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Witness Testimony of Jonathan Pruden, Alumni Manager, Southeast Wounded Warrior Project

Chairman Buerkle, Ranking Member Michaud, and Members of the Subcommittee:

Thank you for inviting Wounded Warrior Project to share its perspective on issues facing our amputees.

My name is Jonathan Pruden and in 2003 while serving as an Army Infantry Captain I became one of the first IED casualties of Operation Iraqi Freedom and subsequently underwent 20 operations at 7 different hospitals including amputation of my right leg.  I was medically retired from the Army and found a new mission working with my fellow wounded warriors. In my role as an Alumni Manager for the Wounded Warrior Project (WWP) I’ve had the honor of personally interacting with thousands of warriors over the past six years, often working hand in hand with VA and DoD to ensure our warriors and their families receive the care they deserve.

Over the past decade DoD and VA have made significant strides in prosthetic care, particularly in comparison to the Vietnam war era when some 6000 veterans with amputations returned to a woefully unprepared system.[1]  Today, improvements in protective gear, rapid medical evacuation, and innovations in military trauma medicine help account for a nearly 90 percent survival rate among those injured in Iraq and Afghanistan, compared to a 75 percent survival rate among those injured in Vietnam.[2][3] While the survival rate has increased, many warriors are returning home with injuries, including major limb loss, which require extensive rehabilitation and present long term care needs. As of March, 1,288 servicemembers experienced major limb loss as a result of combat in OEF/OIF/OND; of that number, 359 lost more than one limb.[4]  Just this past month, WRNNMC has seen the arrival of two quadruple amputees. The long road to recovery and rehabilitation has both physical and psychological dimensions and for those warriors who have suffered an amputation, excellent prosthetic care is critical to ensuring the opportunity for an active, fulfilling life.

Short term Challenge:

Just as our warriors are adapting to wrenching, life-changing injuries, the health care system whose mission is to care for and rehabilitate them – the VA – is moving to institute changes that, in our view, will set back prosthetic care rather than advance it.

It is disappointing that we have come to this point given the long, proud history of steady leadership within VA’s prosthetics program and Congress’ strong support for that program.   Congress has long recognized that VA’s prosthetics program is critical to meeting the specialized rehabilitative needs of disabled veterans.  This Committee, in particular, has played a key role in sustaining that vital mission.  For example, a proposed Veterans Health Administration (VHA) reorganization in 1995 led this subcommittee, and ultimately Congress, to enact legislation directing the Secretary “to maintain [VA’s] capacity to provide for the specialized treatment and rehabilitative needs of disabled veterans (including veterans with  amputations) in a manner that affords those veterans reasonable access to care and services for those specialized needs.”[5]  Congress further directed the Secretary to carry out that requirement in consultation with the Advisory Committee on Prosthetics and Special Disabilities.[6]  Congress certainly recognized that prosthetics is not just another service, but a fundamental component of VA health care. 

While there are areas of VA prosthetics service that need improvement, as we will discuss, WWP is deeply concerned about proposed changes in VA prosthetics’ procurement that could reverse decades of progress, and substantively erode both the quality of care and quality of life of our nation’s most severely wounded.   As discussed below, planned changes to VA’s prosthetic acquisition and procurement policies may greatly impair clinician’s ability to provide the most appropriate prosthetics and at the same time create substantial delays in a system that is already too slow for the amputee who is unable to walk while waiting for a new “leg”.

Under current practice, VA physicians and prosthetists are able to see a veteran, make a determination regarding the most appropriate type of prosthetic equipment for a veteran, and relay that information to a Prosthetics Service purchasing officer to complete a purchase-order to obtain the needed item.   Those purchasing officers exclusively handle prosthetics’ purchases, and are specialists in ordering medical equipment specified by health care providers.  A major change that the Veterans Health Administration intends to institute on July 30th, would require that any prosthetic item whose cost exceeds $3000 -- to include such essential items as limbs, wheelchairs and limb-repair components – must be procured by a contracting officer.  This is not simply a matter of substituting a generalist for a specialist.  Under the proposed change, these contracting officers would use a labor-intensive system (the Electronic Contract Management System (eCMS)) designed to achieve cost savings.  That system, designed for high-dollar bulk-procurement purchases that benefit from using the Government’s purchasing power, requires over 300 individual steps to manually process a purchasing order.  While well-suited for buying widgets, the system was neither designed for nor well-suited to procuring highly specific, individualized medical equipment. Ill-suited to prosthetics, this new process would also require increased coordination between clinicians and off-site contracting officers who would be responsible for purchasing everything from light bulbs to now highly specific prosthetic legs.

This is not a small change.  Moreover, it not only increases the margin for error but also the potential for prolonged, delaying “back-and-forth,” with the likelihood of clinicians having to justify why a more expensive wheelchair is clinically necessary when a seemingly-similar less- costly model exists.  We see no prospect that this planned change in prosthetics procurement holds any promise for improving service to the warrior.  Instead, it almost certainly threatens greater delay in VA’s ability to provide severely wounded warriors needed prosthetic devices.

WWP is aware of concerns raised in a recent IG report that called for separating the duties of Prosthetic Purchasing Agents (PPAs) to ensure that each prosthetics’ order is reviewed and that VA receives the greatest possible discount on prosthetics.[7]  The IG recommended strengthening controls for the review process and issuing improved guidance to Certified Prosthetists.  But VHA’s response was vastly disproportionate to the IG’s modest recommendation.  Rather than simply concur with IG’s recommendation, VHA cited its plan to remove purchasing authority for items over $3,000 from PPAs altogether.   WWP believes VA’s plan goes many steps too far.  While we agree that VA must be a smart buyer, its overriding responsibility is to the veteran and to its service mission – and its plan appears to compromise both those responsibilities.

Instead, its planned change in processing procurements will, at a minimum, inject greater delay – lengthening the time between when the clinician and prosthetist see and evaluate a veteran for a new device and when he actually receives it.  Even more problematic, the change heightens the risk that a fiscal judgment will override a clinical one – that is, the risk that a contracting officer’s judgment will override the clinical judgment of clinicians and prosthetists who are attempting to provide flexible, timely, and appropriate care for our veteran amputees. 

In conversations with several highly placed current and former VA officials in this arena about the decision to use federal acquisition agents, all expressed concerns about creating additional delays for purchase orders and decreasing discretion to do the “right thing” for our amputees.  These potential additional delays are especially troubling because VA outsources the vast majority of prosthetic fabrication.  VA currently contracts with over 600 independent labs, accounting for about 97% of the limbs provided to veterans.[8] Currently, most contract prosthetic labs will start fabrication on a limb before a VA purchase order is received to ensure the veteran receives the prosthetic as soon as possible.  However, as a former VISN Prosthetics Director warned, chronic “delays in providing purchase orders and subsequent payments will mean that many contracted prosthetists will not make a limb if they do not have a purchase order in hand.” 

This plan may hold potential for modest savings, but at what cost?  When a warrior needs a new leg or wheelchair, they have to wait.  Every day they wait their lives are tangibly impaired.  I personally know warriors who stay home from our events, stay home from school and from work, don’t play ball with their kids, or live in chronic pain while they wait for a new prosthesis.  I have personal experience waiting for prosthetics and know firsthand what it is like to live in pain while waiting for a new limb and the frustration I felt when my daughter asked my wife, “Why can’t daddy come on a walk with us?” 

Wounded warriors need this Committee’s help to ensure that they are not forced to put their lives on hold any longer while federal acquisition personnel process purchase orders.  While we acknowledge that prosthetic procurement in its current form is imperfect, VA’s prosthetics’ procurement plan seems to take a meat cleaver to a situation best addressed with a scalpel.  Prosthetics are not light bulbs or hammers.  They are specialized medical equipment that should be prescribed by a clinician and promptly delivered to the veteran.  Congress has long recognized the unique importance of prosthetics by exempting them from burdensome federal purchasing requirements.[9]

Given these concerns, we urge this Committee to direct VA to suspend implementation of this major change in prosthetics procurement.  A change of this magnitude in a critical area of service-delivery to wounded warriors – and particularly one that offers no promise of any service-improvement -- should not even be considered in the absence of a detailed implementation plan.  Minimally, such a plan should include both (1) credible evidence that veterans would not encounter greater resultant delay in receiving needed prosthetics and (2) meaningful safeguards to protect clinical discretion.  Should VHA wish to go forward with this process, we urge the Committee to require it to develop such a plan and to defer implementation until the Veterans Affairs Committees have had sufficient time to review it thoroughly (we would recommend a period of not less than 90 days). 

Long term Challenges

While the proposed change in prosthetics procurement constitutes a matter of immediate, acute concern, we see longer-term challenges as well.  War zone injuries that result in amputations are often complex and can prove difficult for later prosthetic fitting because of length, scarring, and additional related injuries such as burns.[10]  To its credit, VA has instituted an amputation system of care and initiated the development of amputee centers of excellence which can become important components of needed change.  But WWP’s experience is that much more progress is needed to realize the underlying vision.  We are pleased to hear that approval was recently given for the creation of a VA Amputation System of Care registry/ repository.  But we remain concerned that VA prosthetics research – among VA’s strengths in the past and so important to serving wounded warriors tomorrow – has lagged, even as the numbers of new veteran-amputees climb steadily.   In that regard, I had the honor of serving on a 27-member expert panel that is to date the most comprehensive review of the status of prosthetics-device issues facing wounded warriors, but that study is now three years old and many of those recommendations have yet to be implemented. VA must re-establish itself as a leader in prosthetic research and commit to implementing the finds of such research so that veterans can realize its benefits. 

Looking ahead, it is important to recognize that the Department of Defense has far surpassed VA in providing state of the art rehabilitation for this generation of combat injured amputee service members and veterans. With OEF/OIF veterans being seen at VA medical facilities across the country, any one particular medical center may provide prosthetics care to only a few young veterans.  The average age of an OEF/OIF warrior at the time of injury leading to an amputation is 25.[11]  These veterans are young, computer-literate and inquisitive about technology and the options available. Their active lifestyle frequently requires specialized equipment with which VA staff at some facilities – unable to keep uniform pace with technological advances – often lacks familiarity. Today, some 39% of the OEF/OIF amputee population returns to DoD to receive prosthetic care. While DoD is currently able to shoulder that demand, WWP is concerned that as the current conflicts draw down DoD facilities will ultimately scale back their services and associated funding with the decline in combat injuries. VA must be ready to meet this need; but it’s not yet there. There are pockets of excellence within VA’s prosthetic system such as the VISN 3 Manhattan prosthetic department, but that level of expertise is not consistently available to veterans across the VA system.

Wounded warriors advise WWP that the paradigm shift in amputee care has yet to become evident at most VA medical centers.   In fact, an amputee being seen at a primary care clinic is seldom, if ever, asked how the individual’s prosthetic is working, and whether it is causing pain.  Prostheses should be prescribed on the basis of careful evaluation, and joint patient-clinician decisionmaking that takes account of best medical evidence and practice.[12] But, as warriors attest, VA clinicians themselves too often base decisions about orthotic and prosthetic equipment on past practice and word of mouth, rather than informed medical judgment, with the result that the choice of equipment may or may not be appropriate.[13]  With wide variability in providers’ knowledge and expertise with new prosthetic technologies, warriors report significant disparities from facility to facility in the quality of care and the approval of specific durable medical equipment.[14] We are concerned, in that regard, that such disparities may worsen over time, particularly if VA prosthetics service funding is decentralized, as some have discussed. 

Centralized funding of prosthetics service has been vital to ensuring that VA can meet wounded warriors’ needs.  While we are not aware that any change in policy to decentralize prosthetics’ funding is imminent, we are not alone in holding deep concerns regarding such a possibility. Candidly, the concern is closely related to a VHA reorganization that occurred last year, which diminished the standing of VA’s Prosthetics and Sensory Aids Service relative to sister services  -- and which, along with the planned change in prosthetics’ procurement raises red-flags of concern regarding the priority in which VA currently holds prosthetics. Centralized funding is a means of insuring that provision of prosthetic and orthotic equipment for wounded warriors continues to be a national priority and that that priority will not be compromised at the VISN level, such that there develop 22 different levels of priority.  Centralized funding of prosthetics must be preserved.

As a bottom line, we have a real concern about the direction of this program, which appears to have lost the kind of focused leadership it once enjoyed, and has fallen victim to a bureaucratization that has lost sight of its customer, the veteran.

Recommendations:

Let me re-emphasize the dangers inherent in VHA’s proposed changes in procuring prosthetics, and urge this Committee’s intervention, as discussed above.  At the same time we are mindful that there are steps VA can and should take to improve prosthetics care and service.  In that regard, WWP has long urged the need to improve system-wide coordination and consistency, and – in the constructive spirit -- offers the Committee the following recommendations toward continued improvement of the prosthetics program:

  • Ensure through ongoing oversight that the vision of the Amputee System of Care is realized;
  • Press VA to establish a steering committee of experts composed of academicians, clinicians, and researchers to oversee and provide guidance to the Department on the direction and operation of its prosthetics and orthotics program;
  • Direct VA to develop guidance to assist clinicians in more appropriately prescribing durable medical equipment (in particular, expanding clinical practice recommendations through the use of algorithms such as are commonly employed in other fields of medical practice);
  • Encourage VA to serve warriors more effectively through such means as (1) creating an equipment-loan center or centers through which warriors could borrow and test equipment before final issuance; (2) providing veterans -- in addition to any primary assistive device needed for mobility or to perform ADL’s -- with functional spare equipment; and (3) expanding efforts to develop informative materials for veterans and caregivers on available devices; and
  • Urge VA to assign additional VA prosthetics and sensory aids staff at military amputee centers of excellence. 

Continued congressional oversight to ensure both preservation of the prosthetics’ system strengths and progress in improving the quality of VA’s prosthetics and orthotics care (at least in part through VA adoption of the above recommendations) would go a great distance toward improving the lives of those who have lost limbs in our ongoing war, and improving the care of veteran-amputees of all generations. After more than eleven years of war and thousands of combat related amputations, it is essential that VA re-establish itself as a leader in prosthetic research and care and maintain that position as a commitment to our severely wounded. 

That concludes my testimony; I would be happy to answer any questions you may have.



[1] Sigford BJ, “Paradigm Shift for VA Amputation Care,” J Rehabil Res Dev; 47(4): (2010) xv-xx.

[2] Dougherty PJ, “Wartime Amputations,” Mil Med, 1993 158(12): 755-63.

[3] Peake JB, “Beyond the Purple Heart – Continuity of Care for the Wounded in Iraq,” N Engl J Med; 352(3): (2005) 219-22.

[4] VA Office of Inspector General. “Health Care Inspection: Prosthetic Limb Care in VA Facilities” Report No. 11-02138-116, 8 March 2012. Accessed at: http://www.va.gov/oig/pubs/VAOIG-11-02138-116.pdf

[5] 38 U.S.C. sec. 1706(b)(1).

[6] Ibid.

[7]VA Office of Inspector General. “Veterans’ Health Administration: Audit of the Management and Acquisition of Prosthetic Limbs.”  Report No. 11-02254-102, 8 March 2012. Accessed at: http://www.va.gov/oig/pubs/VAOIG-11-02254-102.pdf

[8] Ibid.

[9] “The Secretary may procure 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, without regard to any provision of law.”  38 USC sec. 8123.  Given this specific authority, there is no obvious rationale for changing current prosthetics-service procurement practice.

[10] Ibid.

[11] VA Office of Inspector General. “Health Care Inspection: Prosthetic Limb Care in VA Facilities” Report No. 11-02138-116, 8 March 2012. Accessed at: http://www.va.gov/oig/pubs/VAOIG-11-02138-116.pdf

[12] Ibid.

[13] Arrendondo, et al., “Wounded Warriors’ Perspectives; Helping Others to Heal,” J Rehabil Res Dev, 47(4): (2010) xxi-xxviii.

[14] Ibid, xxvi.