 30 of this year. However, we have serious concerns about VA's
plan to re-implement this requirement.
Additionally, VA Prosthetics has been problematic for quite some
time in a number of ways. The gap between policy, where the Prosthetics
National Director resides, and operations, under which the facility
prosthetics office operate, has created sweeping inconsistency in how
prosthetics policy is implemented. Individual facilities are allowed to
enact or interpret policies that make it difficult for some veterans
with lower extremity impairment to get needed devices in a timely
matter. Resolving local problems is difficult because the National
Prosthetics Office has no authority over the field prosthetics office,
who report to the respective VISN.
New prosthetics policies are being developed without the
substantive input of external stakeholders. While stakeholders have
been invited to participate in workgroups and on the Federal Advisory
Committee for Prosthetics & Special Disabilities, the input from these
groups rarely if ever affect the policy being developed (e.g. Clothing
Allowance policy is still exclusive and punitive for those veterans who
seek a second clothing allowance; power chairs are still not considered
a factor in damaged clothing despite the consensus of the workgroup
that argued otherwise, etc.).
Existing prosthetics policies have not been properly followed in
many locations, particularly in the area of customized wheelchair
choice and backup wheelchair provisions. Some prosthetics offices allow
for loose interpretations of policy that make it more difficult to get
the mobility device that s/he chose and was supported by physician/
therapist prescription. Documented cases of injury due to the issuance
of ill-fitted mobility devices and the lack of a viable backup in the
event a veteran's primary mode of mobility becomes damaged have not
been thoroughly addressed by VHA leadership.
PVA supports H.R. 1058, the ``VA Provider Equity Act,'' bill to
clarify the role of podiatrists in the Department of Veterans Affairs.
Podiatrists at VA are currently classified among optometrists and other
allied health professionals, rather than among physicians and dentists.
The VA pay scale incorrectly differentiates podiatrists from other
physician providers. The resulting salary discrepancies are significant
and create further challenges for VA in the recruitment and retention
of podiatrists. With an aging population of veterans, the demand for
podiatrists is growing. Parity in pay among other physicians will allow
VA to better resource the health care system to meet the needs of
veterans. This legislation provides the VA with tools needed to address
current and future demand. In order to transform the culture and
timeliness of care, Congress must enable VA to quickly hire a competent
workforce with competitive compensation that ensures VA is a first-
choice employer among providers.
Thank you for the opportunity to present our views on these issues.
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