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 Michael Oros, Board Member, American Orthotic & Prosthetic Association
Good morning Chairwoman Buerkle, Ranking Member Michaud, and Members of the Subcommittee. Thank you for the opportunity to provide testimony today. The American Orthotic and Prosthetic Association (AOPA) is grateful for your work to ensure that Veterans with limb loss receive state of the art prosthetic care. We applaud you for convening this hearing, Madam Chairwoman, and deeply appreciate the invitation to shed some light on current issues facing the fields of prosthetics and orthotics when it comes to quality care for our Veterans.
My name is Michael Oros, and I am a member of the AOPA Board of Directors. The American Orthotic & Prosthetic Association (AOPA), founded in 1917, is the country’s largest national orthotic and prosthetic trade association. Our membership draws from all segments of the field of artificial limbs and customized bracing for the benefit of patients who have experienced limb loss, or limb impairment resulting from a chronic disease or health condition. AOPA members include patient care facilities, manufacturers and distributors of prostheses (artificial limbs), orthoses (orthopedic braces such as those used by TBI and stroke patients) and related products, and educational and research institutions.
In my day job, I am a licensed prosthetist and President of Scheck and Siress, Inc., a leading provider of O&P services based in Illinois. Like many other community-based providers, Scheck and Siress is committed to serving Veterans, and does so through contracts with the VA. Scheck and Siress is also proud to employ Melissa Stockwell, the first American service woman to lose a limb in Iraq. After sustaining the injury that resulted in her limb loss, Ms. Stockwell went on to become a Paralympic athlete, and had the honor of carrying the American flag at the closing ceremonies of the Paralympic Games in Beijing. Melissa is now a certified prosthetist, and a member of the staff at Scheck and Siress.
It seems to me that, before we can have a conversation about the quality of prosthetic and orthotic care provided to our Veterans, we need to agree on what “quality” prosthetic and orthotic care is. I’m not certain that I’ve ever seen an official VA definition of “quality” care, so at the risk of being pushy, I’d like to suggest my own for the purposes of our discussion today. For me, as a practicing clinician who has been taking care of Veterans with limb loss for 26 years, four major elements comprise quality prosthetic care:
1) Access. Veterans must be able to receive care on a timely basis, without waiting for weeks or having to travel hundreds of miles for their prostheses to be checked, adjusted, repaired or replaced.
2) Trust. Veterans must know about and be able to exercise their right to receive care from a provider they trust, who listens to them and works with them to achieve the most functional prosthesis possible. Fitting a good prosthesis is as much art as it is science, and a positive, ongoing working relationship between the Veteran and the prosthetist is an important element of getting it right.
3) Expertise and experience. Clinicians serving Veterans must have the training and clinical know-how to select, custom-build, fit and adjust the best possible prosthetic device to address the complex challenges Veterans with limb loss face every day.
4) Outcomes. The result of high quality prosthetic care is greater comfort, higher activity levels, more independence and greater restoration of function for Veterans with limb loss, so that they can live their everyday lives successfully and continue to do the things they want to do despite the absence of one or more limbs.
Overall, the quality of prosthetic and orthotic care for Veterans has never been better. New technology has restored previously unachievable levels of function for service members returning from Iraq and Afghanistan with Traumatic Brain Injury or having lost limbs. However, in my experience, there is really two types of prosthetic care being provided to our nations’ Veterans. Some Veterans are very well informed, technology-savvy, very aggressive and successful advocates for themselves and their care. These are the Veterans that we are most likely to see at a practice like Scheck and Siress, and for them, the Veterans’ Administration creates relatively few administrative and other barriers to care.
However, there is also another group of Veterans, typically older, typically non-service connected new amputees. These Veterans are less likely to advocate aggressively for their own care. It is difficult for me to say whether they are aware of their right to see a prosthetist of their own choice, but they are certainly less likely to request an appointment at a practice like Scheck and Siress. Veterans in this category who have been patients with Scheck and Siress for some time have begun to complain to us about new administrative hurdles to care. We are hearing more about administrative pushback, increased paperwork, and new requirements to be seen at a VA clinic prior to approval to receive care from Scheck and Siress.
So several barriers persist that stand in the way of providing even higher quality O&P care to Veterans, Veterans who are returning from overseas and Veterans of other conflicts who may be losing limbs to diabetes and cardiovascular disease. Each of these barriers is directly related to the elements of quality care I outlined at the beginning of my testimony. All of these barriers can be eliminated, if they receive enough intentional focus by this Committee and by the Veterans’ Administration. If I may be so bold, I would like to outline a concise, achievable agenda for this Committee to promote quality prosthetic care for Veterans. It has three elements:
1) Guarantee Veterans meaningful access to trusted clinicians.
2) Elevate clinician expertise and experience.
3) Move towards evidence-based practice to achieve optimum outcomes
I will briefly discuss the elements of these recommendations now, and would ask that my written testimony, which contains a more detailed overview of these issues, be included in the record.
1) Guarantee Veterans Meaningful Access to Trusted Clinicians.
As you are aware, between 10 and 20 percent of O&P care provided to Veterans nationally is delivered by direct employees of the Veterans’ Administration. 80 to 90 percent of Veteran O&P care is provided by community-based providers, often small businesses, that contract with the VA. This system of contracting with a large network of community-based providers helps to ensure that all Veterans, regardless of geographic location, have access to quality O&P care without having to travel hundreds of miles to reach a VA facility. In some regions of the country, such as New York City, the majority of Veteran O&P care is provided by VA employees. In other cases, such as Chicago, even Veterans who live close by a large VA Medical Center prefer to receive their care from independent providers such as those at Scheck and Siress.
Unfortunately, despite their legal right to choose an O&P provider, in many cases Veterans are under significant pressure to receive their O&P care from VA centers rather than community-based providers. Veterans frequently are unaware that they have the right to receive O&P care from their preferred provider, be it VA or community-based. AOPA strongly supports the right of all veterans to receive O&P services from the provider who they feel best meets their needs. It is imperative that those who have served and sacrificed for our country be aware of their rights, especially on an issue as personal and important as orthotic and prosthetic care. AOPA has supported Ranking Member Filner’s legislation to require the VA and its facilities to take proactive steps to educate Veterans about their right to choose the O&P provider who best fits their needs. However, it is regrettable that this legislation has been made necessary; this is a problem the VA could and should solve administratively.
AOPA believes that the vast majority of community-based providers working under contract with the VA provide high quality care to Veterans at highly competitive rates – rates, in fact, that represent an average discount of 10% below the published Medicare fee schedule. This has been challenged recently by a VA Inspector General’s audit that we are concerned may have been poorly researched and is, if not completely inaccurate, at least extremely misleading. AOPA is disturbed by allegations put forth in the IG’s Audit of the Management and Acquisition of Prosthetic Limbs issued on March 9, 2012, claiming that the average cost of a prosthetic limb fabricated by the VA in house is $2,900, while the average cost of a limb fabricated by a third party contractor was $12,000. We have been unable to determine precisely which costs were taken into account by the IG when making these calculations, and we are disappointed that this analysis was not challenged by the VA Prosthetics and Sensory Aids staff before the report was published. Nevertheless, this is not an apples to apples comparison, and it offers you and the VA leadership no useful information. It is not unusual for Veterans with extremely complicated devices to choose community-based providers rather than VA staff, which would skew the cost of devices provided in-house downwards. Further, the costs quoted for the VA-fabricated limbs almost certainly only take into account only the cost of components, without accounting for VA staff salaries, benefits, facilities costs, administration and taxes. We believe that, with few exceptions, a complete and accurate cost comparison would show that community-based O&P contractors provide excellent value to Veterans and taxpayers.
2) Elevate Clinician Expertise and Experience.
There is another challenge looming that will affect the quality of care for Veterans across the entire O&P field, at VAMCs and independent providers alike. Over the past decade, the practice of orthotics and prosthetics has grown increasingly complex. This is true both in terms of the types of medical challenges presented by Veterans, as well as the technologies used to treat these problems.
Whether they treat young Veterans returning home from the wars in Iraq and Afghanistan who have lost limbs on active duty, or older Veterans who have had limbs amputated as a result of other health problems like diabetes and cardiovascular disease, O&P clinicians are faced with more and more complicated issues in caring for our Veterans, active duty servicemembers, and the civilian population with limb loss. For example, most traumatic amputations from the current conflicts in Iraq and Afghanistan are suffered the result of IEDs, causing additional complications never before seen. The concussive force of the blasts can result in microfracturing in the otherwise undamaged portion of the limb. These fractures lead to the formation over time of bone spurs, which greatly complicate the fitting and use of a prosthesis. On the other end of the spectrum, increasing numbers of aging Veterans undergo amputations due to diabetes, cardiovascular disease, and other health conditions. As Veterans age, their skin becomes more fragile and their circulation deteriorates. This can cause significant challenges in attaching a prosthesis to the residual limb and greater issues in avoiding skin breakdown, ulcers, and infection.
In recognition of the increasing complexity of O&P care, the field recently changed the entry-level credential for orthotists and prosthetists to a master’s degree. Clinicians simply need more time in academic, as well as clinical, settings to emerge prepared to provide high quality orthotic and prosthetic care to Veterans, and the limb loss population at large.
As we sit here today, there are only six institutions of higher learning in the United States that are accredited and enrolling students in master’s degree programs in O&P. Several received federal support in the form of Congressional earmarks to garner the start-up funding required to get their programs off the ground. Graduating classes are very small – in many cases, well under a dozen students. There are an additional six programs at various stages of accreditation that hope to start offering O&P master’s degrees in the coming years. This is an insufficient number of programs to meet the growing demand for highly skilled orthotics and prosthetics professionals and offer Veterans the highly technical, high quality care they deserve. The existing programs simply cannot graduate enough students to meet the need.
If we are to provide the best possible prosthetic and orthotic care to our Veterans – and to the rest of the country – we must quickly and significantly increase the number of accredited master’s degree programs in O&P, as well as expand existing graduate programs. The VA has funding sources s that help to support education for doctors and nurses. The DoD and HHS support graduate medical education in various ways, (mostly through grants of financial resources to students to attend graduate programs, rather than to institutions to create them). But there is currently no legislation that authorizes any federal agency to support the creation or expansion of accredited graduate education programs in prosthetics and orthotics.
Part of the VA’s mission is to support high quality medical education for clinicians who will work in various parts of the health system – VA and non-VA facilities – caring for Veterans and the broader population. The advanced education of the next generation of prosthetists and orthotists is critical to restoring the maximum possible function for our Veterans, and to doing so in an efficient and cost-effective manner.
AOPA recommends the creation of a small, time-limited competitive grant program that could offer federal grants of up to one million dollars each to approximately fifteen universities to create or expand accredited master’s degree programs in prosthetics and orthotics. Only institutions with a demonstrated ability to create or expand accredited programs to grant master’s degrees and/or doctoral degrees in prosthetics and orthotics should be eligible to apply, and one-time grants should be made available to universities that have not previously received competitive awards through this funding source. We recommend that these grants should support curriculum development; accreditation costs; purchase of needed training equipment; development, recruitment and retention of qualified faculty members; and limited expansion or renovation of space to house programs. Use of these grants to support major construction should be prohibited.
As part of the condition of receiving such a VA grant to expand advanced O&P training, O&P programs should be required to work with VA Medical Centers and/or private O&P practices that serve significant numbers of Veterans. One of the reasons the field has moved to the master’s degree requirement is to make sure that O&P professionals have more clinical experience when they secure their credential. By caring for Veterans as part of their clinical training, the next generation of highly qualified prosthetists will be more familiar with the needs of Veterans with limb loss and better able to meet their needs.
We are grateful to Chairwoman Buerkle for your examination of this issue, and look forward to continuing to work with you to create a small, time-limited competitive grant program to enable colleges and universities to create or expand accredited master’s programs in O&P.
3) Move Towards Evidence-Based Practice to Achieve Optimum Outcomes
While AOPA is firm in our belief that the vast majority of private sector clinicians are providing care to Veterans that is as good or better than that they could receive at the VA, we also believe that it is important to hold O&P professionals accountable for the quality of care and the cost of that care. This poses something of a challenge for the VA, due to the fact that there is currently no body of objective, comparative outcomes research to support evidence-based practice in O&P. Currently, the only mechanism available to evaluate the quality of prosthetic and orthotic services offered by any provider – inside or outside the VA – is the patient satisfaction survey. While community-based providers typically score very highly on such surveys, we know that more could and should be done to evaluate O&P outcomes for Veterans.
This leads me to my final point. Unlike other health professions, there is no body of comparative outcomes research to guide O&P professionals. Their judgments about which prosthetic device, service or support is most appropriate for which patient is based largely on personal experience and expertise developed over years in the field. However, there is almost no objective research on outcomes to validate or inform that experience.
In this regard, O&P is stuck where many other health care professions were twenty years ago. Twenty years ago, if you had a back problem, there was no outcomes based research to guide your primary care doctor in advising you on what kind of care to seek out. If she sent you to physical therapy, the PT would tell you the best way to treat your back was PT. If she sent you to a back surgeon, the surgeon would tell you that you could only be cured with surgery. There was no objective research to suggest who was right, and under which circumstances.
Today, if you went to the doctor with severe back pain, your doctor would have the benefit of extensive research that compares the outcomes of physical therapy and surgery in different circumstances, and informs your caregivers’ recommendations. Now that doctors and patients have an objective picture of what treatment works best for which patients, today more patients with back pain have better outcomes, obtained more cost-effectively.
That’s what we want for Veterans who need prosthetic and orthotic care. Our field has important, unanswered questions with significant cost implications for DoD, the VA,
Medicare and health care more generally. Significant research questions remain, including:
· What interventions can prevent amputation or subsequent surgeries?
· At what point in the in the course of patient treatment is orthotic and prosthetic intervention most effective?
· Which patients benefit most from which technologies?
· What O&P practices facilitate successful aging, and how does the aging process affect the use of prosthetics, including increased skin breakdown, loss of balance, falls and other issues, such as promoting return to work?
· What conclusions could longitudinal data relating to amputees and their treatment provide that would improve quality and cost effectiveness of their care?
· What is the optimal timing of O&P intervention to prevent lost of activity, mobility and ability to work and carry out activities of daily living?
Such elements of a coherent O&P research agenda are vitally important
to ensuring that Veterans receive appropriate, necessary care as well as to eliminating unnecessary future health care costs. These and other key questions being asked by the field remain unanswered. An outcomes-based research portfolio, and the resulting body of evidence, in the field of O&P would increase the quality of care for Veterans and others with limb loss while protecting taxpayers by ensuring that patients receive the most appropriate care, and that quality and cost effectiveness objectives are attained in a data-driven manner that generates the best possible outcomes, from the beginning.
AOPA applauds the VA for working toward this end by joining with the Department of Defense in March of 2010 to hold the joint State of the Art Conference on Orthotics and Prosthetics. This conference generated much discussion related to the creation and execution of an outcomes-based research portfolio in the field of O&P. While the discussion was encouraging, we have been disappointed to see that no progress toward the implementation of the recommendations has been made. No report on the conference has ever been made publicly available, and so far as we can tell, no steps have been taken by the VA or DoD to implement any of the conference recommendations.
Despite the government-wide focus on health care outcomes, there is currently no federal research agenda on prosthetic and orthotic outcomes. Not at the VA. Not at the DoD. Not at the NIH, the CDC, or NIDRR. AOPA strongly encourages the VA, DoD and NIH to help improve the care for Veterans, service members, and seniors by implementing a robust comparative outcomes research agenda that addresses the questions in the field and helps to inform effective, efficient delivery of O&P care. We believe this will also yield dividends in assuring that the major technological advances precipitated by research commitments from VA and DoD for Veterans and active duty military are actually pulled through to have a practical impact on care provided to our nation’s seniors and other members of the general public..
Madam Chairwoman, Members of the Committee, thank you very much for the invitation to testify, and for your commitment to providing the highest quality prosthetic and orthotic care to our nation’s Veterans. I look forward to answering any questions that you might have.