[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
LIFE AFTER LIMB LOSS: EXAMINING
VA AMPUTEE PROSTHETICS CARE
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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
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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
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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
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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.]
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A P P E N D I X
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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\.
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\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.
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\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.
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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\
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\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.
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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
[email protected].
[all]