STATEMENT FOR THE RECORD 

PRESENTED BY 

RICHARD B. FULLER 

NATIONAL LEGISLATIVE DIRECTOR 

PARALYZED VETERANS OF AMERICA 

REGARDING 

H.R. 3645, THE "VETERANS HEALTH CARE ITEMS

PROCUREMENT REFORM AND IMPROVEMENT ACT OF 2002"

BEFORE THE  

SUBCOMMITTEE ON HEALTH 

OF THE 

HOUSE COMMITTEE ON VETERANS' AFFAIRS 

June 26, 2002 

 

Mr. Chairman, and members of the Subcommittee, Paralyzed Veterans of America (PVA) appreciates this opportunity to comment on H.R. 3645, the "Veterans Health-Care Items Procurement Reform and Improvement Act of 2002."  The legislation would alter procurement practices by the Department of Veterans Affairs in purchasing health care items.  Except under certain circumstances, the bill would prohibit VA from purchasing any health care item that is not acquired through the use of a Federal Supply Schedule contract or a national contract. 

PVA appreciates the intent of the legislation to achieve cost savings by changing or "nationalizing" the procurement of the immense number of health care items, devices and prosthetic equipment purchased each year by the Veterans Health Administration (VHA).  We have grave concerns however, that by changing how VA purchases products, the VA will voluntarily or involuntarily proscribe and limit what products it purchases to the great detriment of disabled veterans who use those items on a daily basis.   

All of PVA's members are veterans who have sustained catastrophic spinal cord injury or dysfunction.  Because of the nature of these disabilities, PVA members require a lifetime of complex multidisciplinary primary, acute and sustaining health care.  These services must be complemented by the provision of a broad variety of medical supplies, equipment and prosthetic devices to allow the individual to overcome the challenges of a catastrophic disability on a daily basis.  These items range from the obvious provision of a wheelchair and seat cushion, to the not so evident catheters, urine collection equipment, bowel care, hygiene and skin care products that are part of a paraplegics and quadriplegic's routine of daily living. The list of prescribed and over-the -counter supplies are immense.  And, the path to successful rehabilitation and good health comes not just with the provision of these products, but in making sure that the products are tailored and prescribed to meet the unique needs, and even preferences, of each individual patient.  From this standpoint, variety is a necessary prerequisite.  Providers and patients must have a broad array from which to select those products, devices and supplies that address a need that can vary widely from one disabled veteran to the next.

Obviously, one wheelchair, or wheelchair cushion, does not fit all.  Wheelchairs must be carefully selected to meet the motor skills of the user as well as basic utility, whether for routine mobility or needed recreation.  Wheelchair cushions must be designed and fitted to meet the needs of different sized bodies and different pressure point requirements.  An ill-designed or inappropriate cushion can cause a skin breakdown and pressure sore that can cause months of hospitalization, if not death.  Catheterization and bowel care are a daily challenge for almost all paraplegic's and quadriplegics.  The choice of the appropriate catheter and bowel care equipment is as much a medical decision as one of personal preference for the user.  The list of similar examples goes on and on.  

The main point PVA would like to make is that any restriction in the availability of these products or limitation in the variety of products available has a direct bearing on the health of the veteran user. 

PVA and other veterans service organizations are already concerned by VA initiatives seeking to restrict choice in the field of prosthetics and limit the ability of individual clinicians to provide the full range of equipment suited to meet the veteran's need. The Independent Budget for Fiscal Year 2003, co-authored by the AMVETS, Disabled American Veterans, Paralyzed Veterans of America and Veterans of Foreign Wars made the following statement in this regard. 

"The Independent Budget VSOs are continuing to monitor the development of VHA's prosthetics clinical management program, (PCMP) which was established in FY 2001 in connection with the decision to fully centralize the prosthetics budget.  As part of the  PCMP implementation, VHA has strongly recommended that each VISN form a network-level PCMP to review prescription criteria and prosthetic prescriptions within their network.  As this program could be used as a veil to standardize or limit the types of prosthetic devices that a VISN or facility will issue to veterans, strong VHA oversight in needed as this program develops." 

"One VISN has already developed clinical guidelines on motorized wheelchairs and scooters that are quite restrictive and contain some bizarre provisions.  For example, a prescription for a motorized wheelchair or scooter could be refused if there was a recent history of drug or alcohol abuse.  In addition, the examiner must clinically assess whether the veteran can have sexual intercourse without stopping or can garden, rake, or weed.  The guidelines must assess whether the veteran can shower without stopping, and if the veteran can bowl."

Under VHA Directives 1761.1, prosthetic items intended for direct patient issuance are exempted from VHA's standardization efforts.  The reason for this is that a "one size fits all" approach is inappropriate for meeting the medical and personal needs of disabled veterans.  However, managers in VHA's local prosthetics programs, as well as some VA clinicians, still encounter internal managerial pressure to standardize some of the prosthetic devices they issue or altogether restrict certain devices from issuance.  This is a matter of grave concern for the IBVSOs and we remain opposed to any and all initiatives that will result in the standardization of prosthetic devices and sensory aids." 

In conclusion, this section makes the additional argument against standardization. 

"Finally, considerable advances are still being made in prosthetics technology that will continue to dramatically enhance the lives of disabled veterans.  VA was once the world leader in developing new prosthetics devices.  VHA is still a major player in this type of research, from funding research to assisting with clinical trials for new devices.  Formulary-type scenarios for standardizing prosthetics will likely cause advances in prosthetic technologies to stagnate to a considerable degree because VA has such a major influence on the market.  Disabled veterans must have access to the latest devices and equipment, such as computerized artificial legs and stair climbing and self-balancing wheelchairs and scooters, if they are to lead as full and productive lives as possible." 

PVA is concerned that the provisions in H.R. 3645 which, for the most part, limit the procurement of health care items to only those items that are listed in Federal Supply Schedule contracts or national contracts, very well could serve the purpose of limiting the availability of the full array of products available.  This we believe is the wrong signal to send to a VA that is already looking to standardization to achieve cost savings in many areas of prosthetics and equipment procurement.  A supply schedule, like a formulary, is only as good as the people who determine what is on the list and what is not.   

PVA had expressed serious concerns in the past about the restrictive nature of VA's original pharmaceutical formulary proposal as not fully meeting the scope of need of PVA members.  After expressing those concerns, we reached agreement with the Department of Veterans Affairs to have a directive sent to the field to broaden the scope of those pharmaceuticals available to veterans with complex disabilities such as spinal cord injury.  Section (b)1 of  H.R. 3645 seems to provide an exception to allow a clinician to go outside a Federal Supply Schedule contract or national contract if there is a "valid clinical need."  We appreciate this exception provided in the legislation, but believe that the terms "valid" and "clinical" are too vague to provide any flexibility when matched against the larger intent of the legislation.  "Clinical" could encompass those items that might address a medical need.  The word "valid" could be interpreted by an accountant responding only to the cost of an item.  We believe, as written, this section gives insufficient support to the clinician seeking to prescribe what may be outside a federal supply schedule or national contract list, but which may be most appropriate for a seriously disabled veteran. 

If this legislation is to proceed, we strongly recommend the language in this section be carefully reviewed, amended and strengthened to give the maximum authority and flexibility to individual clinicians in prescribing whatever they feel is necessary and appropriate for veterans with specialized needs. 

This concludes my statement for the record.  I will be happy to respond to any questions you may have.