    [House Hearing, 118 Congress]
    [From the U.S. Government Publishing Office]

                        LIFE AFTER LIMB LOSS: EXAMINING
                          VA AMPUTEE PROSTHETICS CARE
    =======================================================================

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                          WEDNESDAY, NOVEMBER 20, 2024

                                   __________

                               Serial No. 118-89

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                  __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    57-945                    WASHINGTON : 2026
    =======================================================================

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           MIKE LEVIN, California
    MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
    GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK,
    C. SCOTT FRANKLIN, Florida               Florida
    DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO,
    MORGAN LUTTRELL, Texas                   Pennsylvania
    JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
    ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
    KEITH SELF, Texas                    GREG LANDSMAN, Ohio
    JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                             SUBCOMMITTEE ON HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

    AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California,
        American Samoa                       Ranking Member
    JACK BERGMAN, Michigan               MIKE LEVIN, California
    GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO,
    DERRICK VAN ORDEN, Wisconsin             Pennsylvania
    MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
    JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

    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

                                  ----------

                          WEDNESDAY, NOVEMBER 20, 2024

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     3

                                   WITNESSES
                                    Panel I

    Mr. M. Christopher Saslo, DNS, APRN-BC, FAANP, Assistant Under
      Secretary for Patient Care Services/Chief Nursing Officer,
      Veterans Health Administration, U.S. Department of Veterans
      Affairs........................................................     4

            Accompanied by:

        Dr. Joel Scholten, Executive Director, Physical Medicine and
            Rehabilitation, Veterans Health Administration, U.S.
            Department of Veterans Affairs

        Dr. Ajit Pai, Executive Director, Office of Rehabilitation
            and Prosthetic Services, Veterans Health Administration,
            U.S. Department of Veterans Affairs

        Mr. J. Drew Craig, Design Chief, Enterprise Measurement and
            Design Directorate, Veterans Experience Office, U.S.
            Department of Veterans Affairs

                                    Panel II

    Mr. Jose Ramos, Vice President of Government and Community
      Relations, Wounded Warrior Project.............................    18

    Mr. Matt Brown, U.S. Army Veteran, The Independence Fund.........    20

    Ms. Ashlie White, Chief Strategy and Programs Officer, Amputee
      Coalition......................................................    22

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Mr. M. Christopher Saslo, DNS, APRN-BC, FAANP Prepared Statement.    35
    Mr. Jose Ramos Prepared Statement................................    40
    Mr. Matt Brown Prepared Statement................................    52
    Ms. Ashlie White Prepared Statement..............................    54

                           Statements For The Record

    U.S. Government Accountability Office Prepared Statement.........    57
    Mr. Scott Restivo Prepared Statement.............................    64
    The American Legion Prepared Statement...........................    66

                        LIFE AFTER LIMB LOSS: EXAMINING
                          VA AMPUTEE PROSTHETICS CARE

                                  ----------

                          WEDNESDAY, NOVEMBER 20, 2024

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:30 p.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meek [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meek, Bergman, Murphy, Van
    Orden, Luttrell, Brownley, Landsman, and Budzinski.
        Also present: Representative Rouzer.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. Hearing for the Subcommittee on Health
    will now come to order. Today we will be discussing the
    Department of Veterans Affairs' (VA) Amputation System of Care
    (ASOC) and the services provided to veteran amputees. At VA
    prosthetics include a wide range of devices, from eyeglasses to
    hearing aids to prosthetic limbs. If I could manage to turn the
    page. Although our main focus today will be on amputee
    prosthetics, I want to highlight the VA's recent failures
    related to purchasing and budgeting for prosthetics. In July,
    committee staff visited the Rocky Mountain VA Medical Center in
    Colorado and discovered that thousands of prosthetic orders had
    been improperly canceled. As a clinician, I was appalled that
    this could happen and it is clearly unacceptable.
        Earlier this month, I was informed that the VA's claimed
    budget shortfall for healthcare, which they argued was related
    to the cost of prosthetics, was a huge exaggeration. If the VA
    cannot even budget correctly for prosthetics and routinely
    cancels orders, how can veterans, especially those living with
    the visible wounds of war, trust that they will receive the
    prosthetics they need? We cannot and should not accept this as
    status quo. Prosthetic care is essential to the bedrock of VA's
    mission. This means assisting veterans with regaining
    functionality and working to improve their quality of life
    after limb loss as a result of their service in uniform. Each
    year, VA sees approximately 95,000 new amputations, primarily
    due to vascular disease or diabetes. However, VA also treats a
    significant number of post 9-11 veterans with combat related
    amputations.
        As veterans' needs evolve, it is the VA's responsibility to
    provide the highest quality of care and advances in research to
    meet those needs. VA services vary across its facilities, but
    its seven fully equipped regional amputation centers can offer
    comprehensive care from prosthetic fabrication to full
    inpatient rehabilitation. These centers should set the standard
    for world class care for prosthetics, and in many cases they
    do. VA's amputee care serves nearly 100,000 veterans annually,
    with many receiving exceptional care. However, the committee
    has heard of significant delays in veterans receiving their
    prosthetics.
        For one example, one veteran recently told my team that he
    has spent over a year waiting for a functional prosthetic leg.
    For 10 of those months, as you can see here, he had to rely on
    duct tape to hold his prosthetic together. Since March 2023, he
    has been forced to travel out of State every 3 months for
    appointments. Despite these repeated trips, there is still no
    timeline for when he will receive his new prosthetic limb. Now,
    it should not take a congressional hearing for him to hear back
    from the VA or for the VA to respond to this veteran. He should
    receive the latest state-of-the-art updated prosthetic limb
    now, ASAP. Veterans depend on these devices for their daily
    lives and waiting for years for our prosthetic limb, socket, or
    terminal device is unacceptable. I expect we are going to hear
    similar stories today.
        Like other VA offices, VA's amputation centers face
    understaffing and are often riddled with bureaucratic
    inefficiencies. These challenges, exacerbated by the Biden
    Harris Administration's poor leadership and staffing decisions,
    are uniquely devastating to veteran amputees. These
    bureaucratic delays not only impact veterans physical health,
    but they also take a toll on their mental well-being, resulting
    in more time in healthcare facilities and less time spent with
    their families enjoying life or advancing their careers. As a
    veteran and a physician, I know we can do better. In addition
    to these issues, veterans face barriers in accessing adaptive
    prosthetic limbs and terminal devices for sports and
    recreational activities. Devices that can be life changing. The
    committee has heard numerous stories of veterans being denied
    these adaptive prosthetics. That is why I recently introduced
    H.R. 9478, the Veterans Supporting Prosthetics Opportunities
    and Recreational Therapy Act or the Veterans Sport Act. This
    bill would ensure these adaptive prostheses and terminal
    devices are defined as clinically necessary for veterans living
    with limb loss.
        I am committed to working with the VA to ensure we provide
    our veterans with timely, high quality prosthetic care that
    they deserve so that they have access to what they need to live
    the most fulfilling life possible and the most fulfilling work.
    During today's hearing, we will delve deeper into these issues,
    hear from witnesses and work toward common sense solutions.
    Thank you all for being here and I look forward to a productive
    discussion on this critical topic.
        Before I introduce the witnesses on our first panel, I ask
    unanimous consent that our colleague, Representative David
    Rouser be waived on for this hearing. Hearing no objection. We
    will move forward. I now will yield to Ranking Member Brownley
    for any opening remarks you may have.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank you Chairwoman Miller-Meeks and thank
    you to our witnesses for being here today. Veterans living with
    amputations deserve access to the most comprehensive pre and
    post amputation care that VA can provide. I am looking forward
    to hearing from our VA witnesses on Panel One about how they
    currently provide this care and areas of improvement and
    advancements that they are seeking. I am also looking forward
    to hearing from our Panel Two witnesses about their own
    experiences and experiences of those they represent with VA
    care.
        Veterans with amputations from any cause must receive well-
    coordinated and comprehensive care from providers including
    their physicians, physical and occupational therapists,
    prosthetic providers and mental health providers. It is crucial
    that we support the provisions of all these types of care to
    ensure that every veteran receives the unique combination of
    these services needed to meet their medical and personal goals.
    While I understand that not every VA facility has the capacity
    to manufacture prosthetics, I look forward to hearing more
    about how VA is working to build in house capacity while
    continuing to work with contracting and vendor partners,
    improve communication with providers in the community, and
    ensure it is providing wraparound services for veterans in its
    care.
        I am especially glad to hear of the work VA is doing to
    both prevent disease progression to avoid amputation as well as
    to the advances in technology and treatment options available
    for those who do receive amputation. This includes VA programs
    like the Preventive and Amputation in Veterans Everywhere or
    PAVE, a program that has been established at every VA medical
    facility and researched through the VA center for Limb Loss and
    Mobility. As we continue to advance our medical understanding
    of these diseases, they can lead to the need for amputations. I
    am sorry, that would lead to the need for more amputations. We
    must continue to improve the care we are providing our
    veterans.
        It is also clear we are living in a time of exciting
    advancements for prosthetic options. With the use of telehealth
    technology, VA providers can be more connected than ever to
    ensure veterans and other providers are communicating about
    veterans' prosthetic needs. Additionally, with advances like 3D
    printing, we have more control than ever over how and where VA
    can manufacture prosthetics and ensure a proper and effective
    fit. I look forward to hearing more about how VA is already
    using this technology and how it can be expanded upon. This
    will be especially important for women veterans who make up a
    small but growing number of the total patients with amputations
    that receive care at VA.
        As U.S. Government Accountability Office (GAO) notes in its
    statement for the record for this hearing, women veterans have
    reported facing difficulty in finding properly fitting
    prosthetics as they are generally sized for men. However, the
    ability to 3D print prosthetics that are designed to fit their
    bodies and accommodate their clothing and shoe options will be
    revolutionary for women veterans. I am also grateful to Mr.
    Ramos and Mr. Brown for being here and willing to share their
    experiences and expertise, as well as Mr. Restivo who has
    submitted a statement for the record. I find this committee's
    work is most impactful when we can hear a variety of veterans
    experiences with the care VA provides and identify common
    ground where those services and care can be improved. I look
    forward to continuing that today.
        Finally, I welcome hearing from our witnesses at the
    Amputee Coalition about its work to support VA's amputation
    care. Having the support of a community of individuals who
    understand the challenges of living with any physical change is
    crucial, including for veterans living with amputations. I am
    glad the Coalition can provide that through its Peer Visitor
    Program and National Support Group Network, and I am looking
    forward to hearing more about the types of support that we can
    expand upon. Thank you again to our witnesses and for being
    here and I yield back.
        Ms. Miller-Meeks. Thank you Ranking Member Brownley.
        I would now like to introduce the Panel One witnesses
    testifying before us today. We have Dr. Christopher Saslo,
    Assistant Undersecretary for Health Patient Care Services at
    the Department of Veterans Affairs. Accompanying Dr. Saslo
    representing the Department of Veteran Affairs are Dr. Joel
    Scholten, Executive Director of Physical Medicine and
    Rehabilitation, Dr. Ajit Pai, Executive Director, Office of
    Rehabilitation and Prosthetic Services and Mr. Drew Craig,
    Design Chief, Enterprise Measurement and Design Directorate,
    Veterans Experience Offices (VEO). Dr. Saslo, you are now
    recognized for 5 minutes to deliver your opening statement.

                   STATEMENT OF M. CHRISTOPHER SASLO

        Dr. Saslo. Good afternoon, Chairwoman Miller-Meeks and
    Ranking Member Brownley and members of the subcommittee. I
    appreciate the opportunity to address the subcommittee today
    regarding VA's amputation system of care. Joining me today as
    you heard is our Executive Director for the Office of Rehab and
    Prosthetics, Dr. Ajit Pai. I am also accompanied by the
    Executive Director of Physical Medicine and Rehab, Dr. Joel
    Scholten and Mr. Drew Craig, who is our Design Chief for VA
    Enterprise, Measurement and Design Directorate. My colleagues
    and I are pleased to share how VA cares for veterans with limb
    loss. Overarchingly, the department employs an
    interdisciplinary team based approach focused on maximizing
    each veteran's functional ability and independence. Each
    amputation procedure presents unique challenges which requires
    specialized follow-up care. VA is committed to building on our
    record of excellence when addressing amputation related needs
    of our veterans. We provide lifelong specialty care benefits
    which includes ensuring access to advanced prosthetics and
    instructor rehabilitative services. VA's amputation system of
    care connects the Nation's heroes to the expert services as
    close to their home as possible.
        In Fiscal Year 2024, the amputation system of care provided
    care to 18,387 veterans through 38,122 encounters that included
    7,896 virtual visits. The roughly 18,000 veterans we cared for
    represents a significant 12.5 percent increase in our
    prosthetic health delivery over Fiscal Year 2023. Further, new
    patients experience a low average wait time of 26.5 days.
    Patient satisfaction remains high in Fiscal Year 2024 with the
    95 percent of our veterans reporting feeling respected during
    clinic visits and 92.8 percent reporting satisfaction with
    their inclusion in care delivery. The Amputation System of Care
    model emphasizes lifelong care which centers on the whole
    health of each veteran including physical and mental well-
    being. Key pillars include preoperative education so that they
    know what to expect throughout their wellness journey.
        VA performs annual assessments thereafter as part of the
    Whole Health approach which incorporates peer support and
    adaptive supports. We also offer comprehensive training for
    providers, specialists, patients, caregivers and families. The
    U.S. Department of Defense (DOD) and VA continue to collaborate
    to ensure seamless, high-quality care for service members and
    our veterans. VA and DoD utilize the Extremity Trauma and
    Amputation Center of Excellence to advance discovery and
    clinical practice. In service to veterans' whole health, the
    department creates new mutual educational programming and has
    created a network of amputation rehab coordinators. In
    conjunction with the DoD, VA's Office of Advanced Manufacturing
    allocates resources to develop and manufacture U.S. Food and
    Drug Administration (FDA) compliant advanced medical devices.
    In recent years, VA has made significant prosthetic
    advancements. We modernized our workflows through the
    implementation of 3D technology and through increased use of
    our telehealth visits.
        Other current innovations include a 3D printed foot system
    to enable veterans to wear shoes of any size type and heel
    height. VA is also testing a prosthetic system which allows
    users to feel touch through their prosthetics. The next gen
    prosthetic devices utilize advanced algorithms to produce real
    time measurements which improves functionality. Surgical
    advancements includes the ERTL technique, targeted muscle
    reinnervation and FDA approved osseointegration implantation.
    VA's groundbreaking research includes a multi-site study which
    tests an internally developed bone anchored prosthetic docking
    system. At VA, we do much of our work to create positive
    veteran outcomes from within. However, we also rely on private
    sector partners to advance our mission of care. The network of
    veterans service organizations aid VA in caring for veterans
    experiencing delays or challenges with amputation related care
    and we continue to learn at every opportunity.
        Chairwoman Miller-Meeks, Ranking Member Brownley thank you
    again for your opportunity to provide remarks on VA's holistic
    approach to amputee care. Our commitment to ensuring that all
    veterans receive the solutions and respect they deserve remains
    steadfast. My colleagues and I are ready to address any
    questions you may have on how we can advance our mission.

        [The Prepared Statement Of M. Christopher Saslo Appears In
    The Appendix]

        Ms. Miller-Meeks. Thank you very much, Dr. Saslo. As has
    been my protocol, I will defer my line of questioning to the
    end. I now recognize Ranking Member Brownley for 5 minutes for
    any questions she may have.
        Ms. Brownley. Thank you. Thank you, Madam Chair. Dr. Saslo,
    the GAO's statement for the record for this hearing identified
    that one of the issues facing VA researchers in this area,
    particularly for women veteran research, is recruitment, giving
    the smaller population. Can you expand on how VA is addressing
    this challenge?
        Dr. Saslo. Yes, ma'am. I will start off, and then I will
    turn it over to my colleagues. We have a number of ways that we
    continue to advance the research of our female veterans. Of
    course, you mentioned the Rehabilitation and Engineering Center
    for Optimizing Veteran Engagement and Reintegration (RECOVER)
    center, which we look at our 3D printed foot. We also have done
    a number of research studies since 2017. We have actually
    completed seven studies. We have five that are ongoing, and we
    have one that is a new study. We can actually offer that into
    submission for the record to actually go over all the different
    studies that we have been working through. I will turn it over
    to Dr. Pai and Dr. Scholten.
        Dr. Scholten. Thank you, Dr. Saslo. I would also add that
    VA uses the electronic health record so we can identify and
    recruit subjects not only from the site where the research is
    being conducted, but we can actually recruit nationwide to
    improve the pool of applicants and increase the number of
    females in the study. The Office of Research and Development
    also includes funding support for travel and some of these
    studies where there is a harder time to recruit individuals, so
    they will include the travel piece within the research budget.
    Finally, the Office of Research and Development also has
    developed the Women's Enhancement recruitment process, which is
    a toolkit that all researchers can use so we can increase the
    number of female participants in all of our research studies.
        Ms. Brownley. Can we have the new research that Dr. Saslo
    referenced written into the record?
        Ms. Miller-Meeks. Without objection.
        Ms. Brownley. I wanted to--so you know, in reading my staff
    report here, that 73 percent of veterans who need prosthetics
    is because of diabetes and not because of injury, which is just
    a shocking statistic to me. I will just say that it seems as
    though the VA should be so razor focused on diabetes to prevent
    them ever having to come over to your department to get some
    form of prosthetics. I think with women, I have to assume that.
    I think the women population is about 20 percent in that area.
    In terms of veterans who have received prosthetics. I have to--
    my sense is that women are more likely to need a prosthetic
    because of injury and not diabetes since they are younger. You
    know, they are younger and we did not have women fighting in
    Vietnam, for example, and so forth. If you agree with that
    assumption, then I am very interested in this new study that
    you are talking about. Is there anything more that you can be
    doing for women who need to receive a prosthetic because of an
    injury? Is there anything more? I know the 3D printing I think,
    is a big one. I would be interested to know kind of what the
    women's satisfaction level is within the VA in terms of those
    who receive a prosthetic. If you could just talk a little bit
    more.
        Dr. Saslo. I will just comment on the fact that as you
    heard me mention earlier, our satisfaction stories overall are
    very high. However, to your point, we continue to look at how
    we can focus our efforts on our growing population female
    veterans, as you mentioned. As they are a younger population
    and our fastest growing population, I will turn it over to Dr.
    Scholten, who may be able to address a little bit further.
        Dr. Scholten. Yes, unfortunately, I do not have the
    breakdown of VA trust scores, female versus male in the
    amputation clinic, but we do make every effort to outreach to
    of female veterans with limb loss. We have. We actually rely
    very heavily on our Veteran Service Organization (VSO) partners
    to encourage female veterans to engage with VA and engage with
    the amputation----
        Ms. Brownley. If you guys, I only have 17 seconds left, but
    if you could talk a little bit about what the VA is doing with
    regards to diabetes and addressing that so that we can reduce
    this percentage of veterans who need a prosthetic.
        Dr. Scholten. We have a complete diabetes management team
    and our Patient Aligned Care Teams (PACT) implement that with
    veterans. As you mentioned before, the PAVE Score or the PAVE
    program helps with prevention of amputation. There is a whole
    health approach essentially for the prevention, for the
    wellness and the diabetic management in order to prevent
    amputation care.
        Ms. Brownley. Thanks.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley. The
    Chair now recognizes Dr. Murphy for 5 minutes for any questions
    he may have.
        Mr. Murphy. Thank you, Madam Chair, and thank you all to
    the witnesses for coming today. I think your assumption that
    older veterans that are primarily female, I just think seeing a
    lot of older patients myself, generally diabetes is worse in
    older individuals and as far as the amputation risk, it is much
    higher then. You know, guys, I serve on this committee because
    I am not a veteran, but one out of ten of my constituents are
    and I am increasingly now just frustrated upon frustrated upon
    frustrated about delays, missed appointments, not being able to
    get referrals. I just want to pull my hair out. I had a long
    call with one of them yesterday who was at his wit's end and
    bounced around VA's gets referred back and forth. You get sent
    to community care. The community care doctor cannot send you to
    an appropriate referral. They have to bounce you back to your
    primary person who may or may not really get to that. The VA
    has lost yet another opportunity to provide excellent care to
    our veterans.
        When it goes on with prosthetics, this is difficult time. I
    mean, I get it. It is not only a change in your ability to
    ambulate or to pick up something, it is also just a change in
    your entire mental calculus on how you view yourself. Delays
    just in these type of instances where you have veterans delayed
    in wheelchairs for extended period of times, not ambulatory,
    not able to get things back. I am reading about the difference
    between the philosophy of DoD versus veterans and how veterans
    actually prefer DoD because they want to get their life back
    and get back into action, if you will, is really something, I
    think a particular note. Just if I can get a few questions, Dr.
    Saslo, can you tell me how the VA is ensuring that individuals
    with lower limb loss who are confined to wheelchairs due to
    malfunctioning prosthetics, legs sockets, how do they receive
    timely repairs? How do they receive replacements that restore
    their mobility? Do you have any statistics that tell me about
    timeliness?
        Dr. Saslo. Well, I will start off with the timeliness
    piece, sir, and that is that our access itself actually falls
    below the target of 28 days, where our access metrics show an
    ability to get veterans into care within 26 days. While that is
    not ideal----
        Mr. Murphy. Can you define into care?
        Dr. Saslo. Getting into an appointment?
        Mr. Murphy. Okay.
        Dr. Saslo. While that is not ideal, we certainly want to
    try to make sure that our veterans mobility is addressed as
    quickly as possible. I do not know if, Dr. Scholten, you would
    like to address it a little further.
        Dr. Scholten. Sure. I am not sure I can speak specifically
    to the sub cohort of individuals you are referring to that have
    had a challenge with their prosthetic device or their
    wheelchair. We have done extensive work to and we are launching
    a wheelchair repair contract which will help improve access for
    veterans and the speed and efficiency to get wheelchair repairs
    made. We encourage for any veteran with limb loss that is
    engaged with their amputation team they have the ability to
    communicate by phone, by secure message, and any way possible
    to try to connect with the team and allow for the appropriate
    appointment to occur in a timely manner.
        Mr. Murphy. Does the VA monitor anything of any
    complications that can occur from delays? You know, you delay a
    wound, you get cubitus ulcers, you get some other things for
    people sitting in wheelchairs and et cetera, et cetera. Does
    the VA monitor any of that? That is a quality measure that the
    private world does.
        Dr. Scholten. I do not have any specific information on
    that question.
        Mr. Murphy. Can you guys tell me briefly about training
    that our prosthetic staff at the VA gets, how they deal with
    these cases? What kind of individuals are training our
    veterans?
        Dr. Saslo. Sure. Dr. Pai.
        Dr. Pai. Yes, happy to answer that. We have robust training
    programs for rehabilitation therapies, whether they are
    physical therapy, occupational therapy, as well as for
    Certified Prosthetists and Orthotists (CPO). We have the most
    robust training programs for certified prosthetists, orthotists
    in the country. We have 15 sites that train 26 trainees
    annually. The majority of these individuals are recruited then
    for VA employee employment down the line. We can use these
    programs as our pipeline.
        For physical therapy, we have 54 training programs not
    specific to amputee care, but in general, over 900 trainees and
    the majority of 80 percent of physical therapy trainees are
    recruited down the line for VA employment.
        Mr. Murphy. You know, I get that the world. I was in a
    physical therapy office in the civilian world in my district, I
    do not know, six, 8 weeks ago. Very difficult to find physical
    therapists, as with any healthcare official or position these
    days. I will tell you, I just am getting more and more and more
    frustrated to hearing from our veterans that they cannot access
    a system that is built for them. There are frustrations, and it
    is not just with this particular committee meeting, of access
    to community care, access overall. I will tell you, I am
    hopeful that in the next administration, the new veteran
    secretary is going to really shake up the VA to determine that
    we are doing things costly, I mean, cost effectively and
    efficiently, and most importantly, providing quality and timely
    care to our veterans. Guys, I just, you cannot sell a product
    that is not working for the people to whom it is supposed to be
    purchased. By whom it is supposed to be purchased. Thank you,
    Madam Chair. I am going to yield back.
        Ms. Miller-Meeks. Thank you, the chair now recognizes the
    gentlelady from Illinois for whatever questions she may have.
        Ms. Budzinski. Thank you, Madam Chair. Thank you to our
    Ranking Member and thank you to the panelists for being here on
    a very important topic today. Taking a look at amputee
    prosthetic care for our veterans. I wanted to pick up just on
    what Ranking Member Brownley was talking a little bit about
    specifically around our women veterans. The GAO report on
    prosthetics for female veterans. One issue that was raised by
    veterans was the lack of commercially available prosthetic
    options that VA providers can use to meet women's needs. My
    question is for Mr. Saslo, what steps has the VA taken to work
    around these challenges present in the prosthetics market
    generally and specifically for women veterans? As a second
    question, how do these challenges differ by type of limb loss,
    such as lower versus upper limb loss?
        Dr. Saslo. I will be happy to start, but one of the things
    I want to emphasize is that, as Dr. Scholten mentioned earlier,
    we really do rely on our electronic health record to really
    look at how we can match the needs of our specific veteran
    population to how we can best address treating them. One of the
    things I think is also important to recognize is that we
    partner very aggressively with our Office of Research and
    Development in looking at how we can develop those recruitment
    processes in order to be able to study our female veterans as
    well as the rest of our population. One thing I will say is
    that we recognize that lower limb loss is a much higher
    prevalence than our upper limb loss. I think we have done a
    great deal of research when it comes to how our upper limb loss
    can be addressed, especially in our female veterans. I will
    talk to, I will let Dr. Scholten talk a little bit more about
    that.
        Dr. Scholten. I would just add that each individual, each
    veteran is treated as an individual, so they are assessed and
    provided an individualized plan of care. That, of course, would
    include which type of amputation they have experienced, as well
    as what are their goals, what were their recreational
    activities, pre-amputation, as well as things they are
    interested in doing post amputation. The VA has also partnered,
    as Dr. Saslo mentioned, with our research partners. As a result
    of that, I did want to reemphasize that the RECOVER program,
    which is out of the Minneapolis VA, they have created a 3D
    printed custom ankle, custom printed foot system so you can
    adjust the heel height to accommodate whichever shoe you want
    to wear. We have made some significant advancements to provide
    some unique customization for prosthetic devices for females.
    There is certainly a long way to go. There is not a lot
    commercially available, but we are hoping to rely on the
    innovation of our VA staff to help move the needle forward.
        Dr. Pai. Add to that, at the Denver VA, they are working
    specifically on upper extremities, so different size hands for
    women Veterans and at the Tampa VA they are looking at the
    prosthetic--they call it a brasthesis or sports bra for women
    with upper limb needs.
        Mr. Craig. Yes. I just wanted to add, we recently completed
    a deep dive into amputee and adaptive driving in the Veteran
    Experience office. Two of the things that we came away clearly
    hearing as bright spots was that veterans truly appreciate the
    way they are treated as individuals, which is not something we
    normally hear when we are out doing our research and also the
    passion of the providers. I mean, I can imagine how it would be
    pretty easy to be very passionate about this, but that is two
    of the bright spots. I think it goes to what you were asking.
        Ms. Budzinski. Thank you. Thank you. If I could just. With
    the time I have remaining, I wanted to shift gears to rural
    health and accessibility. Mr. Saslo, I understand the VA's
    amputation system of care operates as a tiered system with four
    levels of care into which each medical facility is classified.
    How does the VA ensure that care is consistent across its
    medical facilities, particularly in rural areas where we know
    in districts like mine, we just have fewer providers.
        Dr. Saslo. I think the really great part is that as the
    amputation system of care not only has a regional amputation
    centers, but they also have the polytrauma amputation network.
    It is across the entire country where it is a very
    comprehensive training program that is done every year. We work
    with not only the facilities, the providers, but we also make
    sure that there are opportunities for us to learn from our
    community partners. The other thing that I think we are very
    proud of is our mobile prosthetics, which we have. It is a
    rural funded prosthetics process. We have 15 sites in 11
    states, including 32 of our Community-Based Outpatient Clinics
    (CBOC). We are looking at expanding to another five sites just
    in Fiscal Year 2025. I think there is an awful lot of
    opportunity. We have served over 4,200 veterans using that
    process with over 6,000 visits.
        Ms. Budzinski. I will yield back. Thank you.
        Ms. Miller-Meeks. Thank you. The Chair now recognizes
    General Bergman for 5 minutes for any questions he may have.
        Mr. Bergman. Thank you, Madam Chairwoman. Thanks for all of
    you for being here. I am going to ask a question that I do not
    expect an answer to because inside you will know what your
    answer is and not necessarily to be talked about now, is the VA
    being reactive or proactive on the majority of the time? Okay.
    The answer is sometimes you got to be either, you know, each
    different. Okay. Proactivity tends to lead toward less need to
    be reactive, if that makes, you know, any kind of sense. Having
    said that, Dr. Saslo, how does the VA ensure its prosthetists?
    That is a tough one to roll off the tongue. Prosthetists stay
    informed about the latest advancements in prosthetic limb
    technology and innovation?
        Dr. Saslo. Thank you for the question. I think, as we
    mentioned a little bit earlier, there is a lot of training that
    goes on not only from a national, but a regional. We also use
    the concepts of having the three regional amputation centers
    that our physical medicine rehab have fellowships on. We try to
    make sure that we make training as available as we can.
        Mr. Bergman. I know, I think you, probably because I walked
    in late, you might have already answered that in some way,
    shape or form.
        Dr. Saslo. Yes, sir.
        Mr. Bergman. Okay, so let me ask you a slightly different,
    from a different angle, is there any modeling and simulation
    that is used? If that was asked before, I apologize. To do what
    you do.
        Dr. Scholten. I would just add that we work very closely
    with the Department of Defense to review all emerging evidence
    when it comes to amputation care and update our clinical
    practice guidelines every 5 years. In addition, we partner with
    DoD to have training opportunities to learn about the latest
    advancements in prosthetic technology as it emerges so that
    service members and veterans have access to the latest
    technology.
        Mr. Bergman. Okay, well, I am not making a pitch for
    anything in particular here, but each year, Sunday after
    Thanksgiving through the Tuesday, but the show floor opens on
    Monday, Interservice/Industry Training, Simulation and
    Education (I/ITSEC) Modeling and Simulation Conference takes
    place in Orlando. It is a place where obviously a lot of DoD
    folks go, and there is a lot of innovative technologies there
    and good panels, good education. I would suggest if somebody
    from the VA is not attending, it is like you are missing a
    chance to not have to rely on the DoD for what it might tell
    you is there. I would be proactive and send somebody down
    there. Dr. Saslo, what is Veterans Health Administration (VHA)
    doing to get real time feedback from the amputee patient
    population to take corrective action when necessary, and also
    address local facility level issues? What kind of real time
    feedback chain do you got going?
        Dr. Saslo. In addition to the patient satisfaction surveys
    that we use, we also have a veteran experience that looks at
    how we can improve and what we have done. With that, I will
    turn it over to Drew because he is got some really great,
    robust information.
        Mr. Craig. Yes, sir. Each of the outpatient journeys has a
    stop code that is associated with a particular type of clinic,
    and the stop code that is associated with amputation the scores
    are remarkably high among ease, effectiveness, emotional
    resonance and transparency, equity. The lowest score on this
    for this quarter is 83.5. That is graded on a liker score of 1
    through 5. If they give us a 4, I trust I agree with the
    statement made or I strongly agree that we consider that an
    indication of satisfaction with that particular piece. 93
    percent overall satisfaction and 89.4 percent in overall
    quality. These are assessed by ongoing. What triggers the
    survey is a visit to the amputation clinic and then the veteran
    receives a survey. It is not 100 percent, it is not a canvas,
    it is surveys. Out of this one this quarter we have received
    384 responses from veterans who were seen for amputee issues.
        Dr. Saslo. If I could just add on to that really quickly,
    we have a process called a completed post-delivery checkout
    where we look to try to make sure that the veteran actually has
    the opportunity to tell us that we have met their needs, what,
    how their fit is, what their performance is, what their comfort
    is. So far, that we have been successful in trying to address
    81 percent of those. While our goal is always 100 percent, we
    have actually improved our scores of being able to do those
    evaluations to 81. We continue to move that forward. Sir.
        Mr. Bergman. Thank you, Madam Chair. I yield back.
        Ms. Miller-Meeks. Thank you very much, General Bergman. The
    Chair now recognizes Representative Landsman for 5 minutes for
    any questions he may have.
        Mr. Landsman. Thank you, Madam Chair. Dr. Saslo, I just, in
    your testimony, you talked about the work that you all are
    doing to address the gaps in orthotics and prosthetic services.
    Including challenges, limited access. Including challenges like
    limited access in the Midwest. I represent the 1st
    congressional district in Ohio. That is southwest Ohio, and was
    hoping you could talk a little bit about some of the
    strategies. Just going into greater detail on what you all are
    doing to address those gaps. What we should be doing, where I
    should be doing to be helpful. It is to everyone. Starting with
    you, Doctor.
        Dr. Saslo. Sure. I appreciate that. As I mentioned earlier,
    one of the things we are proud of is the fact that we do
    utilize our mobile prosthetics. We also have other mechanisms
    that we are trying to make sure, such as our in-house
    fabrication at 89 different sites. I do not know, Dr. Pai, if
    you would like to also address some of the opportunities.
        Dr. Pai. Yes, certainly. Our prosthetists will oftentimes
    use scanning technology to get a sense of the limb that is
    needed to be fabricated. Right. If they do not have the
    fabrication lab onsite, then they can send that out to a
    centralized fabrication lab within VA that is in house. Then
    the limb is created there, the components, the socket that is
    fabricated, plus the different components are sent back to the
    facility. The prosthetists onsite can put that together and
    work with the veteran. They can make adjustments there at their
    location. They can also do those adjustments in those mobile
    prosthetic vehicles. It is called Mobile Prosthetic and
    Orthotic Care (MOPOC) that we have at those 15 sites. Then the
    other thing that we do quite a bit is virtual care. If, and
    maybe Dr. Scholten, you want to talk about virtual care from an
    ASOC standpoint.
        Dr. Scholten. Sure. We have, as Dr. Pai mentioned, we have
    leveraged virtual care extensively in order to not only improve
    access, but also equity across all areas of the country. Really
    focusing on our rural areas, we have been able to expand our
    amputation clinic team. Now there are only nine VA sites that
    do not have a full team. Now a full team would be considered,
    may include some virtual team members that are beaming in to
    kind of participate with the veteran and the therapist or the
    provider that is with the veteran. We have, we are down to only
    nine sites that do not have a fully functioning team. We
    leverage our other VA capabilities of beneficiary travel in
    order to kind of--in order to allow access for veterans to get
    to the right level of care. In Fiscal Year 2024, we did perform
    almost 8,000 virtual care visits really to really emphasizing
    how we are reaching out to veterans.
        Mr. Landsman. Considering all that, very helpful. As we
    look at next year's budget or finishing this year's budget,
    which will most likely happen next year. What as it relates to
    these gaps which sound like are being filled or you all have
    strategies, is there anything that I should be pushing for are
    those of us who represent Midwest districts should be pushing
    for to be helpful?
        Dr. Saslo. I think, as I mentioned, you know, we are
    looking at the expansion of those mobile sites as well. The
    mobile sites being Fiscal Year 2025, the mobile prosthetics
    labs. One of the other things I think is also important is that
    we really do rely on our community partnerships as well. In
    those areas where VA cannot provide the fabrication or the
    prosthetic services, we try to make sure that our community
    partners are heavily engaged. The one thing that I think that
    we continue to work at evolving is how those partnerships can
    be strengthened in making sure that we are delivering the same
    type of care through our community partners as we do through
    the VA because we have recognized that there are some gaps in
    the way that our customer satisfaction exists and we have
    opportunities to improve that.
        Mr. Landsman. It is great. Thank you all. I yield back.
        Ms. Miller-Meeks. I thank you very much Representative
    Landsman. The Chair now recognizes Representative Luttrell for
    5 minutes for any questions he may have.
        Mr. Luttrell. Thank you, Madam Chair. Well, good afternoon,
    gentlemen. Mr. Saslo, you and Mr. Scholten mention the
    electronic healthcare records and how that information shares,
    how you are gathering information. Just going to piggyback off
    of Mr. Landsman's statement and Ms. Budzinski statement, I
    think, because there seems to be a shortness when we are
    dealing with women veterans on the sizing, sizing scope and
    scale of their prosthetics. Now, I am very well aware that the
    electronic healthcare record system is broken. There is only
    six facilities out of 172 facilities in the continental United
    States that communicate to each other. My question is, maybe
    you can enlighten me on this. I am trying to get clarification
    on this as we kind of wade through these difficult waters. How
    are you aggregating enough data that you can share across
    multiple sites if only six sites are talking to each other?
        Dr. Saslo. I am not sure where the six sites information is
    coming from, sir, but all of our----
        Mr. Luttrell. I just talked to the Secretary today.
        Dr. Saslo. All of our sites have the ability to draw data
    from across the entire enterprise.
        Mr. Luttrell. Communicate to all 172 sites?
        Dr. Saslo. Yes. The CBOC's as well, it draws from the
    electronic health record, depending upon the type of data you
    are trying to pull. It will go oftentimes by diagnostic code.
    It will actually look at the age, the demographics as a whole.
    Much of our data that we have through the Office of Prosthetics
    and Rehabilitation, actually we have individuals that work on
    that data aggregation and help us to drive the care that we are
    providing for it. I do not know, Dr. Pai, if you would like to
    expand on that a little bit more.
        Dr. Pai. Yes, certainly. You are alluding to the disparate
    Veterans Health Information Systems and Technology Architecture
    (VistA) systems that are in our Legacy----
        Mr. Luttrell. Yes. Yep. Correct.
        Dr. Pai. All of that data does get pulled into our data
    bases, our national data bases that we were able to pull data
    from for, to aggregate and to review on a national level. We
    can utilize that data to provide direction to our clinicians in
    the field or to our clinical programming.
        Mr. Luttrell. From Washington State. All the way to the
    Bronx. You guys can communicate without any interruption?
        Dr. Pai. Yes.
        Mr. Luttrell. It is fascinating because I am going to take
    what you are telling me and, and I am going to go back to Mr.
    Elnahal, have the same conversation.
        Dr. Pai. As a clinician, so I worked in a facility as a
    clinician for a number of years. During that time, I could look
    at. We could be able to pull in records from other VA's through
    our joint Legacy viewer or even through the Vista system.
        Mr. Luttrell. Okay, is there a, for lack of a better term,
    is there an enclave that exists inside the VA when it comes to
    aggregating amputees data set data information that--because if
    I understand this correctly, and I have too many friends that
    are missing limbs, there is a series of stages that go along
    with. Once they lose their limb, they get their primary,
    secondary, tertiary, and then their final prosthetic. Is there
    an enclave in place that these data facilities that the VA
    facilities can access? If a veteran is in one of the remote
    places that says, hey, look, here is the next phase of
    evolution when it comes to the prosthetics for a below the knee
    amputee, this is what our private industry has implemented into
    the space. Then you reach out to the veteran and say, hey,
    look, phase 20 or whatever is ready to go. We have it for you.
        Dr. Scholten. Thank you for that question. We have some
    capability, but we cannot get down to the granularity that you
    are speaking of about the specific subtype of amputation and
    the potential prosthetic device or evolution of a prosthetic
    device that might be necessary. What we do have is we have our
    FLOW 3 system, which allows us to track on an individual
    veteran level, the process of their prosthetic prescription and
    then all the way through to delivery and checkout process. We
    can monitor that timeline. We do not necessarily have a way to
    kind of retrospectively go back and identify every veteran with
    a specific type of amputation that might benefit from a new
    prosthetic.
        Mr. Luttrell. You would think in 2025 we might have that
    capability with artificial intelligence and machine learning.
    Is this one of those spots that the VA is kind of behind?
        Dr. Saslo. I think when it comes to using the use of AI----
        Mr. Luttrell. I am trying to. I am just----
        Dr. Saslo. No, sir.
        Mr. Luttrell. I am just trying to make this easier on our
    veterans. It seems like we may be behind the eight ball a
    little bit when it comes to advances in technology for the VA
    and helping our veterans out.
        Dr. Saslo. We recognize the use of AI is actually
    propelling us in healthcare to be able to do a better job. I do
    not know that we are there yet.
        Mr. Luttrell. Okay. Madam Chair, I want to thank you.
        Ms. Miller-Meeks. Thank you, Representative Luttrell. The
    Chair now recognizes Representative Rouzer for 5 minutes for
    any questions he may have.
        Mr. Rouzer. Thank you, Madam Chair. I appreciate that very
    much. I have got a witness that will come up in the next panel,
    but my question is for you all now that I have the opportunity.
    Thank you. It seems to me that in so many cases, you have
    veterans that need prosthetics or whatever the issue may be,
    that everybody seems to be treated as a number, you know, on
    somebody's desk. I recognize the inherent difficulties with the
    bureaucracy, et cetera. When these veterans come in and they
    need help and they need care, why do not we have a system where
    you assign somebody to see their case all the way through? You
    have all these check boxes, and they check this box, but then
    they have to wait 8 months to get to this box, and then another
    8 months to get to this box or 4 months or whatever it may be.
    It just seems to me like it could be organized in a much better
    manner, and perhaps it takes more personnel to do it this way.
    After all, they are our veterans. I mean, you have got a
    Congress that is willing to invest in these things. Any comment
    on that or any thought on that? Has that ever been discussed
    where you basically have a caretaker in the sense of guiding
    them through the bureaucracy and make sure that their case does
    not fall through the cracks?
        Dr. Saslo. I think it is really important to recognize that
    the whole concept behind the amputation system of care really
    does rely on an interdisciplinary team. Sometimes that case
    manager for that particular veteran may be a prosthetist, it
    may be the clinician, but we are also looking at how we can
    maximize the care delivery and the continuity that you are
    speaking to using the concepts of care coordination, integrated
    case management. For those patients that are high risk, high
    visibility, what we are trying to do is to identify someone who
    takes that ownership of that veteran's care from start to
    finish. I do not know if, Dr. Pai, if you would like to address
    the additional pieces of ASOC.
        Dr. Pai. Yes, so care coordination is paramount in this
    population. We want to ensure that we are able to provide our
    veterans with that type of service. Right. Sometimes. I know
    our offices work with your office and the network, and we want
    to ensure that we are hearing when there are issues like that
    and there are gaps, because then we want to try and fix them.
    We did hear from, and I do not know if Mr. Craig, if you want
    to talk about the VEO discussion with veterans on post 9-11,
    but that was something that we heard from veterans that would
    allow us to do better in the future.
        Mr. Craig. Yes. Our research that I spoke about earlier
    focused on post 9-11 combat amputees and their experience
    between DoD and VA and private sector. One of the things that
    certainly came out of that research was that they do need
    someone to help them navigate the system so that they do not
    get put in line behind others who may not have as big a need
    just based on when they were signed up for an appointment. A
    number of our research projects for different populations have
    borne that out. That is something veterans desire.
        Dr. Saslo. If I could just add one other thing, and that is
    to your point, I think we do have the opportunity to refine
    that. I think that we, as we have other navigators for
    specialized types of care like our cancer navigators and things
    like that, we have the opportunity to refine that even more.
        Mr. Rouzer. Well, I think there is a number of cases out
    there that you do not even know about because veterans, they
    just give up. You know, they at least ought to be able to get
    their phone call returned when they call. I mean, it is very,
    very frustrating for every Member of Congress and Madam Chair,
    I have probably taken more time than I should have been
    allocated. I will yield back and wait for my opportunity to
    introduce our witness.
        Ms. Miller-Meeks. Thank you very much, Representative
    Rouzer. I now yield myself 5 minutes for any questions I may
    have. Dr. Saslo, I have heard reports of veteran amputees being
    denied adaptive prosthetics. How many veterans have been denied
    adaptive prosthetics in the past year? What justification is VA
    providing for these denials or Dr. Scholten.
        Dr. Scholten. Thank you for that question. I will go ahead
    and take that. We certainly do not, we do not have the number
    of, when you say veterans that have been denied prosthetics, we
    do not have that number. Each veteran is seen and provided an
    individualized plan of care. That care plan is based on the
    veterans desires to engage in the community and also their
    medical comorbidities and other psychosocial factors. Our
    amputation teams are encouraging veterans to participate in
    recreational activities. We are able with our prosthetic
    regulations to provide any device provided it is FDA cleared
    that is in clinically indicated for a veteran. While that
    development of that individualized care plan allows us for
    those items, even though they are recreational type items, to
    be clinically indicated to enhance their community
    participation.
        Ms. Miller-Meeks. My staff has been in contact with a
    veteran who has been waiting all year for a prosthetic leg. He
    was told by the Nashville Veterans Affairs Medical Center
    (VAMC) that his delay was due to a backlog of 4,000 prosthetic
    devices. Do you think this is acceptable?
        Dr. Scholten. I do not. I do not.
        Ms. Miller-Meeks. What immediate steps is the VA taking to
    address this significant backlog?
        Dr. Scholten. I would be happy to hear get some information
    about that specific veteran case.
        Ms. Miller-Meeks. Thank you. Is the VA leveraging community
    care and third-party vendors to alleviate this backlog? Is
    there anything preventing the VA from outsourcing more
    effectively to ensure timely prosthetic care and access?
        Dr. Pai. I am happy to answer that question. While I
    specifically do not know, or I cannot answer specific to the
    you said Nashville or Tennessee backlog. In general, we do
    leverage community vendors, providers that are prosthetists. We
    work very closely with them. About 2/3 of prosthetic limb
    fabrication is provided out in the community. Our clinical
    teams are the amputation team that Dr. Scholten has described,
    they work in concert with those community providers. Oftentimes
    when a veteran is there getting their prosthetic limb or
    getting their therapy, our clinical team has beamed in with
    telehealth so that they can ensure that the veteran is getting
    the care that they deserve.
        Ms. Miller-Meeks. To better understand the scope of this
    issue, I would like a list of every VA medical center that
    currently has a prosthetic backlog. To be specific, I would
    exclude glasses, hearing aids, scleral shells. I am speaking of
    limb prosthetics, arms, legs, hands, et cetera, broken down by
    item type by December 20th.
        Dr. Saslo, you mentioned earlier about the whole health
    approach and the annual assessment. We know that the majority
    of amputees come from vascular disease or peripheral vascular
    disease or peripheral arterial disease, which could be diabetes
    or other types of peripheral arterial disease or PAD. We also
    know that the life expectancy or mortality once one has been
    diagnosed with PAD is quite significant above 50 percent. My
    question is, given that you have a whole health approach and an
    annual assessment, is the VA screening for PAD with a simple
    device such as an ankle brachial index test?
        Dr. Saslo. Yes, thank you for that question. I think one of
    the examples I think is really important is what we are doing
    with regards to our remote temperature monitoring and our
    sensory Podiometric Smart Map that allows us to actually
    identify veterans that are at risk. We also have things called
    the siren socks or the Orbix insoles. We are taking every
    advantage that we can to identify early diagnoses so that we
    can do prevention. One of the things that we have been able to
    be successful with is actually reducing the number of
    ulcerations based upon some of these uses by about 15 percent.
    We have actually seen a reduction of about 37 percent in our
    amputations and admissions to hospitals of about 10 percent. I
    think it is really important that this is just one set of tools
    that we use when it comes to addressing peripheral artery
    disease.
        Ms. Miller-Meeks. In the 2019 Rand report, and this is
    coming off of some of the other questions, the US Army noted
    that for all individuals sustaining combat amputations, the
    goal is to return them to the highest level of activity they
    wish to achieve. In contrast, the standard of care at the VA
    focuses on returning amputee patients to a community ambulation
    level. I certainly understand that with the majority of
    amputees in VA care being elderly and from vascular disease. It
    enables them to perform basic activities of daily living, not
    to the highest level of activity they wish to achieve. Should
    not the VA hold itself to the US
        Army standards, particularly for post 9-11 service
    connected amputees to ensure they can function to their highest
    potential? Or do we need to legislate that there is a priority
    given to returning young amputees back to a full life daily
    activities?
        Dr. Saslo. We completely agree that we want to return
    people to the full extent of their activity of daily living,
    which is one of the reasons why we really have been trying to
    push for our veterans to get the equipment that they need to be
    as flexible as they can be. One of the things that I think
    reflects that is the number of adaptive sports programs that we
    have that helps to highlight what the capabilities are for
    those veterans that may be seeking to improve their quality of
    life.
        Ms. Miller-Meeks. Thank you so much. On behalf of the
    subcommittee, I want to thank all of you for joining us today.
    You are now excused, and we will wait for a moment as the
    second panel comes to the witness table.
        [Recess]
        Ms. Miller-Meeks. I would now like to introduce the panel
    to witnesses testifying before us today. We have Mr. Jose
    Ramos, Vice President of Government and Community Relations at
    the Wounded Warrior Project. We have Ms. White, Chief strategy
    and Programs Officer at Amputee Coalition. Then I am going to
    recognize Representative Rouzer to introduce our third witness.
        Mr. Rouzer. Well, thank you, Madam Chair and Ranking Member
    Brownley, I greatly appreciate you having this hearing today.
    It is a great honor for me to introduce Mr. Matt Brown. He is
    an army veteran that currently resides in my district. It is an
    honor to represent him. Mr. Brown served in the United States
    Army as a member of the 82d Airborne, assigned to Fort Bragg,
    or what is now known as Fort Liberty, North Carolina. After
    active duty, Mr. Brown continued his service in the Maryland
    National Guard before moving to Wilmington and founding
    Energize Group Dental Marketing. A very successful businessman.
    Today, the committee will hear firsthand from him about his
    very, very frustrating experience dealing with the Fayetteville
    VA Medical Center while acquiring his or trying to acquire his
    prosthetic.
        My team and myself have worked very diligently to get his
    case resolved, and it almost took an act of Congress just to
    get him elsewhere to actually receive the prosthetic that he
    needed. He will go into much greater detail, but it really is a
    very disturbing set of facts that he reveals. He is not the
    only one. He is representing probably thousands and thousands
    of other veterans who are facing the same issue. I greatly
    appreciate you allowing him to come and testify. I appreciate
    it much. Mr. Brown, thank you for your service. Thank you for
    your tireless efforts to advocate for not only yourself, but
    all the veterans that need the help and that they deserve. I
    yield back.
        Ms. Miller-Meeks. Thank you. Mr. Ramos, you are now
    recognized for 5 minutes to deliver your opening statement.

                        STATEMENT OF JOSE RAMOS

        Mr. Ramos. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and distinguished members of the Health Subcommittee,
    thank you for today's hearing. I want to begin by saying that
    every day, Wounded Warrior Project has the privilege of working
    with our VA partners, and we get to see the amazing work they
    do and the dedicated staff who are committed to caring for our
    Nation's veterans. Our organization has been serving wounded
    warriors across the country for more than 20 years, interacting
    with thousands of warriors daily and helping them lead healthy,
    fulfilling and empowered lives. Since the beginning of the
    global war on terrorism, Wounded Warrior Project has been at
    the bedside of just about every single combat amputee, close to
    1,800 of us. Today, we continue to serve these warriors through
    our adaptive sports and independence programs, just to name a
    few.
        While I serve as Vice President of Government and Community
    Relations. I would like to share my story as an amputee. In
    2004, while serving on my third combat tour as a Navy Corpsman
    attached to a Marine sniper team, I was severely injured when a
    rocket hit our position and instantly severed my left arm.
    Shortly after my recovery, I was fitted with a prosthesis. I
    felt whole again and quickly became dependent on it or some
    other type of adaptive device to live a fulfilling life. I have
    tried three times to transition from DoD to VA for my
    prosthetic needs and three times I have left believing that my
    care is better left to DoD. I have experienced getting wrong
    prosthetics a right hand when I am missing my left hand. VA has
    told me that I am better off going to DoD for my care. VA
    providers not knowing about the latest cutting-edge
    technologies and VA changing its policies to make it harder to
    get adaptive devices. Roughly 20 to 30 percent of post 9-11
    combat amputees decide to stay with DoD for their prosthetic
    needs. While many have successfully transitioned to VA, relying
    mostly on community providers, too many have also experienced
    challenges and at times experiences trying to use VA.
        You would think that someone like myself, with over two
    decades of being an amputee who understands the system better
    than most veterans out there because of the work I do that I
    would not face or that would fare off a bit better. On this
    last attempt, which started in late 2022, I decided to go all
    in. I did so because my prosthetist, who had been my
    prosthetist with DoD for the last 18 years, became a VA
    community provider. I figured should be seamless. From the
    start, I felt like I had to fight what I truly needed,
    something I have never experienced at DoD. I felt like the
    system was designed to work against itself and against my
    needs. For example, I dropped off a broken hand in late 2023
    and it took 6 months to get it back. I finally received a
    functionable hand back in June 2024. While I waited, my other
    three hands broke down and now I am choosing to go back to DoD
    for my replacements.
        I cannot wait months. Not having a working prosthetic is
    not simply impacting physical abilities, but as you have heard
    before, it impacts mental health too. I firmly believe that VA
    is committed to serving our Nation's veterans and I see that
    every single day. For VA to truly be the best in the country,
    there are areas where improvements are urgently needed,
    especially when it comes to the care of our most severely
    disabled warriors. I believe that VA should be the world's
    premier place for amputee care and prosthetics. However, my
    personal experience tells me that there is still room for
    improvement. As we highlighted in our written testimony, VA can
    take at least four steps to become best in class for amputee
    care.
        First, recognize the unique needs of amputees rather than
    grouping amputees and prosthetic limbs with other prosthetic
    users such as those who use hearing aids, wheelchairs or even
    hip implants. Just different. Second, increase the hiring of
    prosthetists and expand in house fabrication capabilities
    within the VA to ensure that veterans get timely expert care.
    Third, promote and support holistic, healthy lifestyles for
    amputees by providing necessary adaptive equipment to help
    veterans stay active without forcing them into rehabilitation
    programs that may not be needed. Finally, provide increased
    funding to support and expand innovative programs like the
    Mobile Prosthetic Orthotic Care Program to reach a larger
    population of amputee veterans.
        The VA has struggled to recognize that there is a large
    number of younger, more active amputees demanding more of their
    prosthetics. Veterans deserve the best care and with the right
    investment and commitment, the VA can and should become the
    global leader in prosthetic care for amputees. I thank you for
    inviting me to testify today and look forward to answering your
    questions.

        [The Prepared Statement Of Jose Ramos Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Ramos. Mr. Brown, you are
    now recognized for 5 minutes to deliver your opening statement.

                        STATEMENT OF MATT BROWN

        Mr. Brown. Thank you, Chairwoman Miller and Ranking Member
    Brownley for inviting me to testify about my long and
    frustrating experience with VA prosthetic services at
    Fayetteville, North Carolina VA Medical Center. I am US Army
    veteran.
        Mr. Luttrell. Hey buddy, you are 82d Airborne. You are the
    toughest son of a bitch in this room. All right. Hey, we are
    here for you, man. Suck it up. All right. You are amongst
    friends. Let us hear it.
        Mr. Brown. I am a US Army veteran who enlisted in 2009 and
    sustained traumatic brain injuries and spinal fractures from an
    airborne training operation at Fort Bragg, North Carolina. I
    left active-duty service in 2011, transitioning to the Maryland
    National Guard. I was honorably discharged in 2015. I have
    always been very active. Running, doing martial arts, scuba
    diving. I was diagnosed with bone cancer in May 2021. My life
    has forever changed. When I was still a young man, a family and
    thriving business. Much of my self-worth was derived from my
    physical abilities. To the extent of the cancer, my concerns
    concerning my about having my surgery at the VA center. I was
    given a community care referral to Duke Medical center in
    Raleigh, North Carolina. In summer of 2021, my left leg was
    amputated above the knee in August 2021 at Duke. After the
    surgery, I was in a wheelchair for 7 months. My first VA
    treatment appointment was on November 18th, 2021. VA claims
    they gave me a martial arts prosthetic within 28 days and a
    state-of-the-art leg system within 53 days of this appointment.
    Neither of those worked.
        I learned later that remaining in a wheelchair post
    amputation for as long as I did can inhibit physical and mental
    recovery. I had no idea it would take the VA 2 years to get me
    a proper prosthetic. I would have to advocate aggressively for
    myself at every turn, eventually seeking help from
    Representative Rouzer, Senator Tillis, the Independence Fund
    and this committee staff. My experience with the VA over those
    2 years were bewildering and demoralizing. The staff at the
    local VA hospital consistently failed to communicate well about
    my care, follow through on my care coordination and expedite
    requests for prosthetics. All of the community vendors who
    responded to the VA request to produce the proper fitting leg
    socket for me did their best. Some told me the acquisition
    process at VA was slow and sometimes they would not get paid
    promptly by the VA. This would only add to the stress of not
    being able to resume my normal activities outside of a
    wheelchair.
        In October 2022, I heard about a special socket the VA had
    provided to another amputee, the Quattro Variable Volume
    Socket. Given my level of physical activity and the changes in
    blood flow residual limb, I thought this system would be my
    answer. I asked the VA to obtain one, but they never followed
    through to acquire it. The request sat idle and eventually
    expired. I had to start all over again. I continued to work
    with a local vendor to obtain a properly fitting socket. During
    those months I was using a prosthetic ankle. I visited the
    vendor for routine maintenance in September 2022. The vendor
    told me they had to repossess it because the VA had not paid
    them. I left the vendor without the ankle and had to
    temporarily use an older ankle that was not flexible for the
    next year. VA continued to pursue the same types of sockets. I
    continued to tell the VA that I needed a different type of
    socket, basically the Quattro.
        This Groundhog Day process was extremely frustrating for me
    and my family. I was stuck in a wheelchair for 6 months and
    missed out on many personal activities. In October 2023 I was
    so frustrated with VA prosthetics after a socket they acquired
    from a vendor broke while I was overseas, I contacted Congress
    Rouzer staff for help. They tried to get VA moving, but
    Congress was still slow. After 2 months of congressional
    inquiry, I reached out to the Independence Fund's case work
    team in Charlotte. Their team and Congressman Rouzer's staff
    joined up and pressed VA for answers. In December 2023, VA
    finally agreed to shift my prosthetics care to Richmond,
    Virginia. I was assigned to a VA prosthetics doctor there. He
    assessed my needs for a different type of socket so I could get
    out of the wheelchair and travel more easily for my business
    and participate in sporting activities with my wife and
    friends.
        The Richmond VA doctor worked with me and local vendor to
    give me an interim that will that fit well. It was not until
    May 2024 that VA finally purchased and delivered the Quattro
    socket I am using here today. I have lost 34 pounds since
    getting the socket. I am a new person today. This only happened
    because of continued pressure on VA from Congress and the
    Independence Fund. Looking forward, it is clear to me that VA
    needs a deep dive into what they address and process everyday
    amputees needs for prosthetics, especially ones like mine, and
    deliver them timely. The entire experience can be overly
    bureaucratic, sluggish, often impersonal and sometimes
    uncaring.
        I know VA has testified that the cost of these recreational
    limbs is a concern, but very honestly, these experts do not
    realize what it is like to be confined to a wheelchair, unable
    to swim or run, carry your child and then ignore unseen costs,
    long delays like mine, like mental health anguish I went
    through and the related cost VA paid for additional mental
    health visits I needed over these 2 years. The VA has also
    testified that all these services are already being provided.
    Yet I and other amputees are proof that commitment is not being
    honored and followed by local VA staffs and supported by a
    responsive acquisition system.
        There are lifelong future cost savings for VA when veterans
    can obtain the prosthetics they need to live active, fulfilling
    lives. We are not looking for special treatment. We just want
    to live our lives as independently as possible. I appreciate
    the time you have given me today and look forward to your
    questions.

        [The Prepared Statement Of Matt Brown Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Brown, for making the trip
    here to Washington, DC to share your story and your testimony
    with us. Ms. White, you are now recognized for 5 minutes to
    deliver your opening statement.

                       STATEMENT OF ASHLIE WHITE

        Ms. White. Good afternoon, Chair Miller-Meeks, Ranking
    Member Brownley, and the distinguished members of the VA Health
    Subcommittee. My name is Ashley White. I am the Chief Strategy
    and Programs Officer for the Amputee Coalition, and I am
    testifying today in that capacity. Thank you so much for the
    hearing and this opportunity. The Amputee Coalition is a 501c3
    organization established in 1986 to provide support, education
    and advocacy for the over 5.6 million individuals living with
    limb loss or limb difference in the United States. The Amputee
    Coalition provides information, referral, healthcare,
    navigation services, peer support and community engagement
    programming through its operation of the National Limb Loss
    Resource Center, which is funded through a cooperative
    agreement under the Administration for Community Living in the
    Department of Health and Human Services.
        At the heart of the Amputee Coalition's mission is our peer
    support programs. The organization was founded from a peer
    support program. Our goal is to make sure that no one goes
    through this journey alone. We believe that support comes in
    many forms and can make an incredible difference in recovery
    and rehabilitation. Through an annual contract with the
    Department of Veteran Affairs, our organization provides
    technical support, print and digital resources, certified peer
    visitor training as well as train the trainer training and
    helps facilitate the amputation systems of care Peer Support
    Program. No one is in a better position to understand the
    experience of living a life with an amputation or supporting a
    person with limb loss than someone who has traveled that
    journey. A well-trained peer can offer encouragement and
    information. An individual navigating the start of their own
    journey can better understand, absorb, process and accept. A
    peer reviewed study published in 2022 noted that peer support
    interventions showed promise in addressing suicide risk.
        As noted in a recently published GAO report, over 93,000
    veterans living with limb loss receive care through the VHA
    annually. Beyond combat related injury from serving in the
    Armed Forces. Limb loss can also be the result of complications
    due to diabetes and peripheral arterial disease. The VA reports
    that most of its patients living with limb loss treated by
    amputation systems of care suffer from one of these conditions.
    The previously mentioned GAO report also highlighted as Chair
    Miller-Meeks mentioned and as others have testified today that
    the amputation specialty clinics through which many of the
    veterans receive limb loss receive care related to their limb
    loss are staffed by an interdisciplinary team. This
    interdisciplinary team model is the gold standard and one that
    we at the Amputee Coalition wish all Americans facing limb loss
    could have access to throughout their continuum of care.
        Recognizing that some veterans living with limb loss may
    experience mobility challenges, virtual amputation clinics also
    exist to access care from a VA medical center. This opportunity
    provides veterans living with limb loss the ability to connect
    to a provider from various locations including at home, a VA
    clinic or a community prosthetic partner. This is also not the
    standard of care offered to most available to most civilians
    and we commend the efforts to the VA to make care more
    accessible for those living with limb loss. Acknowledging the
    successes of the VA care model, it is also important to note
    some of the challenges and potential areas for improvement.
        Healthcare access challenges faced by individuals
    experiencing limb loss in rural America continue to be a
    concern for the Amputee Coalition. The GAO report confirmed
    that 28 percent of Medicare beneficiaries who receive received
    amputations live in rural areas, but only 20 percent of all
    Medicare beneficiaries live in rural America. While the report
    did not provide this data for the veteran population, one
    cannot ignore that rurality, it plays a role in access to
    coordinated health care. While the VA employs many certified
    prosthetist orthotists for its various clinics, much of the
    prosthetic care received by veterans is still provided by
    community Orthotics and Prosthetics (O&P) provider. The reports
    we receive highlight from veterans highlight differences in
    communication processes between clinics within the VA and those
    in a community setting that vary from facility to facility.
        Creating more streamlined, coordinated channels of
    communication between community providers and the VA clinical
    teams is vital to ensure that care remains coordinated when an
    individual is receiving prosthetic services outside of the VA
    setting. Our partners and provider groups, also representing
    the orthotic and prosthetic field have also expressed their
    concerns about the Orthotics and Prosthetics workforce
    pipeline, and it is my understanding that the National
    Commission on Orthotic and Prosthetic Education is in the
    process of initiating a study to look specifically at those
    workforce shortages.
        While the VA remains an attractive employer for CPOs, the
    Amputee Coalition is concerned with the recent reports of
    attrition that are coming out of these Masters of Orthotic and
    Prosthetic programs, especially since There are only 13
    programs at graduating Master's level O&P providers.
        In closing, the Amputee Coalition expresses its gratitude
    for the opportunity to be a trusted partner in serving our
    Nation's veterans every single day. We value our partnership
    with the VA and are committed to supporting efforts to improve
    prosthetic care and the mental health and well-being of those
    veterans who have or are at risk of experiencing amputations.

        [The Prepared Statement Of Ashlie White Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. White. We will now proceed
    to questioning. As is my protocol, I will defer my questions
    until the end. I will now recognize Ranking Member Brownley for
    5 minutes for any questions she may have.
        Ms. Brownley. Thank you Madam Chair, and thank you all for
    being here. Mr. Brown, thank you for your service to our
    country and the courage to come up here and share your story. I
    want to understand the period of time that you kind of went
    through this horrible experience. It sounds like. It sounded to
    me like it was a 2-year period from the time that you wanted to
    get out of that wheelchair and get a prosthetic to the time
    that you finally got one that worked for you. Is that roughly
    right?
        Mr. Brown. It is pretty accurate. It was about 2 years.
    There was--it was like, there is a loyalty more to the
    bureaucracy than the end user, the patient. I was like, I am
    the person using it and it is like you get up in the middle of
    the night to go to the bathroom and your leg falls off by the
    bathroom and you fall and you say this thing keeps falling off
    in public, it is falling off. They replicate into the same
    socket all over again. I knew what my problem was. I did my own
    research and I said, this is the solution. I knew another
    veteran who is a friend of mine in Colorado who got that socket
    and I was not able to. The whole time I was asking for a
    running blade so I could start running. I started exercising
    again. I am a really active guy. There was a lot of things and
    it took about 2 years total from beginning to end to get it. I
    just got it this past June, so I am still----
        Ms. Brownley. The running blades, did you get those?
        Mr. Brown. I have the running blade. One issue with the
    running blade is you have to do a running clinic to learn how
    to run. I still, since I have got my running blade, have not
    been able to get to a running clinic. They were like, there are
    two we could possibly send you to. One is in Washington State
    and one was over here. There was not really a way to facilitate
    training and teach me how to run. Here is this item, but there
    is no support on how to use the item. I am kind of using my
    personal trainer at home to try to figure it out on my own,
    which I do not know if it is the safest, but I want to run with
    my wife, so.
        Ms. Brownley. How many prosthetics were you given before
    you got the one? I cannot remember what the name of it, but it
    is what, the Quattro?
        Mr. Brown. Yes.
        Ms. Brownley. Yes. How many? How many tries?
        Mr. Brown. The socket. I do not have the number in front of
    me, so I do not want to be inaccurate. If I had to guess off
    top of my head, we probably had 10 to 14 tries of the socket,
    but it was all different variations of the same attempt.
        Ms. Brownley. And, but, so, but you had, I mean, sort of at
    least 6 months into it, you had done your research and you knew
    what was going to be best for you. It took and you still had to
    go through a lot of----
        Mr. Brown. There was a lot of not understanding my needs.
    Like no one, like they talked a lot about team care when they
    are up here. The team, I am not sure, I have never saw the
    team. I saw a person that was a prosthetist who was 70 years
    old who was out of touch and did not care. He just, he did
    care, but he just did not want to read through it. The one
    problem I had was I am a Brazilian Jui-Jitsu black belt. I
    train a lot, I wrestle and when I would come off the mats my
    leg would not fit anymore. I said I need something I can
    adjust. A friend of mine that is a black belt who is also a
    veteran in another State got this from you. I would like this.
    It was, what we actually found out was the purchase order
    actually had been cut to the vendor and it sat there for a year
    and no one told us. Then I called the vendor like, can you help
    me with this? Like we had your purchase order for a year and
    now it expired. At some point it got authorized and we had not
    even known.
        Ms. Brownley. Thank you. Again, thank you Mr. Rouzer for,
    you know, getting involved and making it happen. Sadly, I
    apologize for the VA and their inability to satisfy you as a
    veteran and as an important patient in their care. So. Again,
    thank you. Thank you very much for being here. Ms. White. I
    wanted to ask you. I absolutely am a firm believer in peer
    support programming and peer support groups and how effective
    they can be for veterans with a variety of different kinds of
    issues. I am just wondering. I tend to spend a lot of time on
    women because I do not feel like women veterans get the
    attention that they deserve. I am wondering how many women have
    you served and do you believe that the women that you have
    served that a woman to woman peer group is the best option
    moving forward?
        Ms. White. Thank you for the question, Ranking Member
    Brownley. With respect to the number of women served by the
    Amputee Coalition, our support programs operate through the
    amputation systems of care. About 14 percent of the individuals
    who come directly to the Amputees Coalition's information
    referral centered. Those are direct calls to us, about 14
    percent of those are veterans, and only about 2 percent of
    those are women. A very small----
        Ms. Brownley. Veterans and non-veterans.
        Ms. White. Veterans and--sorry. Yes, yes.
        Ms. Brownley. I got it.
        Ms. White. If you look at that, those numbers that are
    directly served by our organization, not through the
    partnership that we have with the amputation systems of care,
    It is a small number, but I do believe that many women are
    going to community support groups. There are nearly 300
    community support groups that we help facilitate. They are
    affiliated with us, but they are actually operated by
    individuals who live in those communities. I believe that many
    women are going to those community groups and they are finding
    support, whether that is through a civilian who has a similar
    level of limb loss or a person who has a very similar
    experience to them and may also be a veteran. I think they have
    access to both support groups in their communities as well as
    through the VA system.
        Ms. Brownley. Very good. Thank you for that and thank you
    for what you do, because it sounds like what you do is really
    important to servicing our veterans and having success with
    limb loss and all the wraparound issues and support that they
    need to have the highest quality of life that they certainly
    deserve. Thank you for that. I am over my time. I apologize and
    I yield back.
        Ms. Miller-Meeks. Thank you for yielding. Thank you,
    Ranking Member Brownley. The chair now recognizes
    Representative Luttrell for 5 minutes for any questions he may
    have.
        Mr. Luttrell. Thank you, ma'am. Mr. Brown, Mr. Ramos. We
    try to unpack the suitcase on this. We understand that. We
    understand the varying levels of difficulty trying to get the
    quad for your leg and then what is your arm. Obviously, here is
    the tricky part. Who did you call? Who said no? Where did it go
    from there? I would like to have names so I can personally
    address this issue at the granular level. You know, veterans
    are veterans, we will come--we have this just. We just love to
    come. Just to say things are going bad. I got it. You know, but
    we need to know exactly where we need to touch this. I am going
    to ask both of you, when you talk to your--at what level, who
    you are speaking with and where are they going and where is it
    dying? Where are the barricades and the barriers existing so we
    can get in there and try to clean it up. Mr. Ramos, you can go
    first, and I will go to Mr. Brown.
        Mr. Ramos. I think you asked a really good question. I
    think the challenge is there is not a single person that you
    can really reach out to. To be very honest with you, I think
    the system collectively, the way VA defines prosthetics and
    amputees generally sits under PSAS or the Office of Prosthetic
    and Sensory Aid Services. That truly is more of an acquisition
    logistics and procurement process. It is funded in that way.
    The prosthetists and prosthetic limbs all reside underneath
    that. One of our recommendations here is we got to kind of
    separate and stop talking about prosthetics as the same as
    hearing aids and eyeglasses. I think that is the challenge, I
    think for the both of us reaching out to our providers, our
    community providers. I mean, similar story for me was a lapse
    of time as it relates to the purchase order being submitted and
    not being sent to the provider. Not knowing.
        Mr. Luttrell. It seems like a series of communication
    breakdowns because you are--I do not mind, I have got a brain
    fart here. Your system was sitting there waiting to get. The
    paperwork is waiting to go and it just, it died on the vine,
    correct?
        Mr. Brown. Yes. The communication breakdowns I could not
    have asked for. I could not hope for a better question from
    you, Representative Luttrell. My local VA, this is going to
    sound unbelievable to you that the phones have been broken for
    several years. I cannot call in and make an appointment. I
    heard a lot of talk today about satisfaction scores from the VA
    officials. You can make studies and package data up and paint a
    picture. There is a Key Performance Indicator (KPI) or standard
    that all of us in this room, civilian, veteran, any industry
    value, it is universal and it is a Google rating. The Google
    rating for my facility is like 3.5 stars. If you read those
    reviews, for years we have been complaining with no feedback
    loop to help, that we cannot call in and make an appointment.
    We have to drive in to make an appointment. I challenge all of
    you, take your phones out, Google Wilmington, North Carolina VA
    Hospital and read the reviews. You can go back four or 5 years
    and everyone is on there complaining, we cannot call in. To
    this day, I still cannot call in to make an appointment. I have
    to drive in.
        A fundamental patient care is communication. If we take
    this KPI like we can package up all these KPIs, right? That is
    the standard of excellence for the world. I just challenge you
    in your districts, go look at the Google ratings and read the
    reviews. They are generally not good because of this. Then on
    the level of the granular level, my prosthetists, he verbally
    told me there needs to be five of me here, and there is one,
    and I am 68 years old, and his name was Thomas Ray, generally a
    nice guy that cares, but he was not equipped to handle this.
    His boss, Damon DeLoache, was just out of touch with the whole
    process. On the fundamental level, when I was waiting for my
    prosthetic, I could not call in to get a status update.
        Every Thursday, the prosthetist visited my local VA center.
    I would take my wheelchair, throw it in my truck. I would only
    been an amputee a few months now. I would drive to the VA
    center, sit in my wheelchair, wait in the lobby to hope that he
    would walk past me to ask for an update. If we cannot handle
    the fundamentals of patient communication, like calling in. I
    had--I am kind of a little bit of aggressive guy with some
    stuff. I figured out who the director of that building was. I
    found her picture and I waited around for her. Her name was
    Debbie. I addressed her. I said, you are the director, right?
    She said, yes. I said, the phones are broken. She goes, oh, I
    quote, I know they have been broken. They have been broken for
    years. I just do not know who to call.
        Mr. Luttrell. Okay, next steps for me is going to find out,
    because there are multiple sites, so I need to find out who the
    prosthetist is calling at the next level and where that goes to
    get everything activated and how it comes back down inside the
    organization to clean up this problem set. The gentleman that I
    am going to discuss that with are sitting directly behind you,
    which I think you should have gone first in this hearing. That
    would have given us extra ammunition, if you will, to have
    discussions with the VA staff, or VA leadership. Thank you and
    Chair, I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Luttrell. The Chair now recognizes Representative Rouzer for 5
    for any questions you may have.
        Mr. Rouzer. Thank you. I would be happy to yield some more
    time to my colleague, Mr. Luttrell, if he wants to follow up.
    You had a good line.
        Mr. Luttrell. I could sit here all day. When--I would like
    to dig in with you, Mr. Brown, because when your case was moved
    out of the Wilmington VA, where does that land? At what site?
        Mr. Brown. We end up at Richmond, Virginia.
        Mr. Luttrell. Wilmington goes to Richmond.
        Mr. Brown. Yes, so we moved out of the Fayetteville or
    Veterans Integrated Service Network (VISN) 6 to Richmond. The
    doctor who received me was Dr. Joseph Webster, who is an
    awesome clinician. He was an angel for me. He got me my leg
    back. He was compassionate. He was awesome. It was the opposite
    experience of what I experienced in Fayetteville. We had to
    move my care all the way to Richmond, Virginia to get me past
    this 2-year ordeal.
        Mr. Luttrell. Can you explain to me at kind of a deeper
    level why? The people behind you are listening and I need them
    to hear this, which I am sure they have heard it multiple
    times, but they are going to hear it right here in front of
    Congress. I want to know why and where the communication, not
    most of the communication, but the movement of taking care of
    our amputees at Wilmington seems to be lost. Then you have to
    go to North Carolina. You have to go to Richmond.
        Mr. Brown. Yes, go to Richmond. Just to give you an idea,
    like the level of distrust that develops so rapidly, I actually
    had to start like recording my doctor's appointments to
    document things because of me requesting things verbally and
    not having them. What happened is I would request something. I
    would wait a long period of time for an appointment with a
    prosthetist. I would request something and then he would say,
    oh yes, we are working.
        Mr. Luttrell. Do you have the paperwork that you received
    from the VA that says why this got canceled with a name on the
    bottom of it?
        Mr. Brown. No.
        Mr. Luttrell. That is tragic.
        Mr. Brown. Yes, I do not. I never really could. Like, so I
    was asking the prosthetist, like, when am I going to get this
    Quattro socket? Every time it was a kick the can down the road.
    It was a very vague answer. He was the only prosthetist for our
    region. He swore there needed to be five, there was only one.
    He went out with COVID for 3 months and he finally called me
    back 1 day and he said this to me. I work in healthcare, in
    dental, so I am very familiar with Health Insurance Portability
    and Accountability Act (HIPPA) laws. My company handles a lot
    of personal information and we are really compliant with that.
    He said on the phone to me, he said, Matt, I am home with COVID
    and my dining room table is covered with patient paperwork that
    I am trying to get through while I am out sick with COVID. My
    first reply was, that is a HIPAA violation. My information
    cannot be in your home. It is like there is a deliberateness
    you do things with when you want to achieve. What I will tell
    you is in VISN 6 Fayetteville system, that deliberateness does
    not exist for excellence. Just look at the Google reviews. We
    give the reviews. It is all under four stars.
        Mr. Luttrell. Mr. Ramos, your turn.
        Mr. Ramos. I think this frankly highlights the necessity to
    really evaluate what DoD does versus what VA does. I will say,
    and I will tell you why I say that is, unfortunately, my
    brother in arms here does not have the luxury to be next to an
    Military Treatment Facility (MTF) center of excellence to just
    walk in and get the assistance they need. Right? We should
    strive collectively to ensure that the VA is the center of
    excellence. I am not saying we need to build a center of
    excellence in every single district, because that is not
    possible. There is not many amputees, but, dang it, every
    single active duty or post 9-11 combat veteran will tell you
    exactly if they want to go to the best care for amputee care.
    They are going to fly to Brooke Army Medical Center (BAMC),
    they are going to fly to Walter Reed, or they are going to fly
    to the Center for Intrepid. Right? By the way, they are going
    to pay out of their own pocket to get there. Nonetheless, and
    VA should have the same, exact same thing, and we just do not.
        Mr. Luttrell. When the question is asked why the VA does
    not have the same model as the DoD, what is the response you
    get from those that you are engaging with?
        Mr. Ramos. We talk a lot about the ASOC system or kind of
    the amputee system of care. I will tell you, until I started
    working with Wounded Warrior Project, I did not know it
    existed. We have seven sites, and I think collectively the
    culture is we have the systems in place. I am not saying that
    it is not in place for maybe older geriatric patient
    population. It is just not responsive to a young active
    population who is beating the crap out of their prosthesis and
    trying to live a fulfilling life. When I turn 70, I am still
    going to continue to do what I do. I have four hands because I
    break them fast. I break them fast because I am an active
    individual and their system is not responsive to meet my needs,
    to meet his needs. It is just not designed that way.
        Mr. Luttrell. How long can you stay with the DoD? Do you
    ever have to transition away from DoD to the VA?
        Mr. Ramos. You do not. I do fear part of why I have come to
    the VA system to give it a try is I fear that at some point,
    DoD says, hey, you know what? You are a veteran. Go to the VA.
    The answer is DoD looks at us also kind of a way to ensure that
    they continue to maintain their expertise in dealing with
    combat patients based on what is happening across the globe. We
    have not been asked to no longer come back, but that is always
    been a concern. Right now, as far as I know, now it is a
    different situation for him because he is not a service
    connected, combat disabled veteran that went through the
    system, but I do not. That is why I am going back to DoD, to be
    very honest.
        Mr. Luttrell. Okay. I yield my time.
        Mr. Rouzer. Yes, my time has expired.
        Ms. Miller-Meeks. Thank you. Thank you, Representative
    Luttrell and Representative Rouzer. The Chairwoman now yells
    herself 5 minutes for questions she may have. Mr. Ramos, and I
    think you brought this up, but how did your experience with the
    DoD prosthetic care compare to care provided directly by the
    VA? Were there noticeable differences in quality or timelines?
        Mr. Ramos. I think what would be helpful is to kind of
    maybe give you a comparison of the two different experiences in
    systems generally. Right. At DoD, the prosthetist and the
    clinic or the amputee care clinic are jointly co located.
    Right. When I go talk to my primary provider, my prosthetist is
    there or easily accessible and we can talk about here are my
    challenges. Okay, got it. Here is a prescription. Then go and
    execute. Now if I need something that is modified on the spot,
    they can build out. If it is something that needs to get sent
    out to either rebuilt or new, they do that right there. Then I
    get it in a matter of weeks. Right.
        With VA, for example, the VAMC here in DC, they are not co
    located as a matter of fact, two different, complete different
    spaces. I first have to make a visit with my primary clinician
    and then get that prescription approval that then gets sent to
    my community provider. Now I have to make an appointment with
    my community provider, drive down to Bethesda, and actually go
    through the process of kind of working with the prosthesis.
    That individual then now has to wait for the purchase order to
    come in to them so that they can go and execute on the actual
    prosthetic delivery or fixing. Then from there I have to either
    go back to the community provider and make sure that it is the
    right prosthetic in this case, because I have experienced
    having the wrong one been delivered to me now. Then eventually
    that is what the process looks like.
        It is really a almost instant fixing of addressing need,
    approval of an execution versus coordinating different
    meetings, different appointments, getting approvals, waiting,
    and then eventually getting your prosthesis.
        Ms. Miller-Meeks. Yes. That difference in the care that you
    receive and you perceive may in fact be a difference in mission
    between the DoD and the VA. Certainly we have heard a lot about
    the populations and the type of population that we are dealing
    with as a veteran population, as an active duty DoD population.
    To me, what I am hearing loud and clear is that there needs to
    be a segregation of prosthetic limbs from other sensory type of
    prosthetic devices. That is, when you were here, I was
    adjusting my prosthesis, my glasses, but glasses, hearing aids,
    scleral shells, facial implants, even wheelchairs. These types
    of devices need to be segregated and have a amputee prosthetic
    office that directly deals with that within the VA, and then
    second, perhaps also segregating the populations. No one wants
    to say that. It is not politically correct to say that.
    Although I am almost 70 years old, I would say I am an active
    70 year old.
        Nonetheless, a person's needs who is retired and not
    working is certainly different than a person who is working and
    raising a family and trying to support a family. Mr. Brown, did
    anyone from the--so you were diagnosed with the cancer, you are
    at the VA, you know you are going to have treatment for your
    cancer, you are going to have an amputation. Did anyone from
    the VA's Amputation System of Care team engage you before your
    amputation or how long after your amputation?
        Mr. Brown. Earlier there was a conversation about proactive
    versus reactive. Me and wife are really proactive people. We
    knew this was coming. We knew for about 3 months my leg was
    being amputated and I proactively contacted the VA. No one
    reached out to me. The extent of the team experience they speak
    of was I went there, sat down with that prosthetist and what I
    was told was it was a very short conversation. I was in this
    chair maybe 5 minutes. The VA is world class when it comes to
    prosthetics, was the claim and that whatever you need, you are
    going to get, there are no problems. It was a great
    expectation. Me and wife felt good about our decision.
        Then the amputation happened and then it was kind of like
    the best analogy I can use is it kind of felt like a used car
    salesman. I was told this awesome, rosy story. Then the moment
    it was time to facilitate care, I had to wheel myself to the VA
    on Thursdays to hope to bump into this individual to get an
    update. I was never given a timeline or expectation. There was
    no team experience.
        Ms. Miller-Meeks. Yes, I can certainly understand that.
    Waiting for the stump to heal. There are a ton of questions I
    would have about all of this process. One of the things I also
    heard, and let me say that having been in the military, both
    enlisted as a nurse, as a doctor, worked at the VA, relatives
    at the VA, family members, I can assure you that the people
    behind you have not heard of your story because that is how
    bureaucracies work. What happened at the Wilmington VA probably
    stayed at the Wilmington VA instead of that being ratcheted up
    the chain of command to where the people who can actually
    implement policy changes and make those individuals work to the
    best of their ability do not get that information.
        We also heard from Dr. Saslo and Dr. Scholten that the
    scores that were received and feedback reports had very high
    scores, 88 percent clinical prosthetic patients at the
    Fayetteville VA Medical Center are happy. As I listen to that,
    if someone did not take the proactive approach to go and study
    what socket, what terminal, what prosthetics, if you are a
    woman, do you have a prosthetic that is going to adapt to the
    different type of shoe that you are wearing, to the different
    type of activities that you are engaged in, whether you are
    working or non-working, whether you are lifting children? If
    they do not take the proactive approach to do that, how do they
    know what is available? If in fact they are getting state-of-
    the-art care? How can you determine whether or not you are
    satisfied? All you can determine is you are satisfied with what
    you were given, but not what the range of options are available
    to you, or even if there is adaptive prosthetic devices.
        Based on your experience, Mr. Brown, and conversations you
    have had with other veteran amputees, do you believe that
    statistic accurately reflects the quality of care and trust at
    Fayetteville or the experience other veterans may have?
        Mr. Brown. No, I do not think it is anywhere near accurate.
    I sit in the waiting rooms with the other amputees in the
    prosthetics department and you know, the amputee community, the
    veteran community is small. The amputee veteran community is
    smaller, especially in our region. It is real easy for us to
    find all each other. I started like a little WhatsApp chat with
    all my fellow amputee friends and asked them, how long are you
    waiting for this? How long are you waiting for that? The
    experience is pretty uniform. When you lump in major limb
    amputation with eyeglasses and compression socks, it is easy to
    get a positive review of questions you loaded up to get the
    metric you want as a survey you sent. When you are asking
    someone about compression socks versus a complex item like a
    leg that replaces your--creates your ability to be mobile.
        When I heard the in Fiscal Year 2024, the satisfaction rate
    was like 95 percent. That is not accurate. Going back to the
    Google rating, like I mentioned earlier, that is the world's
    standard for excellence. I personally started looking at the
    facilities in my area and they all were well below four stars,
    most near three stars. I think that is a KPI that no one is
    looking at, that the whole world embraces as the standard for
    excellence. I think that needs to be looked at because these
    facilities do not have good ratings. That is a clean feedback
    loop from us to you. No one in leadership, I think, has ever
    looked at that. No one thinks anyone is looking at it.
        Ms. Miller-Meeks. Well, thank you very much. Ranking Member
    Brownley. Do you have any closing remarks?
        Ms. Brownley. I just want to say I really appreciate having
    this hearing. I have been on the committee, I think, for 12
    years, and I am not sure that we have had a hearing on this.
    Thank you for bringing it forward. I have learned a lot, and I
    think I have got a pretty clear idea. I think that the
    Chairwoman's just sort of laid it out, too, in terms of where
    we need to go on this, in terms of trying to make it better.
    The VA should, when it comes to prosthetics, they should be the
    very best. They should be on the cutting edge. They should be
    world class, and, you know, they should be leading the pack
    across the country. I think there is probably the VA is doing a
    good job across the board in certain places, but, you know, not
    everywhere. I think someone talked about, you know, rural
    America, too, where it is even a greater challenge.
        I just think we need to kind of really work on this to make
    sure that we are providing, you know, our veterans who have
    served our country. You know, losing a limb is--I cannot
    imagine. I honestly, I cannot imagine what that would be like.
    I do understand how impactful it can be if things are not
    working for you, both physically and mentally. Anyway, I think
    we have got some work cut out for us, and I appreciate you
    having the hearing, Madam Chair. I yield.
        Ms. Miller-Meeks. Well, thank you very much, Ranking Member
    Brownley. I thank all of our members who are here today. I
    especially thank the VA. I know that some of these comments
    were probably not something that you particularly wanted to
    hear because it sounds like you are truly trying to give state-
    of-the-art care to all of our veterans, especially our veterans
    with amputee and limb loss. I would like to thank our witnesses
    on Panel Two Mr. Ramos, Ms. White and Mr. Brown for being here
    and for your courageous testimony. Not easy to come all this
    way and bring that forward and that we do need to do a better
    job of holistically looking at our veterans and our veteran
    population.
        I would like to thank everybody for their participation in
    today's hearing and for the great discussions we have had on
    this important topic. I would agree that we have a roadmap for
    where we need to go and how we need to assist the VA in order
    to treat you better to the highest level of your functionality
    and activities of daily living. As I have stated before,
    ensuring that our Nation's veterans receive the highest quality
    of care is my top priority as Chairwoman of the subcommittee
    and holding the VA accountable and providing proper oversight
    is the job that we on this committee have been tasked with.
        I am committed to working with my colleagues and the
    department to ensure that high quality care is delivered to our
    veterans. I look forward to continuing these efforts to working
    with all stakeholders involved.
        The complete written statements of today's witnesses will
    be entered into the hearing record. I ask unanimous consent
    that all members have five legislative days to revise and
    extend their remarks and include extraneous material. Hearing
    no objection. So ordered. I thank the members and the witnesses
    for their attendance and their participation today. This
    hearing is now adjourned.
        [Whereupon, at 4:16 p.m., the subcommittee was adjourned.]
    =======================================================================

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                   Prepared Statement of M. Christopher Saslo

        Good afternoon, Chairwoman Miller-Meeks, Ranking Member Brownley,
    and members of the Subcommittee on Health. Thank you for the
    opportunity to testify before you today to discuss VA's Amputation
    System of Care (ASoC). Joining me today is Dr. Joel Scholten, Executive
    Director, Physical Medicine and Rehabilitation (PM&R); Dr. Ajit Pai,
    Executive Director, Office of Rehabilitation and Prosthetic Services;
    and J. Drew Craig, Design Chief, Enterprise Measurement and Design
    Directorate, Veterans Experience Office (VEO).
        At VA, we are dedicated to addressing the diverse needs of Veterans
    with amputations throughout their lifetime and ensuring access to
    rehabilitation services, specialty benefits and services, and advanced
    prosthetics. Our comprehensive approach focuses on providing tailored
    care, cutting-edge technologies, and ongoing support to improve the
    quality of life for Veteran amputees.

    Overview

        VA's ASoC offers a comprehensive, integrated care model for
    Veterans with amputations or those who are at risk of amputation. This
    holistic approach emphasizes Veteran-centric care through a
    multidisciplinary team, including PM&R physicians, physical and
    occupational therapists, prosthetists, mental health clinicians, and
    various other specialists. ASoC's core philosophy revolves around
    providing lifelong care through coordination, collaboration, and
    education.
        Amputations present unique challenges and complexities for Veterans
    requiring specialized services and support throughout their lifespan,
    including pre-amputation care, post-surgery, rehabilitation, prosthetic
    prescription and training, and lifelong follow-up. The Veteran's care
    journey begins with pre-prosthetic care and preparation. Whenever
    possible, the ASoC team engages with Veterans and their families before
    surgery. This proactive approach allows for crucial education on post-
    operative care, home preparation, equipment needs, and future
    prosthetic plans. It ensures a smoother transition for Veterans
    returning home and assists families in making necessary preparations.
        Once the Veteran's residual limb has healed, the prosthetic fitting
    and training phase begins. The prescription process considers the
    Veteran's goals, prior functional level, and medical history. Fitting
    may occur within the VA system or with community prosthetists with the
    VA team collaborating to ensure the prosthesis meets the Veteran's
    mobility needs. The subsequent training process is intensive and
    requires commitment from the Veteran, their family, and the care team.
    This initial rehabilitation phase can extend more than a year post-
    amputation.
        Post-prosthetic rehabilitation services involve close monitoring,
    especially during the first year. The team anticipates and responds to
    changes in the Veteran's limb and strength and makes necessary
    modifications to the prosthesis and rehabilitation plan. Veterans
    typically return to the Amputation Specialty Clinic multiple times in
    the first year after amputation to ensure the prosthesis supports the
    Veteran in achieving their functional goals.
        Long-term follow up and maintenance are crucial aspects of the ASoC
    model. VA recommends annual assessments for all Veterans with major
    amputations to ensure continuity of care and lifelong management. ASoC
    adopts a Whole Health approach that incorporates peer support, support
    groups, and adaptive sports to help Veterans reintegrate into the
    community.
        Adaptive sports programs play a significant role in the
    rehabilitation process. VA uses health care practitioners to refer
    patients to recreation therapists who educate Veterans and families
    about adaptive sports and leisure activities. They also aid Veterans
    with renewing pre-injury leisure activities, introduce adaptive
    equipment, teach new skills, and facilitate community integration.
    Adaptive Sports programs adhere to specific regulations for equipment
    provision and can have a profound impact on Veterans' well-being. They
    help Veterans restore functional capabilities, boost self-esteem, and
    improve overall quality of life. Recreation therapists, working with
    Veterans in adaptive sports programs, partner with the ASoC team when
    specialty prosthetic limbs are required to participate in a sport.
        Through this comprehensive approach, ASoC provides a continuum of
    support from pre-amputation through long-term care, ensuring Veterans
    receive the highest quality of care and support throughout their
    journey.

    Recent Data

        During Fiscal Year (FY) 2024, the Veterans Health Administration
    (VHA) surgery programs performed over 8,000 amputations, which is a 7.7
    percent decrease from Fiscal Year 2019. Toe/foot amputations were most
    common (69.7 percent), followed by below-knee (19.9 percent) and above-
    knee leg amputations (15.3 percent). A trend toward more distal
    (further away from the body) amputations in Fiscal Year 2024 suggested
    a preference for tissue preservation.
        Veterans undergoing amputations were predominantly male (98
    percent) with a mean age of 70 years. They often had complex
    comorbidities, which included diabetes (87 percent), peripheral
    vascular disease (82 percent), and ongoing tobacco use (over 50
    percent). Notably, most VA amputations result from chronic diseases
    rather than combat or trauma. Only 119 of the over 8,000 Fiscal Year
    2024 amputations were performed on Veterans with Operations Enduring
    Freedom, Iraqi Freedom, or New Dawn designations.

    DoD and VA Partnerships

        The Department of Defense (DoD) and VA have established a robust
    collaborative framework to ensure seamless care for Service members and
    Veterans, particularly in amputation and limb trauma. This interagency
    partnership is exemplified through various initiatives and programs
    designed to enhance patient care, streamline processes, and foster
    innovation.
        One cornerstone of collaboration is the Extremity Trauma and
    Amputation Center of Excellence (EACE), which is a congressionally
    mandated joint effort that focuses on advancing care for individuals
    with limb trauma or amputations. EACE ensures consistency and
    efficiency across both agencies and demonstrates a commitment to
    providing the highest quality care for those who have sacrificed for
    our country.
        Another significant area of cooperation is the development and
    updating of Clinical Practice Guidelines (CPG). VA and DoD regularly
    join forces to create evidence-based guidelines that improve patient
    care for Veterans, Service members, and civilians. These interagency
    workgroups have made substantial progress in developing guidelines for
    upper and lower limb amputation rehabilitation, which ensures
    standardized care practices based on the latest research. CPGs for
    upper and lower limb amputation are publicly available on the VA/DoD
    Clinical Practice Guidelines webpage (https://
    www.healthquality.va.gov). VA clinicians are informed of CPG updates
    through a variety of educational forums, such as webinars, community of
    practice calls, and email distribution to clinical providers.
        The collaboration extends to logistical support with VA's Denver
    Logistics Center (DLC) providing comprehensive supply chain management
    for various VA programs. Notably, DLC grants DoD orthotists and
    prosthetists access to its contracted orthotic and prosthetic
    components, which facilitates timely procurement and enhances care
    delivery. This cooperation is further strengthened by mutual
    participation of DoD and VA providers in each other's educational
    programming, thereby fostering knowledge exchange and professional
    development.
        To ensure a smooth transition of care for Service members, ASoC
    implemented a network of 25 Amputation Rehabilitation Coordinators
    across the country. These coordinators assist Service members with
    amputations in their transition to the VA system. Additionally, they
    help coordinate care for Veterans who receive ongoing treatment in both
    systems.
        The Office of Advanced Manufacturing (OAM) currently executes a
    Joint Incentive Fund (JIF) grant to align advanced manufacturing
    between VA and DoD. A major component of this work was developing a
    shared Quality Management System (QMS) that adheres to U.S. Food and
    Drug Administration (FDA) requirements and allows for the development
    and manufacturing of certain medical devices within VA and DoD, thus
    facilitating easy sharing of products and ideas. With the shared QMS
    and medical devices, transitioning Service members can expect to
    receive continuation of care and similar prosthetics services between
    DoD and VA.

    Research and Innovation

        Since 9/11, technological advancements revolutionized care delivery
    and prosthetic devices. Additionally, VA improved communication between
    Veterans and their clinic teams through platforms like MyHealtheVet, My
    VA Images, and VA Video Connect. These tools allow Veterans to share
    their home and community environments with providers, which enables a
    better matching of prostheses and rehabilitation plans to optimize
    independence. VA's Office of Healthcare Innovation and Learning also
    has been instrumental in implementing cutting-edge technologies. By
    adopting 3D scanners, printers, and digital software, VA developed a
    digital prosthetic workflow and seamlessly integrated new hardware and
    software.
        Prosthetic devices have benefited from micro-computing and design
    improvements. Lower limb prostheses now use advanced algorithms and
    real-time measurements to react to user movements, which reduces the
    risk of falls. Power-generating foot and knee systems can actively
    propel users forward. Upper limb prostheses also have advanced systems
    that can identify muscle activity patterns to replicate desired
    movements more accurately and prosthetic hands that can move individual
    digits for increased precision.
        The human-prosthesis interface has seen advancements through
    various surgical techniques including Ertl technique, Targeted Muscle
    Reinnervation (TMR), and bone-anchored external prostheses. The Ertl
    technique is a surgical procedure in which a tibiofibular bone bridge
    is established with the intent of creating improved distal
    weightbearing. The TMR procedure aims to alleviate phantom limb pain
    and improve muscle control over myoelectric prostheses by intentional
    placement of nerves within selected muscles. Veterans now have access
    to osseointegration (OI) surgery creating direct skeletal attachment
    for the prosthetic limb. Nine Veterans have received OI surgery, either
    in VA or through a community provider, since the inception of the
    program in January 2022. VA is carefully monitoring the demand for this
    procedure to ensure Veterans have access to this innovative surgery.
        Ongoing research and development initiatives continue to push the
    boundaries of prosthetic technology. VA has funded a new research
    center with a focus on prosthetics, which brings the total number of VA
    Rehabilitation Research and Development Centers in amputation care and
    prosthetic technology to three. Current projects include a 3D-printed
    foot system to enable women Veterans to wear shoes of any size, type,
    and heel height; testing fully implanted neuro-prosthetic systems that
    enable users to feel touch through their prosthetic as if it were their
    own limb; improving clinical measures for upper-limb amputees; and
    developing shared decision-making tools for amputation level and
    prosthetic component selection. Research is also underway to improve
    prosthetic attachment methods. This research includes a multi-site
    study which tests a VA-developed bone-anchored prosthetic docking
    system, develops women-specific above-elbow prosthetic suspension
    systems, creates new variable-compliance below-elbow prosthetic arm
    sockets based on athletic shoe technology, and tests the effects of an
    adjustable above-knee socket on asymmetry, residual limb movement
    within the socket (socket pistoning) and comfort/satisfaction in female
    and male Veterans.

    Procurement and Manufacturing

        VA balances efficiency with individual patient needs by following a
    structured approach to procuring and manufacturing prosthetics.
    Manufacturing challenges often stem from limitations in local
    resources, particularly in rural areas. To address these challenges and
    manage the device lifecycle, VA's regulations (38 C.F.R. Sec. Sec.
    17.3200-3250) prioritize repairing existing items unless replacement is
    clinically necessary or more cost-effective. Decisions regarding limb
    repair or replacement involve discussions between the clinician,
    Veteran, and Prosthetic and Sensory Aids Service (PSAS) representative.
        Case studies from the Denver VA Medical Center (VAMC) and
    Fayetteville VAMC highlight ongoing efforts to improve prosthetics
    services. Key improvements include aligning surgical implant handling
    with VHA Directive 1081.01(1), Procurement of Surgical Implants;
    enhancing Durable Medical Equipment contractor stocking; and addressing
    staffing shortages. These efforts have yielded tangible results, such
    as reducing open consults and eliminating delayed orders. The
    Fayetteville VAMC does not fabricate limbs. All prosthetic limb
    requests are referred to vendors for fabrication or procurement. The
    latest Veteran feedback report stated that 88.8 percent of clinical
    prosthetics patients expressed trust in their prosthetics team at the
    Fayetteville VAMC.
        The Office of Advanced Manufacturing is collaborating with various
    VA offices and external organizations to develop an end-to-end digital
    prosthetic workflow. This digital workflow aims to improve efficiencies
    in device delivery, reduce facility space requirements, and enhance
    communication across the VA enterprise including expanding capacity for
    community-based outpatient clinics (CBOC) and rural sites. The workflow
    also offers opportunities to improve procurement transparency,
    standardize care, and better understand the lifecycle of devices
    Veterans use.

    Acquisition Process

        The prosthetics acquisition process within the VA system presents
    strengths and challenges. When VA providers handle artificial limb
    provision internally, the process is generally more streamlined due to
    effective collaboration between the Orthotic, Prosthetic, and Pedorthic
    Clinical Services (OPPCS), ASoC, and PSAS teams. This approach
    minimizes potential bottlenecks and creates a smoother experience for
    Veterans. However, when necessary, community fabrication is available.
    Involving community prosthetists requires additional steps. For items
    over $10,000, purchase requests must go through Contracting Officers,
    potentially delaying the delivery of artificial limbs. This process
    contrasts with the internal VA process, where such delays are
    significantly less frequent.

    Quality of Care

        The ASoC's integrated care model exemplifies a patient-centered
    approach that emphasizes streamlined, coordinated amputation and
    prosthetic care. In Fiscal Year 2024, VA saw 18,387 unique Veterans
    with 38,122 encounters in amputation clinics, which included 7,896
    virtual care encounters to enhance access to specialty amputation care.
    This multidisciplinary strategy offers numerous benefits, including
    improved care coordination, cost savings, and continuity of care.
    Follow-up appointments provide opportunities for more in-depth
    evaluations and strikes a balance between comprehensive care and
    specialized attention.
        Prosthetic limbs are provided for Veterans through both internal
    capabilities and referral to community prosthetic providers.
    Approximately one-third of prosthetic limbs are fabricated within the
    VA system while two-thirds are provided by community prosthetic
    providers.
        To ensure high-quality prosthetic limb procurement, VA promotes an
    interdisciplinary post-delivery prosthesis checkout visit, going above
    the industry standard. In Fiscal Year 2023, for all Veterans receiving
    a limb through VA, 76 percent completed a post-delivery prosthesis
    checkout. Full Fiscal Year 2024 data are not yet available.
        Veteran satisfaction remains a top priority, as evidenced by
    continuous monitoring efforts using data from VEO's Veteran Signals
    (VSignals), a survey platform used to measure Veterans' trust in VA. In
    Fiscal Year 2024, results showed 95.4 percent of Veterans felt
    respected and comfortable during their Amputation Specialty Clinic
    experience, and 92.8 percent reported feeling the health care team
    included what matters most to the Veterans in their plans for what to
    do next in managing their health and well-being. ASoC proactively
    enhances patient experience through annual satisfaction evaluations and
    is currently collaborating with VEO to develop a Veteran Journey Map
    for the Amputation Specialty Clinic.
        To improve service delivery and provide more equitable care to
    rural Veterans, ASoC is exploring digital workflow infrastructure to
    extend prosthetic services beyond VA medical centers into outpatient
    clinics and Mobile Prosthetic and Orthotic Care units. Furthermore,
    ASoC leverages digital prosthetic workflows to enable collaboration
    across clinical services, and OAM is exploring ways to overlay
    different imaging modalities with patient anatomy and prosthetic
    devices. This approach aims to facilitate communication between
    surgery, wound care, rehabilitation, and prosthetics, ultimately
    yielding prosthetic devices that fit well, are comfortable, and prevent
    friction-related pressure wounds.
        ASoC demonstrates an unwavering commitment to providing Veterans
    with high-quality prosthetic devices and care services through a
    multifaceted approach to standards, quality control, and patient
    satisfaction. This dedication is evident in the organization's ongoing
    efforts to refine and implement evidence-based practices, which
    includes the forthcoming Lower Limb Amputation CPG that is set to
    release in December 2024, and a meticulous ``check out'' process for
    prostheses to ensure devices meet patients' needs in terms of fit,
    performance, and comfort.

    Training and Education

        To enhance care quality, promote innovation, and empower those
    affected by limb loss, ASoC and its associated programs offer
    comprehensive training and education initiatives for providers,
    specialists, patients, and families. For health care professionals,
    ASoC provides annual regional trainings, a Monthly Education Series,
    and annual Peer Support Training in collaboration with the Amputee
    Coalition. Three Regional Amputation Center sites offer established
    PM&R physician Amputation Fellowships for specialized physician
    training, while the OPPCS National Program Office complements these
    efforts with monthly Virtual Education Sessions, annual in-person
    training, and the VA Prosthetic and Orthotic Residency Program.
        VA continues to develop training materials for implementing new
    technologies in prosthetic services and funds nearly 300 PM&R physician
    residency positions annually. In addition, VA supports Orthotics and
    Prosthetics (O&P) education through various initiatives, which includes
    funding residency positions, participating in trainee recruitment
    events, and providing resources for non-competitive hiring
    flexibilities. To further enhance the quality of care for Veterans with
    limb loss and other related conditions, VA also sponsors numerous
    physical therapy and occupational therapy residency and fellowship
    programs across various specialties.
        Veterans and their families also benefit from ASoC collaboration
    with the Amputee Coalition. This collaboration includes development of
    a workbook on sex and intimacy after amputation, as well as a robust
    Certified Peer Support program with over 25 trained VA Clinician
    Trainers and more than 40 VA Certified Peer Visitors.
        VA also leverages its relationships with Veterans Service
    Organizations (VSO) to better understand the Veteran experience. VSOs
    inform us of Veterans who are experiencing delays or challenges with
    their amputation-related care, which allows VA to address Veteran-
    specific issues and perform service recovery. These challenging
    scenarios are used as training examples during national forums. VSOs
    have been invited to participate as faculty during our regional
    amputation training conferences to support education efforts and ensure
    the Veteran experience is adequately represented.

    Future Improvements

        VA is actively addressing gaps in its O&P services and facing
    challenges such as limited access in the Midwest and among insular
    islands despite mobile care units. While weighing in-house production
    against outsourcing, VA aims to improve service delivery by
    streamlining procurement processes and hiring additional staff in areas
    of limited access.
        To modernize its prosthetic workflow, VA aims to implement an end-
    to-end digital process to allow for better storage, reproduction, and
    research capabilities. This plan includes expanding access to 3D
    printing technologies and streamlining electronic systems nationwide.
    VA also introduced the Prosthetic Sock Management Tool, a patient-
    centered education tool to aid in education and management of
    prosthetic sock use.

    Conclusion

        Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
    the Subcommittee on Health, thank you for the opportunity to testify
    today to update you on VA's holistic approach to amputee care. Our
    system encompasses innovative technologies, specialized care, and
    unwavering support to ensure Veterans with amputations receive the
    highest quality of care and services possible. Our commitment to
    ensuring that all Veterans receive the care, support, and respect they
    deserve remains steadfast. My colleagues and I are prepared to answer
    any questions you may have.

                        Prepared Statement of Jose Ramos
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                        Prepared Statement of Matt Brown

        Thank you Chairman Miller-Meeks and Ranking Member Brownley for
    inviting me to testify on my prolonged and frustrating experience with
    VA Prosthetics Services and specifically the Fayetteville, North
    Carolina VA Medical Center. I am a U.S. Army veteran who enlisted in
    2009 and sustained two Traumatic Brain Injuries and spinal fractures
    due to airborne training operations at Fort Bragg, North Carolina. I
    left active service in 2011 and transitioned to the Maryland National
    Guard. I was honorably discharged from military service in 2015. I have
    always been very active physically, running, doing martial arts, and
    scuba diving. I was diagnosed with bone cancer in May 2021 and my life
    was forever changed in ways I do not wish on anyone. I was still a
    young man with a family and a thriving business and much of my self-
    worth was derived from my physical abilities. Due to the extent of the
    cancer and my concerns about having the surgery done at a VA hospital,
    I was cleared for a Community Care referral to Duke Medical System in
    Raleigh, North Carolina in summer of 2021. My left leg was amputated
    above the knee on August 1, 2021 at Duke. After the surgery, I used a
    wheelchair for 7 months. During those 7 months I was unable to
    communicate with the prosthetics department because the phones were not
    functioning properly at my local VA center in Wilmington. I had to load
    my wheelchair in my truck and drive to the VA, where I would wait in
    the lobby to see the prosthetics person and ask them the status of my
    prosthetic. In the interim, I was cleared for follow on VA care on
    November 10, 2021. My first VA treatment appointment was on November
    18, 2021. The VA will tell you I was given a martial arts protective
    socket within 28 days and a state-of-the-art prosthetic leg system
    within 53 days of that appointment, but neither of these systems worked
    for me because they would not stay on my residual leg. I have since
    been told that getting out of a wheelchair and beginning to use a
    properly fitting and safe prosthetic within weeks, not months, of an
    amputation is optimal and can be essential to a positive overall
    physical and mental recovery. At that time in early 2022, I had no idea
    it would take VA another 2 years to get me that proper prosthetic and
    that I would have to advocate vigorously for myself at every turn,
    eventually seeking help from Representative Rouzer, Senator Tillis, and
    The Independence Fund to advocate for my health and well-being to the
    VA.
        My experiences with the VA over those 2 years were nothing short of
    bewildering and demoralizing. It seemed the staff at the local VA
    hospital consistently failed to communicate well about my care, follow
    through on my care coordination, and expedite requests for prosthetics.
    During that period, I worked with three different VA network private
    prosthetists in my local area of Wilmington, North Carolina. Although I
    was initially told I could select any provider, the one I selected for
    their reputation was not in the VA network so the VA selected another
    vendor for me at the onset.
        All of these vendors over time responded to VA requests to produce
    a proper fitting leg socket. On more than one occasion they told me the
    acquisition approval process at VA was often slow and sometimes they
    would not be paid promptly by VA for their services. I complained to VA
    about the poor communication from VA to these local vendors multiple
    times. While all of this was going on, VA denied my travel claims for
    the trips I took to Duke in 2021 for my cancer treatment and the
    surgery. I am still working with Congressman Rouzer to resolve this.
    Meanwhile, I have been contacted by bill collection agencies. This only
    added to the stress of not being able to resume my normal activities
    outside of a wheelchair.
        In October 2022, I heard from a fellow veteran amputee about a
    special socket the VA had provided him, called the Quattro variable
    volume socket. Given my level of physical activity and the changes in
    blood flow within my residual limb, I thought this system could be the
    answer to my ongoing search for a proper prosthetic. I indicated this
    to VA and requested they obtain one for me. I found out some time later
    that VA placed a requisition order for that socket, but never followed
    through to acquire it. The requisition sat idle while I repeatedly
    asked for this socket. The purchase order eventually expired and I had
    to start all over advocating again for the proper socket.
        I continued to work with a local vendor to obtain a properly
    fitting socket and during this period of months I was using a
    prosthetic ankle. I visited the vendor for routine maintenance in
    September 2022 and the vendor told me they had to repossess this item
    because VA hadn't replied to their requests for payment. I left the
    vendor that day without that ankle and had to use an older ankle that
    was not as flexible.
        For the next year, VA continued to pursue the same types of sockets
    and I continued to tell VA that I needed a different type of socket,
    basically the Quattro. This ``ground hog day'' process was extremely
    frustrating for me and my family. During this period, I was stuck in a
    wheel chair for 6 months. I missed out on so many personal activities.
        In October 2023, I was preparing to travel overseas and was still
    waiting for a socket to be delivered that fit properly. I let VA know I
    had a time limit on how long I could wait before my travel and VA
    directed a local vendor to provide me with a socket, but the vendor was
    concerned it wouldn't fit well and when it wouldn't I had to travel
    using my old, poorly fitting socket. That socket failed during my trip
    and it was very painful to walk and I came home with an infection. Upon
    my return, I was so frustrated that I let my contact at Congressman
    Rouzer's staff know about this. They assisted me further with VA, but
    progress was slow. After almost 2 months of congressional inquiry, I
    reached out to The Independence Fund's Casework Team in Charlotte.
    Their team and Congressman Rouzer's staff partnered to press VA for
    answers on the continued delays in my care and obtaining a properly
    fitting prosthetic. In December 2023, after calls and emails between
    Representative Rouzer's staff and the team at The Independence Fund
    with VA staff at Fayetteville and Washington DC, VA finally agreed to
    shift my prosthetic care from Fayetteville, North Carolina to Richmond,
    Virginia. My prosthetic doctor in Wilmington had left her practice at
    VA in 2022, so I was consequently assigned to a prosthetic doctor in
    Richmond as a result of the outreach to VA. That new doctor looked into
    my medical conditions and spent significant time assessing my needs for
    a different type of socket so I could get out of a wheelchair, travel
    more easily for my business, and finally participate in sporting
    activities with my wife and friends for personal and family well-being.
        The Richmond VA doctor worked with me and a third local vendor to
    get me an interim socket that fit well and allowed me to travel for
    business in January 2024. It would not be until May 2024 when VA
    finally purchased and delivered the Quattro socket I use today. Since
    then I have lost thirty five pounds due to my increased activities and
    feel like a new person today. This only happened because of continued
    pressure on VA from Representative Rouzer, Senator Tillis, and The
    Independence Fund.
        Looking forward, it's clear to me that VA needs a major rework or
    reform of how they address and process everyday amputee's needs for
    prosthetics, especially ones like mine, and deliver them timely. The
    entire experience can be overly bureaucratic, sluggish, and often
    impersonal, sometimes uncaring. I know VA has testified that the costs
    of these special recreational limbs is a concern, but very honestly
    these experts don't realize what it's like to be confined to a
    wheelchair for months, unable to swim or run, and they are ignoring the
    other unseen costs the long delays I experienced can cause, like the
    mental anguish I went through with my family and the related financial
    costs VA paid for with additional mental health visits I needed over
    those 2 years. There are also lifelong future cost savings for VA when
    veterans obtain the prosthetics they need to live active and fulfilling
    lives and don't have to rely on VA for more medical care. The VA has
    also testified that all these services are already being provided, yet
    I and other amputees are proof that commitment is not being uniformly
    honored or followed by local VA staffs and supported by a responsive
    acquisition system. We are not looking for special treatment, we just
    want to live our lives as independently and actively as possible.

                       Prepared Statement of Ashlie White
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

                                  ----------

        Prepared Statement of the U.S. Government Accountability Office
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                      Prepared Statement of Scott Restivo

        I joined the United States Army in March 2006 and was honorably
    discharged in January 2014. I deployed overseas with each unit I
    served. My combat service began in Iraq from 2007-2008 with 2d
    Battalion, 22d Infantry Regiment, 10th Mountain Division where I was
    attached to Special Forces and participated in air assaults and
    multiple fire fights. I deployed a second time to Iraq from Fort Lewis,
    Washington in 2010 with 2d Battalion, 23d Infantry, as an infantryman
    in a Stryker unit. My last deployment was from Fort Campbell to
    Afghanistan with 3d Battalion, 187th Infantry. During that deployment,
    a guard tower I was posted in was struck by enemy rocket propelled
    grenade fire. Early in my military service I injured my right leg in
    training and that injury was later aggravated on deployment, eventually
    requiring a rod placement. I also have a moderate traumatic brain
    injury (TBI), hearing loss, and ongoing complications such as seizures
    and PTSD in addition to other medical conditions. The rod that was
    placed in my leg by the Army at Fort Drum later dislodged into my knee
    tearing my meniscus and causing revision of my patella tendon. I was
    willing to remain in the Army, but due to administrative issues and
    what I saw as improper handling of my medical care in the Army,
    including a misrepresentation of the origin of my injury as occurring
    pre-service, my medical discharge process was denied and I was not
    medically retired by the Army. Consequently, I do not qualify for
    TRICARE and have since faced prolonged and significant challenges since
    my discharge receiving timely and appropriate treatment and care from
    the Department of Veterans Affairs (VA).
        This is a condensed summary of my medical journey and my advocacy
    efforts relative to the VA:

        -My primary health care doctor at the VA had us apply for the
    Caregiver Program in 2016 given our needs. We were subsequently denied
    admission to the program in 2016, despite my need for continuous care.
    The reason given was I did not need 6 months of continuous care. Due to
    my medical conditions, Lelia had to quit working because I was having
    seizures, incontinence, and non-cognitive episodes. I had a home health
    nurse for wound care, a PICC line my wife had to change every few
    hours, speech therapy, OT, PT, and a leg that was impeding my mobility.
    I endured multiple knee surgeries without improvement, had PICC line
    complications, and ER visits.

        -On November 15, 2016, the VA performed right knee surgery to
    remove the dislodged rod and reconstructed my knee.

        -Post-surgery, I frequently visited the ER with severe symptoms,
    including loss of consciousness, seizures, fever, and a discharging
    incision wound. The VA ER only provided fluids and a few times cleaned
    the wound and stabilized my condition. Multiple outside hospitals
    identified an infection, but could only stabilize the issue and kept
    referring me back to the VA since they did the initial surgery.

        -My wife, Lelia, aggressively advocated for my care and condition.
    She reached out to my Primary Care Provider, Mental Health Specialist,
    Neurology, Orthopedics, social workers, and patient advocates since
    surgery complications began.

        -In January 2017, my wife finally got a call from the head of the
    Nashville VA hospital's Orthopedics department and arranged a time for
    me to be seen. During that visit, 500+ liters of fluid were drained
    from the knee in my right leg and I was wheeled into immediate
    emergency surgery due to sepsis.

        -I awoke days later burning up with a fever, I had gone into shock
    and nearly died from sepsis. My wife had called family members in as
    the staff didn't think I would make it. Four days later I had broken my
    fever only to awaken confused and remember being frustrated, in pain,
    and being wheelchair dependent with round the clock PICC line changes.

        -Recently, we discovered several news articles that revealed the
    VA's sterilization equipment was down during the initial surgery,
    indicating non-sterile conditions.

        -After 6 months of constant advocacy by my wife and pleading with
    the VA orthopedic surgeon an outside Orthopedic referral was finally
    approved in June 2017.

        -During the first appointment Tennessee Ortho Association images
    revealed that the infection had spread into the bone and they could do
    nothing to stop the spread of infection. I was referred for care at
    Vanderbilt University Hospital.

        -I had bone grafts, and several surgeries at Vanderbilt, but was
    still sick and losing more and more mobility. Essentially, I had a dead
    limb I was dragging around with me daily. The last surgery and attempt
    to save my leg was unsuccessful. I broke down and decided I was done
    living ill and I wanted to live my life to the fullest even if that
    meant without a leg.

        -On October 18, 2018, my right leg above the knee was amputated at
    Vanderbilt. Some days I wish the guard tower attack had taken me out or
    the rocket just had taken my leg off then. It had now been 6 years
    since the rod had initially dislodged into the knee, and I suffered the
    slow death of my leg into the bone, primarily due to negligence. This
    is not how anyone should lose a limb.

        -The VA delayed providing me with a prosthetic for 6 months and
    offered inadequate Physical Therapy. The Nashville VA prosthetic clinic
    was ineffective, offering incorrect prosthetics, infrequent
    appointments, and poor communication. I experienced frequent prosthetic
    malfunctions, falls, and inconsistent care. Liners last approximately 3
    months, but I went 18 months with two liners and this caused sores and
    wounds to my stump. I had a loaner leg for over 6 months due to a
    microprocessor malfunction and the need for it to be sent out to be
    fixed by the manufacturer. That was the third time I had a loaner leg
    for extended periods of time. Each time I am in a loaner leg, it
    affects my gate and ability to walk and function correctly. As of this
    testimony, I am still waiting for a proper prosthetic leg that allows
    me the normal mobility I am seeking.

        Based on my experiences with VA, I offer the following
    observations:

        -I essentially have received inconsistent care throughout the
    entire VA system, predominantly in Nashville and not just only with
    prosthetics care.

        -A 2018 VA hearing sought repayment of separation pay, later found
    to be improperly coded, because DOD had granted me relief and the VA
    judge recommended relief, but the VA overruled their judge and recouped
    all pay from March to August 2020. This was during the pandemic and the
    sudden loss of that money caused me and Lelia undue stress and
    hardship.

        -My VA primary care provider changed, leading to misdiagnosis and
    overlooked issues, such as infections and kidney stones. VA imaging
    showed one kidney stone and Vanderbilt's showed multiple.

        -In February 2020, I experienced severe blood pressure issues,
    leading to ICU admission and a finding of a mitral valve issue, yet I
    was discharged without resolving my blood pressure cycling. I was
    admitted to Skyline hospital, they found I was allergic to the
    medication the VA put me on and I was on the stroke watch for 5 days.
    Advocacy efforts resulted in a new Primary Care Manager in 2021 and I
    was assigned to a palliative care team, but my major health issues
    remained unresolved.

        -In 2022, a congressional inquiry revealed lost caregiver
    applications and vehicle grants dating back to 2018. By early 2023,
    vehicle repairs prompted reapplication for a vehicle allowance,
    revealing systemic VA issues. Continuous communication with the chief
    of staff's secretary at Nashville VA resulted in no tangible outcomes.

        -In March 2023, my wife quit her job teaching to advocate for my
    medical issues full-time, leading to a confrontational prosthetics
    appointment and to an inner facility consult with transfer of
    prosthetic care from Nashville VA to Tampa VA.

        -We made regular trips from Tennessee to Tampa for laser treatments
    and prosthetics fittings and while we experienced initial improvements
    in care, we faced logistical and financial challenges.

        -By late 2023, the prosthetic issues persisted, requiring multiple
    repairs and causing frequent falls.

        -Dental complications arose, with VA dental falsely diagnosing an
    emergency infection.

        -Advocacy again led to some progress, such as an adaptive housing
    grant approval, but continuous care and prosthetic issues remained
    unresolved.

        -Our second Caregiver Program denial was appealed, and I faced
    significant ongoing challenges with prosthetic fitting and
    functionality.

        -Travel expenses are not fully covered to Tampa for necessary
    treatment and have imposed significant financial burdens. Communication
    with Tampa prosthetics is now crossing over into other care
    communications issues between other VA providers.

        -In February, 2024, Tampa VA was supposed to have ordered or
    prescribed a new socket for the current daily use prosthetic because
    mine is broken and does not fit. This prosthetic knee was repaired over
    4 times within a 6-month period, and I had been in a loaner leg since
    November 2023. The repaired knee was to be used as a backup in place of
    a loaner leg situation. A new fitting socket and copy of the daily use
    microprocessor was also supposed to be ordered for the function of
    daily use in the event we lose power at our home, as has happened for
    days after storms. I received this new system on July 8, 2024. It was
    not functional for long term daily use; it is supposed to be waterproof
    so I may be able to use it as a shower leg and not need a shower leg
    made, though I have requested a water leg since the day of surgery
    because I want to be safe and feel normal and be able to stand in the
    shower. I did receive two liners and they arrived a year after I had
    last received liners, despite multiple communications stating the need
    for them since our November 2023 visit to Tampa. I left my appointment
    with Hanger Prosthetics in July with the still broken socket and
    malfunctioning knee, carrying the non-microprocessor system with videos
    of gait training so my wife can assist me in learning how to use the
    leg on my own.
        In conclusion, I pray that my journey illustrates the severe
    challenges faced in obtaining adequate care through the VA. Despite
    some progress, due in significant part to The Independence Fund's
    unceasing effort to get our voice finally heard and this story told at
    the upper levels of the VA in Washington DC and by this Committee's
    staff, significant gaps in care and support persist, necessitating
    ongoing advocacy and intervention to improve my quality of life. I
    thought going to war would be the end of the battle, but the fight has
    been for my life in seeking medical care in the VA system. I ask
    Congress for a change of access to timely and efficient prosthetic care
    whenever requested, so that no Veteran suffers the loss and function of
    a limb or inadequate prosthetic limb care the way I have.

                   Prepared Statement of The American Legion

        Chairwoman Miller-Meeks, Ranking Member Brownley and distinguished
    members of the House Veterans' Affairs Subcommittee on Health on behalf
    of National Commander James LaCoursiere and The American Legion, the
    country's largest service organization for veterans, comprised of more
    than 1.5 million dues-paying members, we thank you for the opportunity
    to offer this statement for the record regarding life after limb loss
    and the prosthetics care provided to veterans by the VA.

                               Amputees' Stories

        This year our organization has conducted numerous interviews with
    amputees. This includes an interview with U.S. Army veteran Geoffrey
    Quevedo on November 6th, 2024\1\ and a subsequent interview with U.S.
    Army veteran Earl Granville on November 14th, 2024\2\. Additionally,
    U.S. Air Force veteran Adam Popp was interviewed on the Tango Alpha
    Lima Podcast on May 7th, 2024\3\.
    ---------------------------------------------------------------------------
        \1\ Petrie, Andrew, Joshua Hastings, and Geoffrey Quevedo. The
    American Legion Health Policy Amputee Interviews. Personal, November 6,
    2024.
        \2\ Hastings, Joshua, Sri Benson, and Earl Granville. The American
    Legion Health Policy Amputee Interview. Personal, November 14, 2024.
        \3\ Marr, Adam, Stacy Pearsall, and Adam Popp. A Record-Setting
    Veteran Amputee. Other, n.d. https://www.legion.org/information-center/
    news/tango-alpha-lima/2024/may/a-record-setting-veteran-amputee.
    ---------------------------------------------------------------------------
        On Nov. 30, 2012, while on patrol in Afghanistan, Geoffrey Quevedo
    and a fellow soldier from the 10th Mountain Division discovered an
    improvised explosive device (IED). As they attempted to disarm the
    device, it exploded--catastrophically wounding Geoffrey and his squad
    mate, leading them to be medically evacuated to Walter Reed Medical
    Center in Bethesda, Maryland. Geoffrey originally had his left foot and
    left arm above the elbow amputated. These injuries led to more than 40
    surgeries with the eventual amputation of his left leg below the knee.
    Due to complications, he now deals with chronic pain, vision loss and
    migraine headaches.
        When asked about his experiences in receiving treatment, Mr.
    Quevedo mentioned difficulties in reordering extra sleeves and
    prosthetic supplies from VA. These reorders are due to the wear and
    tear of Geoffrey pushing himself to run 5-kilometer and 10-kilometer
    marathons. He said, ``Sometimes it feels like I'm being punished for
    trying to be active.'' It is clear that VA should recognize these kinds
    of supplies, adaptive sports and recreation prosthetics as clinically
    necessary for amputees.
        We should be eliminating barriers to exercise, not creating them,
    as it is an essential part of living a healthy life and addressing
    upstream health complications. Geoffrey also talked about his decision
    to move closer to his community care provider and his frustration with
    VA's delayed payments to his provider after receiving care.
        When asked to describe his strongest support system, Geoffrey noted
    how instrumental peer support from the amputee community was in his
    recovery. He said it is an honor to be an example to younger veterans
    walking down a similar road: ``Pain becomes a part of life--there is
    really nothing you can do to take it all away. You go from being top
    dog, to someone always asking for help.'' He realized the most painful
    thing about his recovery was dealing with the loss of his independence.
    ``This is why I always tell them to stay active.''
        Earl Granville agreed with Geoffrey, noting that working with other
    amputees has been critical to his own recovery. Earl was deployed to
    Afghanistan when--on June 3, 2008--an IED exploded, ejecting Granville
    out of the vehicle and killing two fellow soldiers, Major Scott Hagerty
    and Specialist Derek Holland.
        Mr. Granville talked about the training he received from the
    Amputee Coalition, where they worked on learning to listen. There, he
    would often break the ice with younger amputees, saying ``Hey, you've
    got that new shiny thing. How is that going?'' Granville now tours
    around the country promoting his philosophy of the three Ps: purpose,
    passion and being part of something bigger than oneself.
        When asked about his experience receiving care, Mr. Granville gave
    the Walter Reed Medical Center a glowing recommendation. He is
    generally pleased with the care he is receiving from VA. One drawback
    he mentioned, however, is the inconvenience of having to go in person
    to a VA facility when a certain process could be conducted digitally.
    ``We need to make it easier on these guys.''
        In addition to interviewing Mr. Quevedo and Mr. Granville, The
    American Legion Tango Alpha Lima podcast interviewed Air Force veteran
    Adam Popp on May 7, 2024. Mr. Popp became an amputee during his
    deployment to the province of Paktia in Afghanistan, where he was
    wounded by a secondary IED, resulting in the amputation of his right
    leg above the knee. Since then, he has become an outstanding athlete,
    setting seven new marks in the Guinness Book of World Records.
        In his interview, Popp mentions that he understands his
    achievements reflect not only his physical fitness, but his strong
    mental state. He admits that in the aftermath of his injury, he did not
    seek out such challenges. ``It's about seeking out selective struggles,
    some type of challenge, and then coming out stronger on the other side,
    whether that is through physical activity, education or personal
    struggles that happen in anyone's daily life.'' He ended with a
    question: ``Is that going to beat us down or lead us to a more fruitful
    and productive life?''

                             Post-traumatic Growth

        The theory of post-traumatic growth (PTG) suggests that people can
    rebuild their foundation by believing they are not defined by what has
    happened to them, i.e., positive psychological change can occur after
    experiencing a traumatic event. PTG therapies often pursue new
    experiences to take advantage of the increased neuroplasticity (the
    brain's ability to form and reorganize synaptic connections) of
    traumatized patients. This increased neuroplasticity follows both
    physical and psychological trauma. Due to the untraditional nature of
    PTG therapies, it has been difficult for the VA to implement system-
    wide programs. The Staff Sergeant Parker Gordon Fox Suicide Prevention
    Grant Program should continue to seek community partners who deliver
    PTG programs for veterans. The image of the broken hero needs to be
    replaced with one of strength and mental resilience.

                              Opioid Use Disorder

        Many veterans become amputees due to explosions or blast-related
    events; these lead not only to injuries such as amputations but often
    cause spinal cord injuries (SCIs) and traumatic brain injuries (TBIs).
    These types of injuries can lead to chronic pain, loss of movement, and
    other serious medical problems throughout the body.
        About one-third of veterans with SCIs will experience persistent
    neuropathic pain after injury, and opioids are considered among the
    most effective treatments for neuropathic pain. This puts veterans
    suffering from polytrauma at a substantial risk for opioid use
    disorder.
        According to the National Library of Medicine, U.S. military
    veterans have been heavily impacted by the opioid crisis, with drug
    overdose mortality rates increasing by 53 percent from 2010 to 2019.\4\
    The need to improve overdose prevention efforts remains clear and more
    should be done to provide effective alternatives to opioids for chronic
    pain management.
    ---------------------------------------------------------------------------
        \4\ Woller, Sarah A., and Michelle A. Hook. 2013. ``Opioid
    Administration Following Spinal Cord Injury: Implications for Pain and
    Locomotor Recovery.'' Experimental Neurology 247 (September): 328-41.
    https://doi.org/10.1016/j.expneurol.2013.03.008.
    ---------------------------------------------------------------------------

                                 Gaming Therapy

        In January 2024, The American Legion conducted a System Worth
    Saving (SWS) site visit to the James A. Haley Veterans' Hospital
    (JAHVH) in Tampa, Florida. During a tour of the facility, the SWS team
    was given the opportunity to meet Jamie Kaplan, a recreation therapist
    who informed us about JAHVH Gaming, a gaming community of about 350
    servicemembers and veterans who meet five nights a week. The array of
    adaptive gaming controllers and other gaming prosthetics was most
    impressive, using combinations of hands, feet and even lung power.
        These innovative approaches are a critical part of addressing the
    isolation felt by many veterans with limb loss and can provide both
    support and entertainment. When The American Legion's Health Policy
    team highlighted these innovations with Mr. Quevedo in our interview,
    his face brightened--envisioning playing video games with his
    daughters. More should be done to make such dreams a commonplace
    reality.
        During the Tampa visit, the late Autrey James, previous Chairman of
    The American Legion's Veterans Affairs & Rehabilitation Commission,
    became extremely interested in the gaming program and spoke about the
    Legion's efforts in California to create supportive veteran gaming
    communities. He informed Mr. Kaplan that the Legion's Department of
    California had established a Gaming Committee in 2023 to help promote
    camaraderie, improve mental health and aid recruiting efforts.

                        Age/Gender-Appropriate Resources

        The young age of traumatic and non-traumatic amputees highlights
    the need for age-appropriate resources. Many of the post-9/11 veterans
    are still within working age, as indicated by a study that showed 37
    percent of veterans with limb loss are employed. Post-9/11 veterans
    have different prosthetic needs compared to older veterans.
        According to recent research, approximately 85 percent of veterans
    with a limb amputation are under the age of 35. Older veterans with co-
    morbidities related to their limb loss are often physically challenged
    and have difficulty exercising; this is in contrast to younger veterans
    who are more physically able but face other challenges such as mental
    health difficulties due to trauma and PTSD.\5\
    ---------------------------------------------------------------------------
        \5\ Murray, Craig D., Heather Havlin, and Victoria Molyneaux. 2023.
    ``Considering the Psychological Experience of Amputation and
    Rehabilitation for Military Veterans: A Systematic Review and
    Metasynthesis of Qualitative Research.'' Disability and Rehabilitation,
    March, 1-20. https://doi.org/10.1080/09638288.2023.2182915.
    ---------------------------------------------------------------------------
        Last, with the increase number of women veterans serving during the
    post-9/11 era, we have also noticed an increase in gender-specific
    prosthetic needs. In past years, amputations among veterans were a
    male-dominated concern. Many women who served in recent wars have also
    suffered from limb loss and they have different needs when it comes to
    prosthetics. For example, thinner and lighter devices are required to
    provide the function and agility women need to be as independent as
    possible.

                                   Conclusion

        The lack of age/gender-appropriate resources for young veterans
    must be addressed. Alternatives to opioids must be made readily
    available to veterans who suffer from spinal cord injuries and chronic
    pain. Access to alternative treatments for polytrauma--such as PTG
    virtual reality therapy, adaptive sports and recreation prosthetics -
    must be increased and additional research must be funded. VA and DoD
    need to work more closely in helping to ease the burden of
    transitioning servicemembers who require prosthetic maintenance,
    training and rehabilitation.
        The American Legion strongly supports VA efforts to fund, develop,
    and provide gender-specific prosthetic appliances, orthotics, and
    services through multiple avenues--such as medical facilities,
    community outreach centers and mobile clinics. VA must continue to
    engage in research and innovation to ensure that veterans are provided
    with sufficient opportunities to mobilize independently.
        Research should encompass the latest technologies in prosthetics
    and orthopedic devices and should include comparative analyses on best
    practices and outcomes derived from the Medicare program and the
    commercial health insurance market relating to the coverage of
    assistive technologies.
        Finally, the tragic effects of physical and mental disabilities
    overwhelm some veterans who end up taking their own lives. Without
    question, successful treatment plays a key role in suicide prevention.
    The restoration of mobility, positive psychological changes, safe pain
    management and a sense of community are powerful tools in reducing
    veteran suicides.
        Two of the veterans who shared their stories with The American
    Legion have felt the tragedy of suicide. Mr. Quevedo's former squad
    mate, Quinton Picone, died from suicide 5 years after the IED incident
    in Afghanistan. Mr. Granville's twin brother Joe took his own life in
    2010; the brothers had served together in the Army on multiple
    deployments.
        Suicide prevention remains The American Legion's most important
    mission. In partnership with The Columbia Lighthouse Project and the
    QPR Institute, our national ``Be The One'' program has provided
    training in suicide prevention for more than 10,000 members of The
    American Legion family - our goal is to train more than 100,000 by the
    end of 2025.
        Furthermore, The American Legion Buddy Check Program aims to
    reconnect veterans who may need assistance but do not know where to go
    or who to ask for help. In concert with this effort, the VA held its
    first Veteran Buddy Check Summit last month, an event that was
    extremely well received.
        Chairwoman Miller-Meeks, Ranking Member Brownley and distinguished
    members of this Subcommittee, The American Legion thanks you sincerely
    for your leadership and for allowing us to explain the position of our
    membership on the issue of VA prosthetics care for amputees. For
    additional information regarding this testimony, please contact the
    director of our Legislative Division, Julia Mathis, at
    jmathis@legion.org.

                                     [all]