Joint Hearing of the Committee on Homeland Security and Governmental Affairs of the U.S. Senate and the Committee on Veterans’ Affairs of the U.S. House of Representatives at 1:00 p.m. CDT.
Witness Testimony of Alethea Predeoux, Associate Director of Health Legislation, Paralyzed Veterans of America
Chairwoman Buerkle, Ranking Member Michaud, and members of the Subcommittee, thank you for allowing Paralyzed Veterans of America (PVA) to testify today concerning prosthetic services of the Department of Veterans Affairs (VA). Ensuring that our nation’s injured veteran population is able to receive state of the art prosthetic devices in a timely manner is an extremely important issue for PVA. PVA has more than 19,000 members who all utilize the services of PSAS on a regular basis. Our National Service Officers work very closely with VA to ensure timely delivery of quality prosthetic items needed by veterans.
In recent months, the VA Office of Inspector General (OIG) and the OIG’s Office of Audits and Evaluations have released numerous reports on PSAS inventory management, the management of PSAS acquisition of prosthetic limbs, and prosthetic limb care. PVA believes that these internal audits and investigations have identified many areas in need of improvement within PSAS, and PVA generally supports the spirit of therecommendations provided by the OIG. The recommendations provide not only an opportunity to improve upon the prosthetic services for veterans with amputations, but for all veterans that utilize VA prosthetic services.
The OIG’s evaluations and assessments are taking place during a critical turning point for PSAS. The Veterans Health Administration (VHA) Office of Procurement and Logistics (P&LO) is currently undergoing a structural reorganization. These changes include a joint purchasing structure for prosthetic items that includes both PSAS and P&LO making prosthetic purchases. Specifically, the division of purchases will be based on the cost of items, the “micro-purchase threshold.” Essentially, when an item costs a specific amount or higher, it will be purchased by P&LO. While the VA reports that this change will result in increased oversight and review of prosthetic purchase orders, PVA is concerned that this dual purchasing track that involves both PSAS and P&LO has the potential to create delays in the delivery of items to veterans.
PVA is further concerned that this new system will also lead to less VA accountability for veterans during the ordering and delivery processes. When an order for prosthetics is placed, at any point before the item is delivered, veterans, or often times a National Service Officer on behalf of a veteran, is able to contact a PSAS employee with questions regarding the device or the status of delivery. With P&LO now handling prosthetic purchases, it is unclear which office will serve as a point of contact to provide veterans with timely assistance when questions or concerns arise before the prosthetic item is delivered.
To ensure that the newly divided purchasing authority for prosthetics does not lead to increased delays in delivery of items and services, PVA recommends that PSAS leadership use a tracking system to provide veterans, clinicians, and VSOs with timely updates, as well as reasons for delays, when necessary. The VA has developed the eCMS planning module to manage prosthetic orders. This system will serve as a single point of entry for P&LO prosthetic purchases. PVA encourages VA to notify veterans and their health care providers electronically through the eCMS system to address issues that arise with prosthetic orders such as delays in delivery. PVA also recommends the VA develop guidelines that establish the length of time in which an order should be completed.
PVA has reached out to PSAS leadership on several occasions to identify the status of the reorganization and appreciates the opportunity to provide our input. While we have been informed that the dual purchasing system was piloted in three Veteran Integrated Service Networks (VISNs) beginning in January 2012, and will be further implemented in additional areas in July 2012, we are not aware of how VA intends to make sure that veterans are aware of these changes. Therefore, PVA encourages VA leadership to consult with veterans and their families, as well as stakeholders who regularly work with PSAS to provide input as they further develop the process for prosthetic purchases through P&LO. Many veteran service organizations and veterans have been working with PSAS for many years and could provide valuable input that will help VA ensure that this change does not negatively impact veterans. PVA would also encourage the VA to provide Congress and veteran service organizations with updates and any findings that are compiled as a result of the pilots that were implemented in January 2012, and future findings as the plans move forward.
As it relates to the impact of this procurement reform, dividing the purchasing of prosthetics between PSAS and P&LO, PVA has concerns regarding potential differences between the two departments’ internal policies, and how such differences may negatively impact the quality of care and services provided to veterans. The P&LO office is governed by policies of VA acquisition. Such policies are meant to address the purchasing of various items for many different offices within the VA. As such, PVA would like to make certain that the change to P&LO managing the purchases of high cost prosthetics does not lead to the standardization of prosthetics or increased limitations on ordering devices. PVA strongly urges the VA to continue to abide by VA policy that adheres to title 38, United States Code, Section 8123, which states that:
The Secretary may procure the prosthetic appliances and necessary services required in the fitting, supplying, and training and use of prosthetic appliances by purchase, manufacture, contract, or in such other manner as the Secretary may determine to be proper, with regard to any other provision of law.
This statute enables VA to meet the unique prosthetic needs of veterans in a timely manner without the limitations of cost saving measures such as standardization of items or contract bulk purchasing. Veterans must have access to the prosthetics that best fit their individual needs.
For many years, PSAS has done a good jobof ensuring that the number one consideration when ordering prosthetics is quality—the ability to meet the medical and personal needs of veterans. The VA must make certain that the issuance and delivery of prosthetics continues to be provided based on the unique needs of veterans, and to help them maximize their quality of life. As VA undergoes this procurement reform, and the reorganization of the Veterans Health Administration, leadership must ensure that prosthetics do not become subject to issuance restrictions based solely on cost or internal pressures to control spending.
While PSAS has done a good job of providing veterans with the prosthetics that they need, no health care system is perfect, and gaps continue to exist in VA’s delivery of prosthetics. As stated previously, delays in delivery of prosthetics continue to exist. Often these delays are due to inconsistent administration of prosthetic policies between VISNs that ostensibly operate under the same guidance. For instance, when a prescription for a prosthetic device is issued, purchasing agents and administrators in one VISN often use an approval process that may vastly differ from those used in the neighboring VISNs. This becomes particularly problematic when a facility in one VISN places an order for a veteran through its subsidiary facility, in another VISN, and each uses different approval processes. When this occurs, orders go back and forth between networks before they can be authorized, placed, manufactured, and delivered to the veteran.
With established guidelines required for all staff handling prosthetic orders, the back and forth during the approval process would be eliminated. Ultimately, such inconsistencies in the administration of PSAS policies lead to prolonged delivery of prosthetic items to veterans. PSAS must require all VISNs to adopt consistent operational standards in accordance with national prosthetics policies that provide veterans with the best possible customer service.
Delays are also caused by an outdated filing system for veterans’ medical records. When veterans travel across the country or relocate, should they need to seek services at a VA medical center for the first time, they often have to wait for medical records to be emailed, mailed, or even faxed. Urgent prosthetic care is delayed because there is no system in place that allows veterans’ records to be instantly viewed by more than one medical center when necessary. This gap in care must be addressed to make certain that veterans do not go without their much needed prosthetic items.
Another example of administrative inconsistencies involves the prosthetic purchasing agents and the clinicians that prescribe the prosthetic. PVA has found that it is not uncommon for clinicians to prescribe a prosthetic based on their medical expertise and the medical needs of veterans, however, when the contracting officers receive the order, the request for the device is modified or even denied due cost, or the VA not having an established contract with the manufacturer of the device. PVA understands that in the current fiscal environment the VA must ensure that its employees are making smart and efficient spending decisions. However, PVA believes that smart, efficient decision making includes providing veterans with a quality prosthetic device that meets their needs and provides them with quality of life and independence.
Additionally, the quality of prosthetic devices is extremely important to providing veterans with quality of life. When veterans are issued prosthetics, it is VA policy to ensure that they have an alternative device that is able to be used in the event that the primary prosthetic is not available. The second prosthetic is commonly referred to as the “back-up” device. While the VA issues back-up devices to veterans with prosthetics, often the back-up prosthetic and the primary prosthetic are not of equal quality. This poses significant problems for veterans when their primary prosthetic is undergoing repairs, or simply not available to them.
PSAS should work to provide veterans with quality prosthetic devices as back-up options for veterans. Ordering quality prosthetics for veterans has many benefits. While better quality items may not always be the cheapest option, in the long-run it is cost efficient for the VA. Providing veterans with quality prosthetics leads to longer periods of use and less spending on replacement items, and also prevents potential health hazards that may result from veterans using equipment that is not durable or meant to meet their unique physical needs.
There is a direct correlation between quality care and quality of life. Prosthetics is one of the most important elements of providing disabled veterans quality of life. VA prosthetics should give veterans the opportunity to live with a disability without the concerns of physical limitations that prevent them from being active, productive individuals. Although PSAS could improve upon the management and acquisition of prosthetic items such as limbs, for the past several years PSAS has provided thousands of veterans with specialized, state of the art, quality prosthetic devices. PVA believes that the only way to continue this performance is to streamline the administrative practices of the VA, and make certain that veterans are provided with quality prosthetic devices that meet their needs in a timely manner.
Again, PVA thanks the Committee for their attention to this important issue and encourages continued oversight of VA prosthetic services. I am happy to answer any questions from the Committee.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the following information is provided regarding federal grants and contracts.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, administered by the Legal Services Corporation — National Veterans Legal Services Program— $262,787.
Fiscal Year 2010
Court of Appeals for Veterans Claims, administered by the Legal Services Corporation—National Veterans Legal Services Program— $287,992.
Associate Director of Health Legislation
Paralyzed Veterans of America
801 18th Street NW
Washington, D.C. 20006
Alethea joined Paralyzed Veterans of America in 2007 and works in PVA’s National Office in Washington, D.C. As a member of PVA's Government Relations staff, Alethea is responsible for monitoring and analyzing policy within the Department of Veterans Affairs (VA) to determine how such policies impact the health care of disabled veterans, particularly, veterans with Spinal Cord Injury/Dysfunction (SCI). Alethea also covers issues involving women veterans, VA human resources, prosthetics, and mental health. Alethea’s professional experience is in the area of legislative affairs and government policy.
In addition to her policy work, Alethea also manages the production of The Independent Budget, a comprehensive budget and policy document produced by veterans for veterans.
Alethea earned a Master's Degree in Public Policy from George Mason University, and completed her undergraduate studies in Political Science at Spelman College.
 The Department of Veterans Affairs, Office of Inspector General: Office of Audits and Evaluations; “Veterans Health Administration: Audit of the Management and Acquisition of Prosthetic Limbs,” March 8, 2012; 11-02254-102; http://www.va.gov/oig/pubs/VAOIG-11-02254-102.pdf
 Ibid, pg. 17
 Title 38, United State Code, Section 8123; March 31, 2011.