Chairman Johnson, ranking member Donnelly and distinguished members of the committee. Thank you for the opportunity to provide a perspective on how the Department of Defense (DoD) cares for individuals with limb loss, and in particular prosthetic care, new technologies, and the collaboration between DoD and the Department of Veterans Affairs (VA).
It is always important to look back before looking forward, to take from lessons learned. The Washington D.C. Times-Herald reported “In a few days the Army will print a formal regulation which will give officers and enlisted men who have lost arms, or legs, or both, in the line of duty, the opportunity to return to Active Duty.” This was written on November 11, 1951. Fast forward to 2003 and the Army found itself repeating the effort to return individuals with limb loss back to Active Duty. To date we have had over 305 individuals with limb loss on Active Duty, and over 53 of these have deployed again into combat roles in Iraq and Afghanistan.
On January 20, 2004 the Office of the U.S. Army Surgeon General in response to a request from the U.S. Congress as part of the Fiscal Year 2004 Omnibus Bill submitted an infrastructure improvement plan for the U.S. Army Amputee Patient Care Program (USAAPCP). In this we stated “The goal of the USAAPCP is to return patients to “tactical athleticism,” or to their pre-injury level of activity. The philosophy of the program is “Tell me how far you want to go, and we will work with you to achieve your goals.”
The DoD Amputee Patient Care Program grew over the past 10 years out of necessity to meet the demands of a population that is significantly different from the typical VA patient. At the beginning of current military conflicts, the DoD treated patients with limb loss that primarily resulted from dysvascular disease, diabetes, and tumors. The DoD lagged the VA and many of the activities the VA was doing in the prevention of limb loss. DoD still has a significantly lower patient population than that of the VA. However, we are faced with a population that is much different from the typical patient seen in the VA. Our patients are young, active Service Members, frequently with severe trauma and multiple limb loss, that desire and deserve to be returned to the highest levels of activity and some deserve to be returned to Active Duty. These Service Members are strong-willed, impressive Warriors who challenge us daily to improve how we care for them. We started from a very decentralized, small program and built an efficient, progressive program. We developed a world leading, world recognized program for amputee patient care to meet our patients’ needs.
The DoD and the VA have long shared a strong working relationship in caring for our wounded warriors and make significant advances in the care of patients with limb loss through many focused programs. In April of 1945 the National Research Council Advisory, Committee on Artificial Limbs, a technical body within the National Academy of Science, tasked US Army to develop amputee research at its 7 amputee patient care centers. These were very quickly merged into one center, the Army Prosthetic Research Lab (APRL) at Walter Reed Army Medical Center (WRAMC) early in 1946. Shortly thereafter, on March 1, 1946 the Veterans Administration joined forces with the APRL in financing the research. In 1948, the VA established the Prosthetics Research Department headquartered in the NYC VA Center. In 1956 the VA expanded this by supporting the Prosthetics Research Lab (PRL) at Northwestern University. Working together, the DoD and VA efforts lead to many of the prosthetic advances that were still utilized at the beginning of the current conflicts.
In 2004 Congress provided $2.5 million for Prosthetic Device Technology Enhancement and Clinical Evaluation at WRAMC, and added $10 million in 2005. The Military Amputee Research Program was developed to best manage these funds across the DoD. At this same time Defense Advanced Research Projects Agency (DARPA) programmed $30 million for advancements in upper extremity prosthetics. Much of the research that has been completed has been in partnership with the VA, and would not have been easily completed without the VA’s involvement. The advanced arms developed through the DARPA project were first tested within the VA facilities. The newest research to help our patients return to the highest levels of function is a study projected to begin in the Salt Lake City VA, late this year or early in 2013 on osseo-integration. This is based on earlier research which was partially funded by the DoD at the University of Utah. Successful osseo-integration could potentially provide patients that have difficulty wearing the traditional prosthetic socket the opportunity to wear prosthetic devices.
In 2005 $10 million in military construction was reprogrammed to build the Military Advanced Training Center (MATC) at Walter Reed. At the same time the Intrepid Fallen Heroes Fund offered to build the Center for the Intrepid (CFI) in San Antonio, Texas. Shortly thereafter the U.S. Navy dedicated funds to renovate facilities at the Naval Medical Center San Diego to house the Comprehensive Complex and Combat Casualty Care Center. These three phenomenal centers are dedicated to providing world class care to our Wounded Warriors.
Several factors explain why the DoD led efforts to provide prosthetic care for Wounded Warriors. One of the keys is DoD’s interdisciplinary program, pulling together a range of providers who work with the patients on a daily basis to address patient needs. While the standard of care requires that a Wounded Warrior be seen within seven days, the standard at Walter Reed National Military Medical Center (WRNMMC) is 72 hours. Another factor has been the integration of logistics and contracting within the prosthetics service at WRNMMC. WRNMMC contracting provided blanket purchasing agreements to simplify the acquisition of all supplies and components required for treatment of the Wounded Warrior. Logistics embedded a warranted contracting officer into the Orthotic & Prosthetic Service at WRNMMC enabling same day ordering with next day delivery of prescribed components. The development of the blanket purchasing agreements insured best value through discounted pricing and fixed component costs. A logistics technician embedded within the Service provides the ability to warehouse non-patient-specific items for fabrication and custom fitting, further reducing delays in the delivery of care.
A third factor is the success of DoD research efforts and partnership with industry that has led to the commercial availability of the Genium/X2/X3 microprocessor knees, the BiOM robotic ankle, and the Power Knee 2. Blanket purchase agreements for these items will not be developed until the technology matures and the price stabilizes. These items are purchased through sole source indefinite duration, indefinite quantity contract vehicles with the only suppliers for these unique medical devices. These contracts minimize delay in the provision of the required components.
Department of the Army civilian prosthetic providers provide the most cost effective delivery of prosthetic patient care. Contract providers enable the DoD to rapidly expand or contract the requirements based on the size of mission at any moment in time. These contracts are small business set-aside, competitively bid contracts with a single provider award. Best value is guaranteed within these contracts through pricing proposals provided by the vendor in the bid phase of the procurement. The civilian model has a wide degree of variability in costs because of the use of “not otherwise classified” codes within the healthcare common procedure coding system. The DoD requires offerors to list what “not otherwise classified” procedures and components they propose to bill and the amount of reimbursement they that are seeking. DoD contract officer representative (COR) may reject any bid with a ‘not otherwise specified code” determined to be excessive.
A large percentage of our patients receive a significant portion of their care through the Veterans Health Administration at VA. This is crucial to the success of both DoD and VA patient care, as the DoD does not have the capacity to provide lifelong prosthetic care to all Wounded Warriors. In the early years of current conflicts, patients reported frustration with long delays in the VA process. Things have improved since the VA expanded its Amputation System of Care, organizing and structuring interdisciplinary care teams, increasing VA/DoD collaboration including advanced technology training initiatives, clinical practice guidelines, the establishment of the DoD-VA Extremity Trauma and Amputation Center of Excellence (EACE), and the development of Regional Amputee Centers (RACs). These initiatives have demonstrated that there is a much closer relationship and greater parity with the DoD advanced rehabilitation centers. We are actively engaged with the transition of our Wounded Warrior amputee patients to VA care and recognize, as reflected in a recent VA Inspector General report, that the care provided by the VA is comprehensive and lifelong.
We continue to work closely with the VA, we have their providers working in our clinics at both the CFI and at the MATC, to create a great relationship where we share knowledge and assist patients as they transition to long term care with the VA system. Through our long history of DoD and VA collaborative research and patient care efforts we are continuing to meet the needs of our Wounded Warriors and Veterans.