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John Register

John Register, Veteran

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

Thank you for this opportunity to testify on the ability of the Department of Veterans Affairs (VA) to deliver state of the art care to veterans with amputations.  I testify today on behalf of myself and an organization for which I serve on the Board of Directors, the National Association for the Advancement of Orthotics and Prosthetics (NAAOP).  NAAOP is a non-profit trade association dedicated to educating the public and promoting public policy that is in the interest of orthotic and prosthetic (“O&P”) patients and the providers who serve them.  My service on NAAOP’s board has exposed me to the field of limb prosthetics from a policy perspective and that perspective is further informed by my own experience with amputation and prosthetic limb use. 

The issues to be addressed in this hearing are critical to the ability of veterans with amputations and other injuries and conditions to live active, fulfilling lives, to live as independently as possible, to participate in community activities, to raise families, and to work.  I served in the U.S. Army through Operations Desert Storm and Desert Shield over a period of six years.  I speak today from personal experience as an amputee veteran who has worn a prosthesis since 1994 when I lost my leg at the knee joint due to a severe injury sustained during an athletic competition.  I currently work for the United States Olympic Committee (USOC) and direct the Paralympic Ambassador Program and the Paralympic Experience Youth Outreach Program, as well as the USOC’s Paralympic Military Program, a program for service-members who return from conflict with physical disabilities.

Office of Inspector General Reports on Prosthetics:  I have reviewed the three reports recently issued by the Office of Inspector General and have some general observations to offer on the two reports that were issued on March 8th entitled, “Veterans Health Administration:  Audit of the Management and Acquisition of Prosthetic Limbs,” Report No. 11-02254-102, and “Healthcare Inspection:  Prosthetic Limb Care in VA Facilities,” Report No. 11-02138-116.  The third report issued by the OIG on March 30, 2012 (Report No. 11-00312-127) and entitled, “Audit of Prosthetics Supply Inventory Management” addresses the broader VA prosthetics benefit and goes well beyond limb prosthetics.  I, therefore, will not address this report in my comments.

  • The term “Prosthetics” is used by the VA to describe a wide variety of devices that have nothing to do with limb prosthetics or artificial limbs.  In fact, the data establish that of the $1.8 billion spent by the VA on “prosthetics” in FY 2010, only $54 million (or 3 percent) was spent on prosthetic limbs.  This is a relatively small portion of dollars spent by the VA on the broader category of prosthetics.
  • The VA’s nomenclature (i.e., defining “prosthetics” as virtually any device that assists a veteran, including internally-implanted devices) does not easily mesh with the field of limb prosthetics, which is closely aligned with the field of orthotics (commonly referred to as custom braces for the back, neck, legs, and arms).
  • The VA has made a major investment in its internal limb prosthetics capacity since 2009 with the development of the Amputee Systems of Care (ASoC) program, a series of prosthetic centers with differing levels of prosthetic expertise and capacity.  The VA has emphasized accreditation of these programs and certification of the professionals in these programs as a measure on quality.  The new investments in amputee care are designed to integrate care for veterans and treat the whole patient, not just the prosthetic needs of the amputee.  Maintaining internal VA capacity and expertise to treat amputees in an integrated manner is important and the VA should be commended for its commitment and focus on this important population.
  • At the same time, especially with respect to its practices with private prosthetists who have contracts with the VA, the VA appears to treat limb prosthetics in much the same way they procure other prosthetic commodities such as wheelchairs and hearing aids, without fully recognizing that prosthetic care is highly clinical and service oriented.  The component parts of a prosthesis are but one aspect of quality prosthetic care that results in an amputee walking or functioning consistently well without significant pain.
  • The Healthcare Inspection Report (11-02138-116) details relatively high satisfaction levels with lower limb prosthetics, most of which are provided by contract prosthetists, but less satisfaction with upper extremity prosthetics.  This is a small but important veteran population and we support the recommendations to improve care for these veterans.  Notably, the Department of Defense and the VA have made significant investments in technology in the area of upper limb prostheses and even held a joint research conference in Baltimore, Maryland two years ago.  However, we understand that a written report of this conference has not yet been published.  We encourage the VA to publish this report and to make additional improvements to its upper limb prosthetic program to improve access to appropriate technology and good quality care.
  • We note that despite some internal payment controls that need improvement, the Healthcare Inspection Report (11-02138-116) concludes that the vast majority of veteran amputees have high satisfaction rates with their prosthetic care which are primarily provided by private practitioners under contract with the VA.
  • NAAOP questions several conclusions in the VA OIG Report entitled, “Veterans Health Administration:  Audit of the Management and Acquisition of Prosthetic Limbs” (11-02254-102).   
  • NAAOP takes strong issue with the OIG’s calculation of the difference in what it asserts it costs the VA to provide a prosthesis, on average, to a veteran through its in-house capability at the Veterans Health Administration (VHA) versus what it costs the VA to purchase an average prosthesis under contract from a private prosthetist.  The OIG asserts that VA spent $12,000 on average for a prosthesis while the average cost of a prosthetic limb fabricated in the VHA’s prosthetic labs was approximately $2,900.  This is a highly suspect calculation of VA’s true costs of providing prosthetic care to veteran amputees and sends the erroneous signal that the VA is vastly overpaying for contract prosthetic care.  This is simply not the case.  It is not clear which costs the OIG factored into its analysis because the report offers no detail on its calculations, but it is highly likely that OIG failed to include the critical costs of labor (salaries for certified prosthetists and technicians), overhead (the costs of maintaining clinical facilities, laboratory machinery, information processing, etc.), and myriad other costs that go into the fabrication and fitting of prosthetic limbs.  In fact, if the OIG were to factor into the calculation the recent investments the VA has made on its Amputee Systems of Care initiative, the cost of providing prostheses to veterans through its internal capacity would be significantly higher than calculated.
  • As the VA enhances its internal capacity to meet the needs of veteran amputees, it is important to recognize the legitimate role of private prosthetists who have provided prosthetic care to veterans for decades under contract with the VA.  Allowing veterans to access private prosthetists in their own communities preserves quality by allowing choice of provider.  The relationship between a prosthetist and a patient can mean all the difference in successful prosthetic rehabilitation.  Proximity to care is also very important for veterans.  It is important that the VA maintains access to local private prosthetists under contract with the VA to conveniently serve veterans—within the overall plan of care designed by the VA clinical team.  Finally, choice of prosthetic technology is critical in order to allow veterans to access the most effective prosthetic alternatives that address their medical and functional needs.
  • NAAOP agrees with and strongly supports the recommendation in the Healthcare Inspection Report (11-02138-116) that VA’s Under Secretary for Health consider veterans’ concerns with the VA approval processes for fee-basis and VA contract care for prosthetic services to meet the needs of veterans with amputations.  This is a key area that addresses the satisfaction of prosthetic care among amputee veterans.  In fact, there is legislation pending before this Committee that seeks to address this very issue, H.R. 805, the Injured and Amputee Veterans Bill of Rights.

My Experience with VA Prosthetic Care:  I currently live and work in Colorado Springs, Colorado.  I began my initial care at the amputee clinic in the Denver VA Hospital and was referred to a local prosthetist in Colorado Springs for my primary prosthetic care.  This is typical of VA prosthetic care.  I sought this prosthetist out because a) they were close to my home and b) they understood the high level of activity to which I was accustomed.  This was done in no way to disparage the care I received at the Denver VA.  In my experience, I have always been treated with dignity and respect at the three VA hospitals I have been fortunate to work with.  Finding a local prosthetist is typical of VA prosthetic care.  Just a few years ago, approximately 97% of prosthetic limbs were provided by private prosthetic practitioners under contract with the VA.[1]  (I understand this percentage has decreased in the past few years as the VA has invested in their internal capacity to fit and fabricate limb prostheses.)  I developed a close working relationship with my local prosthetist over the years and would like to continue seeing him.  This prosthetist is certified and accredited by one of the two accrediting organizations that VA recognizes and requires.  My local prosthetist’s office in my town is seven minutes from my house by car.  He has signed a VA contract to provide prosthetic services to veterans and he is, in fact, a fine prosthetist.

Working in concert with the VA amputee care system, which brings together a comprehensive team to assess my prosthetic and other health care needs, my local prosthetist’s services have kept me a very active and energetic amputee, walking well, engaging in strenuous exercise, and functioning fully.  The ongoing care I received from my contract prosthetist was very convenient, creating little disruption with my USOC job, my family, and my lifestyle. 

Unfortunately, my prosthetic needs changed recently and I became interested in a new technology that permits microprocessor control of the prosthetic knee.  This new technology is an incredible advance in prosthetic care in that it prevents my knee from “buckling” which causes instability and could cause a fall.  Using microprocessor technology, the prosthetic knee anticipates your movements and adapts instantaneously in order to function as close to a natural leg as possible.  The VA Hospital in Denver told me that the only way to be fit for this new technology would be to have my new limb fit, fabricated, and serviced at the Denver VA Hospital’s amputee program.

I did not realize I had a choice in the matter and believing the new technology would meet my prosthetic needs, I agreed and began the fitting process at the Denver VA, driving 70 miles each way to receive the prosthetic care I could have accessed just seven minutes down the road from my home.  I also did not realize that I could have been reimbursed for my travel expenses until my fourth visit.

I traveled to Denver numerous times during the fitting process before I finally received my new limb.  Every time I need adjustments or servicing of the prosthesis, I must take the better part of a day off from work, drive a significant distance, and obtain my care at the Denver VA.  Again, I have no complaints with the amputee/prosthetic care they provide at this hospital.  They are professional and knowledgeable, but the wasted time and energy is a major imposition in my life and a disruption to my job and family responsibilities.  In addition, I have had times when a quick visit to my local prosthetist could have resulted in quick adjustments to maintain the fit and function of my prosthesis.  Instead, I have found myself delaying care until something significant happens or the need for prosthetic care intensifies.  This is not an efficient, convenient, or patient-friendly system.

I consider myself very fortunate that I am not in a position where I am vulnerable or uneducated about my prosthetic options.  But I worry about those veterans who are not in the position to advocate for themselves and simply accept what they are told about their prosthetic care options.  And such options appear to be very inconsistent across the Veteran Integrated Service Networks (VISNs).  The VA needs to ensure that all veterans with amputations consistently receive the high quality prosthetic care they need and deserve.  One of the primary ways to ensure this is to make sure that veterans know that they have rights and responsibilities.  They should have a choice of prosthetic practitioner, a choice of technological options, and a choice to seek a second opinion when desired by the patient.  This is completely consistent with the OIG’s recommendation that the VA improve its approval processes for fee-basis and VA contract care for prosthetic services to meet the needs of veterans with amputations.

In fact, this recommendation, and the agreement by the Under Secretary of Health to this recommendation, seems at odds with the VA manual provisions that suggest that each VISN maintain between three and five contracts with private prosthetists, an exceedingly low number that does not square with the notion of veteran choice of practitioner.  This is perhaps why some regions examined in the OIG reports maintain far more contracts with private practitioners than three to five.  We would hope the VA revises this guidance in the future to more accurately reflect the needs of veteran amputees.

Support for H.R. 805, the Injured and Amputee Veterans Bill of Rights:  H.R. 805, the Injured and Amputee Veterans Bill of Rights, has been introduced in the past three Congresses by Ranking Member Bob Filner.  In fact, this bill—its predecessor, H.R. 5730—passed the House in December 2012 but the Senate did not have time to act before the 111th Congress adjourned.  This legislation proposes the establishment and posting of a “Bill of Rights” for recipients of VA healthcare who require O&P services.  This Bill of Rights will help ensure that all veterans across our country have consistent access to the highest quality of care, timely service, and the most effective and technologically advanced treatments available, all in concert with the enhanced internal capacity of the VA in the prosthetic field.  NAAOP believes that adoption of this “Bill of Rights” will establish a consistent set of standards that will form the basis of expectations of all veterans who have incurred an amputation or injury requiring orthotic or prosthetic care. 

The bill proposes a straightforward mechanism for “enforcement” of this “Bill of Rights,” with an explicit requirement that every O&P clinic and rehabilitation department in every VA facility throughout the country be required to prominently display the list of rights.  In addition, the VA’s websites would also post this Bill of Rights for the interest of injured and amputee veterans.  In this manner, veterans across the country would be able to read and understand what they can expect from the VA healthcare system in terms of their orthotic and prosthetic care.  And if a veteran is not having their orthotic or prosthetic needs met, they will be able to avail themselves of their rights and become their own best advocate.  But above all, no veteran will be in the position of resigning him or herself to the fact that they are not functioning well with their O&P care for lack of information about their rights.

This bill would simply condense to writing the O&P rules and procedures that the VA has used for years.  An analysis of Congressional testimony delivered in 2008 by the Chief of the VA Prosthetic and Sensory Aids Service before the House Small Business Committee confirms that none of the rights listed in H.R. 805 (and its predecessor, H.R. 5730) would expand the rights the VA has granted veterans for years, including in the area of practitioner choice and choice of prosthetic technology.[2] But the bill would, in fact, put these rights in writing and post them for veterans to see, understand, and employ to help ensure they receive the quality O&P care they need and deserve.  This bill would also provide Congress with easy access to the level of compliance with this “Bill of Rights” across the country and could identify particular regions of the country where problems persist.

I understand the Congressional Budget Office gave the bill a nominal “score” in terms of what this would cost the VA.  This is because none of the rights in the bill expand the rules and procedures the VA has acknowledged it uses for veterans in need of O&P care.  Thirty-five veterans’ organizations, rehabilitation associations, and consumer and disability groups support passage of H.R. 805.  While passage of H.R. 805 will not solve all the problems and shortcomings with the current VA prosthetics program, I believe it will have a material effect on the ability of the VA to deliver consistent, state of the art care to all veterans with amputations.

NAAOP and a number of national O&P associations recently met with senior VA officials in charge of the Prosthetic and Sensory Aids Service.  While the VA does not appear to support passage of the legislation, they do appear to recognize the problems that I have personally experienced as representative of some veterans’ experiences with the VA limb prosthetics program.  We have agreed to continue discussions to see if there are ways to address issues raised by H.R. 805.  But passage of legislation would establish, in law, a baseline of expectations for injured and amputee veterans that would not subject the contents of the “Bill of Rights” to the discretion of future VA administrations. 

Conclusion:  On behalf of NAAOP, I want to thank you, Madam Chairwoman, and this Subcommittee for examining this critical issue.  The OIG’s Healthcare Inspection Report provides valuable information on this subpopulation of veterans that will guide advancements in O&P care in the future.  On the other hand, NAAOP questions significant aspects of the data presented in the Audit of the Management and Acquisition of Prosthetic Limbs Report.  My organization, NAAOP, and I hope to continue working with this Subcommittee and the VA to help ensure that veterans with amputations and other injuries receive the highest quality orthotic and prosthetic benefit possible.  Finally, we call on this Subcommittee to seriously consider passage of H.R. 805, the Injured and Amputee Veterans Bill of Rights, in subsequent legislative hearings as soon as possible, and to ultimately enact this legislation this year. 

I thank you for this opportunity to testify before the Subcommittee and welcome your questions.

[1] Congressional Testimony of Frederick Downs, House Small Business Committee, Subcommittee on Contracting and Technology, Hearing on Ensuring Continuity of Care for Veteran Amputees; The Role of Small Prosthetic Practices, Serial No. 110-105 (July 16, 2008).

[2] Congressional Testimony of Frederick Downs, House Small Business Committee, Subcommittee on Contracting and Technology, Hearing on Ensuring Continuity of Care for Veteran Amputees; The Role of Small Prosthetic Practices, Serial No. 110-105 (July 16, 2008).