[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


          VA SPECIALIZED SERVICES: LOWER EXTREMITY CONDITIONS

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

                                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

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       
       


         Available via the World Wide Web: http://www.fdsys.gov
                     
                     
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
29-681                      WASHINGTON : 2018                     
          
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). 
E-mail, [email protected].                    
                     
                     
                     
                     
                     
                     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 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            C O N T E N T S

                              ----------                              

                          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

                              ----------                              


                          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.

                                 [all]