you can watch our full coverage of the inquiry online at c-span.org's video library. tony blare goes before the up qir ri next -- inquiry next week. ..

can fix that. [laughter] all right one. how is that? not yet? i'm glad this is happening with me now. [laughter] all right. how's that? new [cheering] i want to share averitt quote. a philosopher once wrote that friend should improve caviness to and the base missouri and by the doubling of chollet iwo and

the dividing of greece who were. and your love to do well. america and remember some the founder were this is our family, the family we never wanted to be part of, but i can't imagine a more patriotic, and more passionate or proper group of americans now than to be with this weekend. thank you all. [applause] well, we've come together this weekend for a lot of support and a lot of hard work and i would like to recognize hour amazing partners at the new york life foundation the admiration.

please, stand up. [applause] this is our time and we are so fortunate to have a very special guests with us today to honor ever loved ones and offer words of comfort. very proud to be part of the white house running for says campaign and to work closely on a regular basis with the first lady and dr. joe biden are also blessed to cut the chairman of the joint chiefs and his wife as friends and tireless advocate for the families of the fallen. ladies and gentlemen, the families, it is with pride that i introduce our dear friend, the vice president joe biden, joe biden, accompanied by the chairman of the joint chiefs. [applause]

♪ ♪ ♪ thank you for the kind introduction and good morning, everyone. i want to welcome all of you to washington, d.c., and i hope you feel right at home while you are here. i am so honored to be with all of you. memorial day is just a few days away, and if i can say one thing to all of you and your families it is thank you, you are our heroes. i've been tralee overwhelmed by the great green encouragement of our men and women in uniform coming and inspired by the dignity and the sense of

patriotism that military families like yours exhibit everyday. each of you like our service men and women, veterans and their families have dedicated so much for your country and we are truly honored by your sacrifice. it is our duty to honor the service of those who have sacrificed for our country and america thinks you. our thoughts and prayers are with all of you. this weekend on the memorial day and everyday. now it is my pleasure and my honor to introduce general dempsey, someone along with his wife has done so much to support our military family. general dempsey. [applause]

thank you. [applause] you are very kind but we are here to honor you this weekend as we try to do every day of the year. we want to thank the vice president and dr. biden for being here. we share the stage with them on many occasions many evenings like this one are for the families of the wounded warrior so, and i can tell you that their heart is exactly where you would want it to be so it is an honor to share the stage with you again. i like to tell folks a little bit about this day in history because it helps us connect to our past, so in this day in history in 1986, you might recall the phrase hands across america because 6.5 million people linked hands from battery park new york city to long beach

california. they were doing it in the name of homelessness and hunger, but i think about that in terms of what taps does for us. i know you have a special place in your house for taps. we have a special place in our hearts of the founder who 18 years ago decided to link up parts across america and how about we get a round of applause. [applause] you know, most americans have not had the life altering experience of being a handed a folded flag with those of you in this room have come and in many ways you are the face of the war over the past decade but even prior to that. so, what we want to tell you today is that your example truly

does inspire us that we understand and honor your sacrifice and what you've done for the nation and promise you that we will never forget. i just had the privilege to go and spend some time with your children, by the way they are an unbelievable lunch. the great looking kids and now i know why they are so good looking i guess. i know there are some mentors and each of them as you know has a soldier, sailor, airman, marines and coast guard or veteran mentor and it's the highlight of my year in buying back again i want to miss one as long as she continues to invite me. [applause] so, we are with you. i promise you that, and ladies and gentlemen, i now have the privilege and honor to introduce a man who it demises service,

set for some support for our military families, the vice president of the united states, joe biden. [applause] thank you. thank you. please, be seated. am julca laden's husband, joe has i'm known here in washington and in my household. [laughter] general dempsey, i've been around washington for a long while. i was one of those folks to call its chairman of the foreign relations committee for a long time coming and i have gotten to meet an awful lot of incredible military personnel and some remarkable women and men who have worn the uniform and they

all have different qualities, but i want to tell you just for a second about why i like dempsey so much and when dee dee even more. i really mean this. these guys get it. you're not a number. you're not a soldier or a soldier's family. these guys wear it in their heart to. i've been with them when we visited the bases where some of your heroes have fallen and watch, watch how dee dee response. i watched the general. he's a tough guy but i watch and you can almost hear his

heartbreaking. there's something special about both of them. and i guess you know, too. what he says he will be here as long as he is invited he really means it. he's not here because it is his job as the joint chairmen of staff. dee dee isn't yet because of that. if you saw his family, by the way, his children served. they are in harm's way now. [applause] i watched jill and dee dee talk. we don't have the military history they do but our son spent a year in iraq -- [applause] when he came home -- it's going to sound strange to you or me

vbied anybody but the audience, he felt little guilty as he came home home because there's so many funerals i have attended, so many bases that i have visited. and you know, not all losses are equal, not all losses are equal. of what used to drive me crazy i could be wearing one of those red shirts, not for the military but when i was a 29 year old kid i got elected to the united states senate out of nowhere on november 7th, and i got a phone call like you guys got with someone walking up to me. on december 18th i was in

washington, the first united states senator i ever knew what. i was in washington as i and my staff got a phone call saying that my family had been in an accident. just like you know by the tone of the film called you just knew when they walked up the path and you knew when the call came you knew, you felt it in your bones something bad happened. and i knew. i don't know how i knew, but the call said my wife is dead, my daughter was dead and they weren't sure how my sons were going to make it. christmas shopping 81 tractor-trailer broad slated them and killed two of them and, well i have to tell you i used

to resent -- i knew people meant well they would come up and say i know how you feel [applause] 90 they meant well. i know they were genuine but they didn't have any damage idea, write? [laughter] stat black hole you feel in your chest like you were being sucked back into it. looking at your kids, most of you had kids here it was the first time in my career in my life i realized someone could go out and the public shouldn't say this with the press here but it's more important for the

first time in my life i understood how someone could consciously decided to commit suicide not because they were deranged but because the hit into the top of the mountain and they knew in their heart they would never get there again. they were never going to get, never going to be that way ever again. that's all a lot of you feel. by the way, the moms and dads, no parent should be should be pd by their son or their daughter. i unfortunately had that experience, too. but you know what? i don't know about you know, but i was angry. man, i was angry. you'll probably handled it better than i did. i was angry with.

when i, not that it's relevant what religion but i was a practicing catholic at the time but i was mad at god. i remember being in the rotunda walking through to the plane to get home to go to identify -- anyway, i remember looking up and saying god, as if i were talking to god myself, you can't be good. how can you be good? you probably handle it better than i did, though i was angry. and i have a great family and this woman literally saved my life five years later. i have a great family.

my mother, my brothers, sisters, the best friends in the world, they were all of their for me. there's still something gigantic missing, and some of you a loss occurred to years ago, some of you may be two months ago. just when you think maybe i'm going to make it your writing down the road and pass a field and see a flower and it reminds you when you hear a song on the radio or you just look up in the night coming in juneau, you think maybe i'm not going to make it. because you feel in that moment the way you felt the day when you got the news.

out of the blue i got a phone call one day from a guy who who was much older than me and i didn't even know he was a former governor. that's all right. i used to be peace. [laughter] don't worry about it. for real. what happened was i got this call out of the blue from a guy that was a former governor of new jersey. i had never met him and he said, you know, called to express my sympathies. i know what it's like. and i felt like saying, you know. he said i know what it's like. when i was attorney general i was a young guy and i lived across the green in trenton new jersey in the state capital from my office as attorney-general and used to go home for lunch every day and one day i'm looking across and it was only a block away and a woman that came in to help once or twice a week came out and said attorney

general, your wife just dropped dead. he said i remember. i started listening. he said you know what helped me? he said for what it's worth i recommend it to you he said start to keep a calendar. keep a calendar. every day when you go to bed mark on that calendar whether the day was a one which is as bad as the data you heard the news or ten. you won't have ten for a long time, but measure, just marked down. he said after two months take out the calendar and put it on a graph and you will find that you're down days are just as bad as the first day because here's what happens instead of being like this, they get further and further apart. he said that's when you know

you're going to make its. that's when you know you are going to make it when you realize the measure of your progress, you're mother's, you're fathers, husbands, wives and brothers, sisters and that's how you know that's when you know you might. i will let me a i don't know all of you. many of you kids and grandkids in the rooms, you know as well as i do that they need you were. but you know what most people don't understand in this room you need them the more than they need you. you need them more than they need you. you will find something remarkable has happened. my mother's a sweet irish lady. she said something that time the accident happened that i felt was the cruelest thing as a can of identifying.

she said joey she adored my wife and my daughter. she said with everything terrible something good will happen if you look for a hearty enough. i said what a cruel thing to say. really, i did. you know you're going to find out? your relationship with your son or daughter which is already close is going to be like a bond of steel through your chest and there's together. you'll find with their brothers and sisters they are going to be each other's best friends their entire life. everybody's friends of their brothers and sisters, you're going to find there's a degree of difference in depth of the relationship you never ever thought could happen. and i'm going to see something outrageous. i was a good and caring father before the accident. in a bizarre way it's almost

harder for the parents of our fallen heroes because no one ever expect to have a child predecease them. never. the irony is when daschle is the most incredible woman the world. when she makes up the resources on december 18th we have a special mass for the grave site. on mother's day jill walked me out to the cemetery and brought flowers i brought for my mom and she brought a favorite flower for my deceased wife and daughter. what happens to is that there really is hope.

that eight in the back never goes away, but it gets controllable. when i asked jill to marry me, this is personal but it's important i hope to you, and i had to ask her by the way five times. [laughter] [applause] that's not a joke that is the god's truth. five times. finally, five years after the accident, five times. the last time i came back and look on her apartment door i just came home from africa as a trip as a senator and i said to look, you've now engaged my pride. [laughter] this is the last time i'm going to ask. she's at the door. i didn't walk in, she's at the door. i said the last time. let me say to you i'm going to ask you -- don't say anything -- i'm going to ask you will you marry me. you don't have to tell me when -- [laughter] you just have to tell me if.

and if you say no, that's it. and she looked at me and she said yes. then she leader tells my sister when asked why she finally said yes, she said i fell in love with the of boys. [laughter] [applause] too soon, not reasonable, beyond your expectations, and a matter of fact, you are going to go through periods when after a while you see somebody you may have an interest in and you're going to feel guilty as hell. you're going to feel this awful feeling of guilt. but just remember to things: keep thinking what your husband or wife would want you to do.

keep thinking what it is and keep remembering those kids of our him or her the rest of their life blood of my blood, bone of my bone because folks, it can and will get better. there will come today i promise you and the parents as well when the fault of your son or daughter or husband or wife brings a smile to your lips before it brings a tear to your ausley it will happen. my prayer for you is that they will come sooner or later but the leading have more experience and is telling you it will come.

you see how can i have an advantage over anything? you have that incredible thing called the military. you are not alone. sitting around the table, people you didn't know before, being able to share what it's like, how do you put them to bed, how do you say their prayers, what do you do, what do you do when they ask about? that's why i think as i said coming and i said to bonnie that's why what you've done is so critical. most of us go through what you're going through totally alone. and after a while, it doesn't make the loss any easier or harder. after a while you get tired, you feel like you are relying on family to much, you feel like i can't say to my mom or my sister

help me raise my kids. i can't say to my brother -- i mean, it's about time, i've got to get -- if you have somebody to talk to. foot afford it's worth i'm a psychiatrist or psychiatrist but i sought help on how to deal with my kids coming and you have that advantage as well. it became salles lister for me to talk to people we didn't even know what had called me and said they'd been through it and i would call. kasich something to say you can make it. so hang on to each other. hang on to each other, and i can't tell you, i can't tell you how deeply the five of us in this stage feel about the sacrifices you need for this

country. that doesn't fill in the black hole. but you should know only 1% of you thought of the war much less than one person that fought the war are going through what you're going through. we owe you more than we can ever repay. as i said in my prayers, that smile will come sooner rather than later but i promise you it will come. and god bless you all and may god protect our troops. thank you. [applause] [applause] [applause]

[applause] [applause] in all the conversations amol conversations

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[inaudible conversations] no schappell [inaudible conversations]

thank you so much to our special guests. [applause] we are honored to have such special friends of the chairman and his wife and vice president in the dr. jul in. they truly as you can see from their work and their presence with us here today and their words of encouragement help much their hearts go out to each and every one of us and how much they truly know and understand and they are with us and support us and we are just so pleased to have been lucky to have been joined today so thank you to our special guests. [applause] it is now my pleasure to introduce a lady that both of you know, she is a person who

has been a part of the family since its very inception. she comes and gives her words of wisdom, her words of hope, her words of a shared journey and her laughter and humor. she is truly a friend of taps and we love her so much. it's my privilege to introduce to you now dr. dorcy -- darcy. [applause] woo-hoo i tell you i've never had to follow the vice president. [applause] [laughter] but forgive me if i am not as of

some. how amazing for him to come and share his story. he truly is one of us. [applause] what we have a couple of minutes before launch so while they are making sandwiches, thank you all for coming, for your courage and patience today for putting up with some of the extra rest of the house to go on when we have a special guest. i am a military bader. i'm a military wife, and the military mother. shattered once or twice as it was in your life. years ago when our son died

while dropping bombs on another war there was no taps, there were no support groups, there were no books. we were told to be strong. you will have a smile on your face and i learned early on the grief will wait for us it will wait forever, and i am so grateful that now we have a family, our club house for the weekend coming and we are here. thank you for coming. even though some of your not -- i have seen some suitcases under the table. you don't know if you're going to stay. i give you another ten minutes. then maybe i'm going to go. please, give us an extra ten minutes. please, give us an extra hour and the next day, because every single person in this room has been where you are now. every one of us has been where

you are now and we didn't believe we would be here again and again but to see us hugging each other? it's a family reunion and that's what this is. this is our family. so, to give you a couple of tips on how to survive the circus this weekend. you've already learned a couple of them. one is have a little patience. have a hug. we only have a couple, so take your time. hugged each other. give yourself permission to be here. you needed her track shoes if you for the schedule however you don't have to go to everything. pace yourself. sometimes leaning going in the bed is a good thing to do. go to a free workshop you think some good and i will tell you on behalf of all of the speakers here if it's not the right

workshop for you, get up and go and just say that's not what i thought it was, that's not where i am today and every speaker will be okay with that. this is your time. do what you need to do to heal. bring a little patience. be prepared for all of the motion that we've got to read all of them. we come sometimes with our hard light of this year and sometimes with a heart that is heavier. sometimes we aren't even quite sure we have a heart left. you are going to need a lot of kleenex or perhaps that isn't enough to put a box of here okay. [laughter] but i've learned over the years this isn't enough and if you ever notice we need a tissue we actually say barrault. the one to borrow a tissue?

yeah, thank you very much. here, have it back. but i learned a long time ago people will give us one. there you go. i hope you're over that soon. it's been 40 or four days. you ought to be better by now. [laughter] you know why the third or fourth day it's worse. we were none in the beginning we had no idea what we were doing and as we go through the weeks and months of grief it almost seems as if we are in the frosty, so if you are in that stage you are right where you need to bea. if you are a prior like me unprofessional crier i figured out a long time ago i would have to carry 30 or 40 of these packs blue all over me. or every morning just go in the bathroom and get some prelate

paper. [applause] i left him this much. all you have to do. you know i'm going to do this. you just stick in your pocket and out you go. [laughter] is anyone going to notice? yes. everyone is going to notice that. are they going to say something to you? know. [laughter] how do they know that? because we have seen someone with a little bit of the restroom on the back of the shoe and none of us say anything to them. look at that. we don't say excuse me -- no, we don't. so no one is going to say anything to you, and if they do, you and i can simply look at them very kindly, and i want you to say very clearly im bereved and nobody knows what that word means, so they're going to go okay.

that's fine. [laughter] and if they continue the conversation, just look at them and say i'm prepared. and i've never had anybody go further than that. [laughter] cry if you need to cry, laugh if you can't come and if we can find joy again try you can do no less. if you ever laughed with your husband or wife or son or daughter or mother or father or brother or sister or and/or on goal or grandparent or x or fiancee come if you have ever had a laugh with them during life you can do no less now than to bring it back. you know you have to places in this world. we've always had choices who to date, who to marry, what to do. if you want to bury them, cremate them, what funeral home, and then other choices, july 1

to wake up this morning, july 1 to briefed today? what am i going to do? some of you are at trace points right here today, the choice can i say, can i make it come to an id with a strange group of people with to let people in their pocket? [laughter] what do you choose to bring with you? what do you choose to remember? you can carry in your and hurt and bitterness for the rest of your life. you can choose a good memory. you can choose joint. you and i are blessed beyond any measure because someone in our life with a walk in or were born into our life, we have no idea how they got here and we feel

helplessly mad leslie in love with them. i wouldn't have missed a moment. i think the truly believed in the world are those that have never known of love at all and hewey and i in this room are because somebody left and we left them and we still do. we did not lose them. we did not. [applause] they are forever and always right now. we talk in the present tense in this room because they are still here. it's what makes the tears come down in the beginning and i hope someday to bring a smile. please, stay, family. please, turn to each other. please find that hug that is

waiting to reach to yours you will find people wearing shirts that have been here a long time who are willing to reach out to you between the two and to pry and sing and dance not in sadness, but in gratitude that somebody loved me that much, and that did go away that i didn't lose them and neither did you. change the language. yes, they died and that is a hard thing to say. religiously or spiritually, they are right here, right now in the darkness of night never to be

forgotten. when choose a ander for now, guilt for not a depression for now, the shoes to grieve one more time you can do no less than honor in honor of our lives that is what brings us here not to the justice that we love but you and i our message with the love of someone we still love. i want you to spend. we have workshops. i was going to tell you that story. they teach years. when you see me in the hall this weekend would you tell me a life story? what you pick a moment if you

can't think of anything else tommy the color of their eyes and you and i will hug for that. it's been a very long journey for me and i finally choose to enjoy every single moment. i am forever blessed because i have been loved by old boy and an old man and a pretty good job. [laughter] right now as we are getting ready for the weekend would you reach out for the person next to you and connect hands, just hands, wipe your hands off. we now in this room are forever linked to our husbands and wives and sons and daughters and brothers and sisters and moms and dads and grandma's and

fiance's and all of the people that are across the rainbows' ahead of us we are in this room now a family circle broken by death but mended by love. i am so glad you're here and sorry that we have to be. but i choose loved. join me in that. welcome home. taps family, you are in the right place. welcome home. [applause]

life is incredibly precious and it passes buy too quickly. so during your time here use all of your unique god-given talent to serve one another has that will be the true measure by which your life will be judged. follow the golden rule. the department of veterans

affairs provides care for 42,000 veterans who've lost limbs. a house hearing recently looked at the quality of health care provided for veterans of the petitions and prosthetics. the officials and veterans testified at this three hour hearing chaired by new york republican and marie burkhalter -- burkle. good morning the subcommittee will come to order. good morning and welcome to today's subcommittee on health during optimizing care for veterans and prosthetics. our nation's commitment to restoring the to devotees of disabled veterans struggling with devastating combat wounds resulting in the loss of a limb begins with a civil war. restoring the veterans to fulness was a core impetus behind the creation of the department of veterans affairs

and then now it continues to play a vital role in to permanence mission. press technology and va care have come a long way from the civil war era. wooden peg legs and a simple hooks' following world war ii, 1945, veterans of dissatisfied with the quality of the va prosthetic care squirm in protest. congress responded by providing the va with increased flexibility for prosthetic operations and launching federal research into the development of nammuldi and assisted devices. with these reforms, va and led the way in prosthetic care and research guided by dedicated professionals both inside and outside of the department who worked tirelessly to provide the veterans with the quality care that they earned and so much deserved. as a result, the model of the v.a. care today for today's veterans includes leading edge artificial limbs and improve services to help them regain

mobility and chief maximum independence. still, the magnitude of the heartbreaking injuries gained by service members and veterans returning home for military services from iraq and afghanistan find the va struggling to keep pace with the rising demand of under the more active veterans of amputations. prosthetic care is unlike any other provided by the department prosthetic devices, particularly prostatic limbs quite literally become a part of their owner, requiring the integration of body, mind and machine. the goal is not just to teach the amputees to walk using artificial arm or hand, but to provide will tight disciplinary continuing care to maintain long-term lifetime functioning quality-of-life which is why i am troubled by the department's proposed changes to press that

it procurement policies and procedures. the forthcoming reforms will among other things take prostatic purchasing authority from the press that providers and transfer them to the contracting officers. this is alarming to me as we will hear soon it is also alarming to many of today's witnesses. i would like to read a quote from captain jonathan, a wounded warrior himself who states in his testimony that we see no prospect that this plan to change holds any promise for improving services to the warrior. instead, almost certainly threatens greater delay in the ability to provide severely wounded warrior is needed to prosthetic devices and heightens the risk if fiscal judgment would override a clinical one. i think that the members of this committee agree along with many of you in the audience this morning we cannot allow this to

happen, and this morning we will look to the department for assurance that it won't happen. it is nothing short of inspiring to see how far modern technology and most importantly the spirit, courage and resolve of our veterans themselves has come in restoring local become a dignity and hope to the nation's heroes and they are our heroes and this nation owes it to them this debt of gratitude to make sure veterans have exactly what the need to survive, to thrive and to have a quality-of-life. it is vital that we set the prostatic care of course that matches the courage and bravery of the men and women that served the nation in uniform. again, i think all of you for joining us this morning. i now recognize the ranking member for opening remarks he might have. >> thanks very much, madame chair. i would like to thank everyone for attending this very important hearing we are having today. the purpose of today's hearing is to look closely at the va

prosthetic services and to examine that number one, the demand for our prosthetics services and number two, quality-of-care and access is used. number three, the impact of ongoing procurement reforms, and number four, if current acquisition and management policies are sufficient. as the office of inspector general reports have shown, there are numerous concerns in putting frequency of overpayments in nearly a core of the transaction totaling over $2.2 million in fiscal year 2010. the absence of negotiation price guidance and other controls in the limited information to access its current prosthetic limb fabrication and acquisition process these are effective. i have said on this committee before what seems to be the case

that there is little accountability and management, and once again, procurement procedures and policies brought in place or not follow the managing nearly $2 billion worth of prosthetics. the va and the last year's budget mission claims that $355 million of savings in fiscal year 2012 and 2013 due acquisition and prevents. but if the va can't follow its own policies and procedures on how much faith do we have in the claim of acquisitions dating? i hope the va can help us understand today what accountability we should expect and to make certain that the va doesn't continue to overpay for prosthetics in the future and that taxpayers and veterans receive the best value for their

devices, and for management to ensure the prostatic surface is fully meeting the veterans' needs. finally, as it has come to my attention that the va has proposed changes in the procurement of prosthetics and that there is a high degree of concern among some of our witnesses today as to the effectiveness of these changes i look forward to hearing from the va on these issues as well and i would like to thank all of the panelists for coming today and i want to thank those of the panelists who are veterans for the great nation of ours. i'm committed to working with all of you to ensure that our wounded veterans, as those that have served honorably have made such great sacrifices and are able to go about their lives comfortably with these devices and with the best support and services from the va announced

possible, so what he once again for coming today and thank you very much, madame chair for having this very important hearing. i yelled back. >> thank you very much. i but to invite the first panel to the table. joining us this morning are john register and jim ms. miers. mr. jester is a veteran of operations desert shield and desert storm and a world-class athlete when a mine gold medals in the armies armed services competition. in 1994 he suffered an injury that led to the amputation of his left leg. undaunted with the aid of the press that it, he went on to win a silver medal in the 2000

paralympic games where she set the american long jump record with a distance of 5.41. he now works for the united states committee where he manages the paralympics academy outreach program and the paralympic military program to read we also have the privilege of being joined by mr. jim mayor who served as an infantryman in the united states army during the vietnam war. he's a combat disabled veteran and a bilateral below the knee amputee. after serving so honorably in combat, he has devoted his life and career to assisting his fellow veterans working for 27 years with the va and 12 with our veterans services organizations. perhaps most notably she's also spent 21 years as an amputee visitor and mentor, the va and the walter reed army medical center. now at the walter reed national military medical center where he is affectionately known.

gentlemen, thank you both so much for your service to the nation and for your continued service to your fellow veterans for your worthy endeavors today. both of your truly inspiring to all of us and it is an honor to have you here with us today. i very look forward to hearing your testimony. mr. register, you may proceed. >> thank you very much, ranking member think you and members of the subcommittee. its outstanding. thank you for the opportunity to testify to deliver his state of the art care to veterans with amputations. today i am testifying on behalf of myself and organizations which serve on the board of directors being the national association for advancement of products the national association that promotes public policy with prosthetic patient providers who serve them.

i served earlier in desert shield storm and my injuries actually have been may 17th, 1994 semi anniversary is actually tomorrow i was a the pentagon where a friend of mine found photos of the actual accident, so i have been in my bag and then kind of stretching out a little bit right now seeing the photographs again but it's remarkable about the care and that is what i'm going to talk about a little bit today. ..

right here in the capital region and had outstanding care. in my experience have always been treated with dignity and respect at three v. hospitals i've been fortunate to work with. fighting a local profit if this is. % a prosthetic limbs are provided by prosthetic heart stationers under concept that the va. this has decreased in the past two years as the va has bested to the internal capacity to say it the prosthesis. i felt a close relationship with the process is over the years would like to continue seeing him. he is certified and accredited by the agencies, the va recognizes that requires. my local office in town is seven minutes from my house and he is

designed that care and so the ongoing care at the processors with high quality and very convenient for my convenient job, family and lifestyle. i had a new prosthetic and was coming up, i began to be interested in the new technology at the va hospital in denver to get this one fitted i didn't realize i had i had a choice in the matter believing that we'd meet my prosthetic needs i.e. began the fitting process at the denver da driving 50 miles each way to receive the prosthetic care and i could just easily gone down to get the care done and been -- it was also later with after my fourth or fifth visit i was reimbursed for a gas mask a missive that was something i didn't know. so i'm getting none of my social

networks. before i finally received my new land, which i'm wearing today i am really thankful for. every time you need adjustments or service being of the prosthetic eye must take a better part of my day off work to pay my va care the denver pa. great care, not disparaging that. just a bit of an inconvenience. i've no complaints about the prosthetic care received. i consider myself very fortunate brimful verbal or uneducated about the process, but i worry about those who are not in simply accept what they are told about the options. veterans should have a choice in the park titian or choice of technological options and received this section when it is by a patient. pass the legislation like h.r.

805 npt veterans bill of rights is critical. i reviewed three reports recently issued by the opposite effect of general and had observations to just offer this committee. the first is the 1.8 billion spent by prosthetics in 2010 on the 54 million or 3% defund prosthetic limbs and this is a relatively small portion of dollars spent by the va on a category prosthetics. ba has a major investment in internal limb prosthetics capacity with the development of the npt system of care, a programmer should be commended for commitment and focused on this important population. the report also notes high satisfaction of lower than prosthetics the less the upper extremity and we agree with the oig that the va should improve on this scare the population to publish the report on opryland research associate with the dod research conference held two years ago.

an aop takes issue with oig's calculation of the difference in what it asserts is a cost to provide prosthesis on average two veteran and in-house capacity in the veterans health administration. the report stated that 12,000 on average for prosthesis for the average cost fabricated vha's lab was approximately $2900. this is a blow of providing prosthetic care and want to know what went into that report. as the va enhances the capacity is important to recognize the prosthetic care to veterans for decades with the care on prosthetics in their own hometown communities, preserve quality by allowing their choice and provide a relationship between the prosthetist and

going onto high-level competition went to the higher quality quality of life. i think the last two points as i think it's important to va maintains access to local private prosthetics that the va to conveniently service veterans and this is why the maa o. p. addresses concerns that the va approval process for fee-based nba contract for prosthetic services to meet the needs of veterans with amputations. we asked the committee to consider passing of legislation pending before the committee that seeks to address the issue of a shower 805 uninsured. so on behalf of i want to thank you chairwoman of the subcommittee for examining this critical issue in thank you for the opportunity to testify before you and i welcome your questions.

>> thank you very much. mr. mayor, you may receive. >> thanks for the chance to talk to the subcommittee today in thank you for the kind words in your introduction i really appreciate that, man. i have received, like john, i received a lot of prosthetic care. i received it from the va, brooke army medical center, walter reid and the area. in reference to my peer mentoring and peer visiting amputees have broader broader over the years, i have gotten to know the current warriors and their families, their concerns and ensure it, i think i understand the catastrophic injuries they have overcome through military health care and rehabilitation and i understand her being at their bedside in all so from being in that hospital bed. as of may 1, there is 1459

amputees -- i'm sorry, for years at the amputations i should say. they care for those warriors is that the very core of the va's mission. it is clear that prosthetics today is at a crossroads. dh and he has a chance to regain its leadership role that she referred to in the excellence in this field of prosthetics provision in npt carer. but the current direction and decisions about when prosthetic care suggest that the veterans health administration, vha is about to further compromise its ability to serve these veterans. in 2004, eight years ago, secretary principi testified before this committee that va in his opinion had lost its edge and prosthetics. it wasn't doing enough to ensure the va developed world-class

prosthetic care and rehabilitation programs. his primary solution at that time is to build a center of excellence in npt research and rehabilitation. secretary principi's was eight years ago still ring true today, but the number of warriors with amputations has since increased by over 900% pure it in 2006 congress revisited the issue and propose legislation to create an va five such centers. the leadership of the vha oppose the bill legislation died. in my humble opinion as a result, the va lost its leadership position in prosthetics and was eclipsed by dod. since 2006, dod has not established as one, but three amputee centers of excellence, which are holistic care. the warriors they receive world-class care and when they are no longer on active duty, they're going to have to turn to

the va. in my opinion the va has to ensure that the expertise necessary to continue the level of clinical care that the warriors have become accustomed to in the military and the va's administrative processes guaranteed timely care. i want to reference your remarks, had an chairwoman about transfer unwanted prosthetic purposes within prosthetic services in the va to acquisition, to supply. i totally agree. i think the potential wait times because of the lack of knowledge on the supply side about prosthetics as if this were about purchase item, i probably wouldn't be worried about it, that john and i know that when prosthetics are delayed, it is not a wait time. it is an inability to function in my life or to thrive in life. i want to couple that with i understand that va is moving towards decentralizing the funding for prosthetic

purchases. this is an issue that was solved over 20 years ago by centralizing our fencing off those funds to local medical va medical facility directors could not use that money for other purposes. 20 years ago, veterans were delayed until the next fiscal quarter or the next fiscal year because the monies were used for other purposes. i would like to summarize by saying what i think it's a happy with va right now. i think it is time for them to suspend the decision -- their decision on vha transfer your other prosthetic purchases to supply. also to drop any discussions that decentralize funding. at the same time it is time for full-scale program evaluation led by a more impartial body such as das office of policy and planning and put stakeholder cohorts on that effort. i list those in my written statement.

and how that effort report directly to the oversight of secretary chin sakae. to me he is shown coming its ability to take test issues and decide what is right for the veterans. thanks for the chance to be here. >> thank you go through much. i now yield myself five minutes for questions. i'll start with you, mr. register. you receive care both from the dod as well as from the va and you mention that in your opening statement. can you compare and contrast the services? how would you say one was versus the other, either positively or negatively? >> yes, i will. i think i want to clarify when i went to the depart of defense at walter reid, this was before all of the new kind of bells and whistles they have no with the amputee care because it is extraordinary but the servicemembers have. so they were pretty much the

same. they were almost on an equal basis. i'd prostatic linda williams made there in also in the va right here in the d.c. area. i had no issues going between either one or the other. i think when it came time for understanding a little higher level that did the deed, i found both lacking in that knowledgebase and i began seeking it out is going to become aware class advocate and looking up is going on in the united states in the world and what people were walking -- actually running on. that's when i started looking at who needs to begin to lie on this thing so i can run it i have to mount time. and then i found outside both the dod and the pa system. in fact, some of that was the expertise was so critical that i went to california from virginia to find one prosthetist who gave me the line right and correctly. if i did not get that person i

would not be a silver medalist at a enough fact. for my ongoing care right now, again it is not -- it was worth the inconvenience than it is what i see. having been down to brooke army medical center after san diego california and here at walter reid that the care is exquisite in these individuals coming through, they are looking to get back into the site and back with their units, so that is the same level high activity that i was lacking before that they are not receiving to go back and do those things. amputees are back in the fight and going on to higher employment, going on to be with their families. that is what i see as the difference. >> thank you. mr. mayer, you talked about at the loss of leadership and like to know if you can identify or help me to understand when and how va lost it premier status

and military took it over. >> i will try. i had the pleasure of being the first staff committee manager for the first via prosthetics advisory committee in the early 90s when secretary dubinsky ran the va. i didn't have a vote. i just know it's an organized the agenda. the burning issues of today are already being reconsidered by vha. my quarrel is not with the psa s. employees and their ability. they are professionals. they do a good job. my quarrel is that the more senior ranks of vha management. it doesn't matter who was there. culturally and i understand the motivation, they look for because of budget reasons they look for flexibility at the local management level at the

facility. prosthetics, monies and procedures are very interesting, large target. that is how i would summarize it. >> thank you. mr. register, and your testimony talk about differing needs depending whether it's an upper body or lower extremity. can you talk about that with the effeminate as you see them or different? >> i think with my upper lumbar extremities that these of getting the hand function back is one that is pretty critical. as you look at how that is common developed over time, it is really amazing of the injured chris v. that the upper bodies have with getting that same function back. with lower extremities, it is a matter of just walking and functionality of the land.

it's kind of comical what's inside the would've amputees, below the knee amputees when i'm done that brooke army medical center is below the amputees and above me have rates going up for the about me and bt is called baloney are paper cuts because they don't have their knee. so i think it's a matter functionality and walking and getting back up right with that, whereas with arms we write with the armed and it's more mechanical. it's more tangible without. it's a different between the upper extremity and lower extremity. >> thank you very much. will yield to the ranking member for the questions. >> thank you very much. i want and want to thank both of you for your survey says is great nation and for coming here today as well. mr. mayer, you recommended that for the strategic plan for vha

can participate at the operational control should be centralized in the secretary's office. could you explain a little more why that should be? >> it is just an opinion based on historical it's variants. like i said, vha and psa have a long history of dedicated professionalism. when it comes down to these issues, you now, i am just here to tell you, john is right. this generation of warriors are actually. my day, we wanted to learn how to walk. walking doesn't get it for these guys. they go in the mountains, go into paralympics. i get out of breath just watching the skies. if you thought these complaints are big ben, you know who's

going to get the complaints. it's going to be members of congress and veterans service organizations. that is why kind of okay, not to vha's senior management. secretary shiitake has shown pretty at it in style when it comes to large issues. cool. >> you also mentioned the department of defense has the superior over the va as it relates to this issue. why do you think that is the fact that it is not to go to the secretary of the department of defense and appears it is at the lower level. why is that quiet >> it's a question of leadership recognizing the clientele and their needs and the fact that john said a member want to get back in the fight. they've got to be trained and conditioned and have to go three board process to certify they can return to duty. congress provided the funding. congress still provides the

funding. it is the war funding. my only can learn about that is given the budget situation, i don't know how much longer the funding will let the centers operate at the level they do. but i think the real key is what i call holistic. i don't want to go in the details of trying to name. it's not just the surgical expertise and clinical expertise. it's the merger right together a physical therapy, outpatient care p., adaptive sports, challenges and to me, one of the best-kept secrets in the military is the outpatient nurse amputee manager. for years at walter reid and watch the individual, steve springer quietly fix problems, keep the track on recovery, be the advocates and never in a way that calls attention to this rule, the really calls attention to the warrior. that's what makes it work in co-locating research with the clinical part instead of being standalone is another big

accomplishment. >> how long did it take to get the new site allergy that permits macro processing control of the prosthetic knee through the va? >> well, i've done it twice now. the first time was here in the virginia area when i first got what we call this the leg and that is the first macro processing technology to work pretty well. that process took about a month to maybe a month and a half, maybe six weeks. the current process of going back and forth took three months to get the prosthesis. in fact, the situation was i was going up and i try and show by example, so i tend to national wheelchair games which will be in richmond this year and i have a wheelchair made for playing wheelchair basketball. so my chair had come in and i

went back to the va to get it up in the denver area, traveled almost 70 miles and i knew i had to go there to get it. on the way i sent a note in us in the lobby area waiting for my appointment and i saw an e-mail from a substandard saying your leg is here. 10. i think great. luscious put it on. i can walk out of here with it. he said no, we want to come back again and fabricated to make sure everything is good to go. so i could of left that gave her three pieces my equipment from a wheelchair, sports chaired, but because the va wanted to ensure that the fabrication of my socket was done to marry that with the new acts to that i have was funny and ludicrous to me that i could not just go and put it on with my allen wrench and walk out the door with it.

>> thank you. thank you bag chair. >> i now recognize the gentleman from tennessee. >> thank you. the staff wrote this memo for the most acronyms i've ever seen. i count at least a dozen a night that the plo was the people's whatever it, but it's a different organization. john, why do you think -- or do you think or either one of your congrats is, is there a drop of? i've been to walter reid on multiple occasions and it is unbelievable and now bethesda two-seat amputees up in the care they are getting. is there a drop off when these warriors are handed off an air of silly right there is different exit teixeira and then mr. mayor and eyes.

is there a drop of? do you see that? certainly in your case because you're incredibly motivated not in your case. >> is that to me? thank you for the question. i think what mr. mayor brisbane was spot on. there is a little bit of a job that happens from dod to the va, but it's a much larger issue than the amputees. there's a systematic care that happens, a continuum that goes forward. what i am seeing now with the drop has to do with my own personal opinion is that there is a center of excellence that when these young men and women are coming back to the dod hospitals and come back as units, when we see a killed in action, i look at the paper notes are going to be six or seven coming back and going to hit those hospitals that survive that. so those are the ones i'm focused in on. when i see them come back, they

are extremely motivated to get back because they don't want the soldiers -- that a lot of of a fallen comrade and leave a buddy the battlefield. they feel like they lost the ability to fight. they can he sport a mechanisms and tools to rehabilitate, they're ready to be active again. on the va site, the population has been different and that is not in the activity level as high before getting back into a war fighting situation. so that is the drive. but i do see right now is that the new sports on earth and there are sports programs, they really push out into the communities now come increase in activity level of the veteran peace train. those coming to the hospitals are linked in with community-based programs across the united states. so the model is being changed and i think that is going to change the dynamic for the va. >> party that may be

generational. as you are older, your expectation may be too can be late. i can emulate well, that's a success. a 23-year-old is not a reasonable outcome. a reasonable outcome mr. returned to snow skiing in whatever he did before, that packing, whatever it may be. i totally agree on the upper extremity. we just graduated a year ago. the young medical student lost his right arm with a black hawk helicopter crash and came back in the two medical and graduated and it's tougher for him. he's going into emergency medicine that because of dexterity you need with their hands, he could walk, but it's difficult for him to do a lot of things and that's probably a satisfaction difference you see if you get back to job and income have been keyword come me feel pretty good about that would there have a prosthesis or not. the other thing and you brought up a great point, it is very individual who you relate to.

as a physician myself, when you have the relationship with your patient, you great confidence. they now do, and they know your leg in exactly about you. i want to say for myself and i can speak for most of the committee, i don't care what it costs for you to get care you need for unit warriors to get the prosthesis they need and mr. maher said it very well, it is inconvenient. it affects how you live. you take one day or three days that you can't do something to take care of your family come i can't go to work because of your prosthesis. that's unacceptable. in your budget, 1500 something i wounded warriors whose last extremities. we can't as a committee in a country do enough with this warriors in those days are going to go on. mr. mayer can tell you that he will change as you could older. your late changes, things just

change in gravity has a great effect on us. and so we have a commitment to designate warriors. not for this great care now, but for a lifetime of great care and i think i can speak for the entire committee on that. i think we all feel that way. again, i'll want to make sure that they cared as a drop from the time you the dod because i have seen that facility up there multiple times and it's phenomenal to make it to the va. the later, if i get a chance i want to get on the answer of why you think the va's prosthesis is 2900 versus 12,000. i read your testimony. i yelled that. >> thank you. i now recognize mr. runyon. >> thank you, not an chair for your services to this country.

just talking about whether its contact or fee for based equally satisfied with both whether it's a private.here or with the va, treatment equal? >> yes. i have no come up from what i've experienced at the three das have gone to, wanted a clinic in california. there was also one in virginia as well as the one in denver. i have received great care. >> at kind of comes back to a lot of things we discussed herein this committee and obviously i think mr. mayer stated we have a 900% increase in the need for prosthetic treatments. and moving forward and knowing there is a need out there, what did we talk about all the time is access to that care.

when we move forward from this, obviously yourself wanting to get back into the attic mode, when we look at the holistic approach of all of this, and avoiding the onset of things i diabetes by saying that they do not compromising your help because you don't have the access to care, whether you want to make the 70-mile trip to denver or not, there is something to be said about seven minutes away versus 70 miles away. i think it becomes an issue. i see in my district all the time. i'm not going to spend my holiday traveling to get treatment until i really need it. i think that is something we have to look at. as you just said also, you don't see -- you agree that the treatment on both the private side and va site are equal. that i don't think -- and you've

got a data. you didn't see are entitled to reimbursement for travel. at the end of the day, also another cost of the pa system, where we could get that same cost to another veteran to help them along. and i just think i don't have a lot of questions. i just want make that because there's an access to care issue here and as we've increased, as mr. mays had with the 900% increase, it's a huge, huge issue. i just wanted to -- or throw that out there. i really didn't have any other questions. >> madam chair, may i respond quick >> sure. >> is a great observation. but i want to say is what mr. mayer was talking about is one of these veterans are fighting the system of care and not moving away or they are moving back to where they found the quality. for example in brooklyn medical center, they make get their care.

they're often going back to regular life, that they are not fighting the care within the outcome is so they wind up coming back to san antonio because they have the system of care they don't want to get away from it. it's not getting back into athletics. that just happened to be what i did. it's getting back into school, back with your families, walking your daughter down the aisle. it's taking your son fishing. it is all of those things they had before that they want to get down to the highest level of care where they don't have to travel so far to do it is paramount for that individual. >> thank you. yield that. >> any other further questions? >> with that we want to stay thank you to both of you for thinking in person for your and sacrifice to that nation, both then and now as you continue on. thank you rematch. you are both dismissed.

i would like to invite the second panel to the witness table. >> good morning and thank you for being here this morning. with us is michael oros, for the orthotic association, joy ilem for disabled american veterans, captain jonathan pruden, retired southeast for the wounded warrior project and alethea predeoux come associate your for the paralyzed veterans of america.

thank you all for being here in particular would like to recognize ms. ilem for service. a service connected veteran who served as a combat magic in the united states army. captain prevented a veteran of the united states army who was severely injured when a roadside bomb struck a humvee he was driving while serving in iraq into the greek and subsequently lost his right leg. thank you both for honorable service and your very important advocacy efforts on behalf of all disabled veterans. am eager to begin discussions that we will begin, mr. oros if you would like to begin. >> good morning. thank you problem inherent to receive the highest quality prosthetic care. my name is michael oros and a board member of the american orthotic prosthetic association. and the leading provider of

orthotic and present experiences in illinois. for me as a practicing clinician is really for elements to high-quality care. the first to be access. veterans receive their care and attended basis without having to wait weeks to travel hundreds of miles for the care. second, trust. veterans receive care from a provider they feel good about and listens to them and works with them. experience and expertise. clinicians serving veterans design, set and adjust the best path for prosthetic device to address the veterans complex challenges. and finally, positive outcomes. the result of high quality prosthetic carries greater comfort, higher activity levels, more independence and greater restoration of function to this veteran. the potential quality prosthetic and orthotic for veterans has never been higher. however, veterans experienced resident care is highly

dependent on their ability to advocate for themselves. liberals seem to stimulate providing uniform high-quality care to all veterans. these barriers can be eliminated and i would like to suggest an achievable agenda to promote quality prosthetic care. it has three elements. the first would be to the guaranteed a meaningful access to a trusted clinician of their choice. currently 80% of all orthotic and prosthetic care is provided by community-based providers in some places such as new york city the majority of veterans care is provided by the va employees. however, cities like chicago, even better is close to a va medical center may choose to receive their care by those independent contracted providers. those who have served and sacrificed for our country should do to freely choose the provider who best meet their needs, especially on an issue is personal and important as prosthetic and orthotic care.

reports of the field suggest they are real and increasing administrative barriers to veterans choosing non-va providers. it's been suggested the va is moving care in-house banquet because it is cheaper. kyoko disturbed by dave allegations that the average cost of a prosthetic limb fabricated in-house by the va is about 25% of the fabricated an outside contractor. the cost quoted for the v8 fabricated ones certainly omit the cost of things that va salaries and benefits, facility costs and administration. we believe a complete and accurate cost comparison would show contractors provide excellent value not only to veterans, the two attacks payors. it would be to elevate the clinician expertise and experience. over the past decade, orthotics and prosthetics has grown

increasingly complex and technology has grown increasingly as instigated. in response, the field has changed the entry level credentials are that of a masters degree. currently there are really only six dictation and when approximately eight to 12 students and masters degree programs with a few more in the credentialing process. this is simply an insufficient amount to meet the growing demand. kyoko recommends creation of small time-limited grant programs to offer grants to either create or expand masters programs. we are grateful to chairwoman buerkle on this issue. finally, demand evidence-based practice to achieve optimum outcomes. it is important to hold all professionals accountable for the quality and cost of the care delivered. this is a challenge for the va because frankly there isn't

currently little body of objective comparative outcomes or research to support evidence-based practice is as it pertains to orthotics and prosthetics. for example 20 years ago if you had a back problem there is no outcomes or research to guide you as to whether the right decision would be surgery or physical therapy. today objective research documents which trade networks best for which patients. the result better outcomes obtained more cost effectively. that's the one for veterans in the prosthetic and orthotic care pretty comparative outcomes research portfolio and orthotics and prosthetics. this and increase quality of care for veterans and others with unlawful protecting taxpayers by ensuring patients receive the most appropriate care. not an chairwoman, thank you for invitation to test it out forward to answering questions. >> thank you very much. mrs. ilem coming may proceed. >> members of the subcommittee, i'm pleased to present the capabilities to delivers kadir

care veterans and imputation. many va members have experienced lamaze due to combat, and are intent users of health care specialty services that va is responsible for ensuring veterans that these types of injuries have every opportunity to regain health, functioning, well-being and quality of life. as in previous generations of veterans, our newest war veterans but imputation spots remain physically fit, highly active in participating can tentative post injury. these expectations and interests require a team of health care specialists on my phone care. the va inspector general issued three reports related va amputee care and prosthetic services. the ig found overall most veterans contacted were pleased with the quality of va care and services received the summit indicated certain processes for obtaining prosthetic limb should be more streamlined and

simplified. in one report the personal comments for veterans related to imputation cared provide good feedback and can help reduce identified hurdles and bureaucracy for routine maintenance and repair of prosthetic limbs. reestablish a permanent mechanism to receive this population. the extensive system for imputation care collectively deliver specialized expertise across the va health care system. in our opinion the program is functioning well and we urge to evaluate these veterans over time to better understand the complex and evolving health care needs and when necessary to readjust va services accordingly. the ig also cannot did an purchasing prosthetic limbs and concluded that it had overpaid private vendors by $2.2 million in the year as fast and that va is not getting the best value for these purchased items.

we agreed with the ig's recommendation and it appears that procurement reform, a new policy to better manage acquisition functions are underway. however dav is very concerned that during the transition prosthetic va services should retain appropriate staff to ensure a strong connection between veterans and clinical components care while contracting will always be a dominant aspect to prosthetic supply to determination of what type of prosthetic are appropriate and should remain with medicine and rehabilitation passionless aided by prosthetics representative in conjunction with direct involvement of the disabled veterans being served. one of our commenters put it best. without precedence and ordering specialized prosthetic items in limbs, veterans could experience unnecessary delays as they would simply be invoice numbers rather than patients with unique needs. while va could expand its

in-house prosthetic manufacture with the ig's cost-cutting, cost should not be the sole factor for an expansion of in-house fabrication of lens. in our opinion the most important aspect of abt kerry is maintaining options for veterans preference in selecting a qualified prosthetist they feel most comfortable with inconvenient to those services. current authority provides va flexibility to manufacture and procure prosthetic devices to wanted were veterans of that without any provision of law, including cost. however why we believe this authority should be used to provide patient centered care and timely delivery of prosthetic items, we urge the va to focus on improving business relationships of private fabricators and work to internally improve control of prosthetic training, certification and inventory management has recommended by dig. a third ig report we reviewed evaluated effectiveness of the medical center's management of

prosthetic inventories. while dav was very disappointed to learn of the specific findings identified in this report, we understand however the prosthetics service has been waiting a number of years for development of an integrated technology solution for managing acetic inventories. we urge development of a solution together necessary actions to resolve this issue. in closing, while dav is an extensive area of operation and the changes can and should be made to improve leverage purchasing power the expenditures are well worth the cost to partially repay sacrifice of disabled veterans made in military service and the integral component of holistic health care and manager that completes my statement and happy to answer any questions you may have your >> thank you very much. mr. pruden, you made need.

chairwoman buerkle and members of the committee, thank you for inviting wounded warrior project to shysters active on issues facing amputees. as chairwoman burkle mentioned, i was wounded in 2003 while serving as an army infantry captain in iraq is one of the first ied casualties are subsequently underwent tommy operations that have been different hospitals including the imputation of my right leg. over the course of the past six years was wounded warrior project ever closely with thousands of wounded warriors, many amputees have observed both va and dod care. my friend jim transverse observation of the prosthetics is a crossroads these% is inaccurate. the path they should take is clear for us that wounded warrior project with over 1400 amputees, many still adapting to life changing injuries it seems that va is headed down the wrong path and moving to institute changes double setback

prosthetic care rather than improve it. we hope this hearing will alter the current course. appropriate entirely care for amputees. currently, the va uses a process under which conditions and prosthetist see a veteran to you which is most appropriate for the individual. with this information announces their completes the purchase order to a tampa native item. those purchasing officers or specialist to handle exclusively prosthetics. the veterans health administration intends to institute major change in july 30th to describe. under the change on a contracting officer could appear an item cost more than $3000 her this would affect essential items including muslims like mine and wheelchairs. it would require the use of the system design for both return the purchases that involves manually processing over 300 individual steps to develop the

purchase order. the system may be great for by their boxer my posts, but certainly not appropriate for providing timely and appropriate medical care. equally troubling, this change offers no promise of improving service to the warrior and send me greater delays. the change could realize modest savings but a cost? a warrior needing new laker rick scioscia not wait longer than absolutely necessary. i'm the worst mistake him for our fans, school, work, can't play ball with their case or live in chronic pain while they wait for a new he says. i know firsthand what it is like to not go to put my son in the crib while waiting for a new prosthetic to live in chronic pain and had my daughter asked my wife once again why can't johnny come walk with us. what the va moving a hand unchanging camera practice, wounded warriors need the committee's health. a prosthetic win is not a mass

produced which prosthetics are specialized medical equipment that should be prescribed by clinician and promptly delivered to the veteran. we urge the committee to direct me to stop implementation of the change in that procurement. beyond the immediate turn our warriors face other challenges. injuries resulting amputations are often complex and can prove difficult for later prosthetic beings. the paradigm shift promise some years ago is far from complete and more progress is needed to realize that amputees system of care. as a bottom line we have broken urn about the direction of the program which appears robust the focus about chris he once enjoyed and funded to ensure bureaucratization that has lost sight of its customer, the veterans here today vha seems intent on toss at the veteran's procurement that is so essential to timely and appropriate care. tomorrow we fear centralized funding of aesthetics will be tossed out that we may end up for his chin mentioned earlier,

brewer 20 years, for all the money for hospital budget is spent and you couldn't get a new limb or wheelchair until the next fiscal quarter. our oldest improve prosthetics care and service. that and we offer the committee with a number of recommendations that are false statement. in closing, let me highlight a few areas in which the committee can make a profound difference. first, ensure that through ongoing oversight that va's vision of an amputees system of care is actually realized. second, trust me to reestablish an energized the community of experts rovers can provide guidance on the direction and operation of the prosthetics and narcotics program and finally, it is essential that va reestablishes ultimate theater of care and maintain a position as a commitment to our wounded warriors. that concludes my testimony. thank you and i welcome any questions. >> thank you very much. ms. predeoux come you may

proceed. >> thank you members of the subcommittee. thank you frontline paralyzed veterans of america to testify today concerning prosthetic services of the department of veterans affairs and showing our nation injured veteran population is able to receive state-of-the-art devices in a timely manner is an extremely important issue for pva. with the 19,000 members all utilize prosthetic services on a bigger basis. in recent months the va office of inspector general least termers reports on prosthetics of psa has come and entry management cannot position of unsympathetic when care. pva believes these audits and investigations have identified many areas in need of improvement within psa snp va generally supports the oig recommendations. these recommendations provide not only an opportunity to improve upon services for veterans of the mutations that all veterans to utilize prosthetic services. the evaluations and

effectiveness are taking place during a critical turning point for prosthetics. the veterans health administration is currently undergoing a structural reorganization that directly impacts prosthetic services to veterans. i believe my remarks this organization. under the current changes ascetics will no longer be responsible for managing the purchases of prosthetic items. rather that he is currently implementing any structure that is psa has some offices to just six making purchases. while the va report at this change will result in oversight and review of prosthetic workers, the concern this purchasing track has potential to create delays in delivery of items to veterans. pva is further concerned the new system only to last accountability for veterans during ordering and delivery process is. when an order for prosthetics is placed at any point before the agonist deliver, veterans are oftentimes national service of theirs on behalf of the veteran is able to contact the employer

questions regarding an order device or the status of delivery. but the va office of procurement now handling prosthetic burgesses is unclear which office will serve as a point of contact to provide veterans with timely assistance or questions or concerns that may arise. pv has reached out to psa s. leadership on several occasions to identify status of the reorganization and appreciates the opportunity to provide input. while we have been informed into a purchasing system of edited and three veteran integrated service network beginning january 2012th goal be further implemented in additional areas in july 2012, we are not aware of how va tends to make sure veterans are aware of changes. therefore we encourage leadership to do so with veterans and families as well as stakeholders who regularly work with offices to provide input as they further developed a process for purchases to the office of procurement and logistics.

they further recommended the regularly update the committee with finding compiled as a result of the pilots implemented in january 2012 as well as future findings at business nowhere. lastly, the opposite procurement and logistics is governed by policies of the acquisition. such policies are meant to address purchasing of items for many different not to affect, tv would like to make certain that changed the opposite procurement and logistics managing purchases of high-cost press headaches does not pay to the standardization of items, particularly highly specialized prosthetics such as artificial limbs on the specialized wheelchairs and surgical implants. a someone urge the va to abide by the policy that adheres to title 38 united states code section 8123 that enables to make unique prosthetic needs of veterans in a timely manner without limitations of cost saving measures such as standardization of items or

contract will purchasing. veterans must have access to prosthetics that best fit individual needs. for many years p. sas has done a good job of making sure the number one consideration is quality, the ability to make sure the veteran meet the needs. the va must make to delivery continues to be provided based on the unique needs of veterans and to help maximize the quality of life. again, pva thinks the committee for this issue and encourages continued oversight. i'm happy to take any questions from the committee. >> thank you are very much. i yield myself five minutes for questions. mr. oros come in your opening statement you mentioned for very important tenets of tries, access to trust, experience and positive outcomes. as you look out the va prosthetic care, do you think that encompasses those four tenants such lit up this

morning? >> i think it can, but once again in a somewhat dependent on the veteran stability to advocate for themselves. i think the outcomes piece frankly we are missing almost across the board. both inside and outside systems. >> can you give us some insight to how we could -- how do we change that? remake the outcomes were positive? how do we make sure these? >> there are validated instruments, cuts that could be undertaken when prosthetic limbs are prescribed. are we truly tanning fashion going to use the word, the most bang for your buck when it comes to a particular prosthetic knee. they're simply right now are not research dollars allocated to studying comparative effectiveness when it comes to orthotics on prosthetics. an absence of that we will

continue to use our experience in our best judgment as to what we think are the best particular components for veterans without any necessary evidence to support that. >> to have any information or knowledge as to why there hasn't been that kind of research done and compilation of data about the outcomes? >> my suspicion is we are really just too small of a profession is really a. so it's not industry differing, and that frankly has to come from the federal government. and i can explain beyond that. >> thank you. mr. pruden chemie talked about va prosthetics has lagged in recent years. now mr. oros talked about outcomes. you were talking about more generally in terms of research. one impact i shouldn't speak for you. i should let you say what research you were referring to.

and then if you click after you tell us that peace, what impact does that have on veterans and the services they need? >> the va has stepped up in a number of capacities in the past few years, but as mr. mayer pointed out earlier, dod has taken the lead on the development and all these advanced technology things. in years past, va has been one of his key roles in one of the reason exists is supervised specialized medical equipment for a combat wounded, four of veterans. nva really needs to have the capacity and focus on research for medical equipment when dod and global war on terror dollars go away. this also ties into the discussion about centers of excellence at walter reid, brooke army medical center and

so forth are doing these dollars go away, they dod facilities will certainly scale back their capacity as for rehabilitation and for research. a multi-call for is for va through the amputee system of care and enhance them in research to be prepared to meet the needs as dod scales that. >> thank you. ms. predeoux, i am extremely concerned with regard to your comments about the filing system being outdated and the backlog it creates. could you comment on that for us. >> yes. in a written statement that the filing system, it refers to medical records and if for instance the veteran or to relocate, for example, are direct to her of benefits relocated from missouri to san diego i took quite a bit of time for the medical records to be transferred from san diego to

d.c., simply because there's not one central system in which all the medical centers are able to locate and actually view the medical records of a veteran announced the penalty for us testified, it's not just a wait time. it is a matter of being able to be comfortable and actually be mobile. >> that was going to be my follow question. when those are not able to be transferred timely alias, that means better and then does not -- >> the record is not able to be transferred for the medical provider to see them and they are not able to get it is needed. it could be a chair, a repair, those types of items. >> thank you all very much. i now yield five into the ranking member. >> thank you very much, madam chair. i will start with mr. oros. mr. mayer recommended the committee asked the va to freeze the pending reorganization the va to freeze the pending

reorganization to evaluate a new strategic plan reorganization to evaluate a new strategic plan can be achieved and the wounded warrior project agrees with that assessment. do you agree with that as well? each of the panelists can answer that question. and why? >> i guess i'm not entirely familiar with the differentiation between what mr. mayer is asking to be done in the current system. >> do you think we should ask the va to free the reorganization, bring everything in-house? >> absolutely. absolutely. >> i'm happy to provide a comment on that. with regard to the rear cassation, all of our concerns are provided in a written state in. until i think we can answer that, it would be great to be a lot of the results of how things

work in the pilots implemented in january. it is my understanding and the pilots different than the europe was implemented in different ways. so it would be interesting to see how batteries work for them the delivery of items, the timeliness, those issues that has. >> how different pilot programs, the diverse, the way they implemented, is the diversity great or as a minor? >> i think it is minor. it is administration of certain pilot these and how they handed off items are needed to be handed off to pln now versus psa s. that is my understanding. >> why should the va undertake research and compared it prosthetics outcomes? ..

is because of the paradigm shift that did occur within the dod main tamminga veterans, unstable veterans for so much

longer and providing this up front and beauty care but just a transition that certainly is the lifelong care on the good care and out comes a but certainly be in the portfolio. >> i guess this would be for anyone else who might want to answer it. there's been some discussion about the cost in the private sector verses the va. has anyone done any analysis of what the cost is within the department of defense? >> we haven't, but i think the comment made pertinent when we saw the report and the difference between the cost comparisons may be that was just material we would certainly like to see a better analysis.

>> nei i see that $2.2 million while it seems like a lot of money the most severely injured earl wants will utilize the license to cost more than $3,000 or blind all of the savings could be realized is unconscionable. >> point well taken and i agree with the point that will be asked on the va and the cost should be similar to the va with the va and the dod costs are the

same them probably the methodologies correct if it's not then i would be interested in seeing that as well. so i yield back. thank you. >> mr. bilirakis. >> i appreciate very much. i think the whole entire panel for their testimony today. my first question is for mr. mr. perot. thanks for your testimony. you mentioned in your testimony your concerns about the va changes in the prosthetics acquisition process. would you elaborate on the real world implications that this will have on our veterans specifically from the time ase prosthetic is ordered held long does it typically take to write under the va current process and

what time frame would you anticipate under the new proposed acquisition process, and then what are the quality-of-life and health issues that could arise from the delay? >> the estimate under the current system there are safeguards in place to ensure the va is being fiscally responsible and it can take a month, two months, some predicted a the clinical needs of the patient and availability of the product in their area which is appropriate our concern is with the new system would be supposition that it may take months and months longer to put purchase orders for new equipment and the new veterans shouldn't have to wait and the clinicians hand shouldn't be tied if they feel is a vice it is appropriate and going to provide the best care for a warrior they should be able to prescribe the device over a

dozen va clinicians and processes where currently serving in the former chiefs of prosthetics. they share the concerns about the of the tremaine timely and potential delays in the veterans receiving the needed prosthetic devices under this new system. dr. beck will come up in a few minutes and see one of the things that we are going to consider as if a device is generally available and interchangeable than it will fall under the federal acquisition regulations who is determining what is generally available and interchangeable. it's going to be somebody in acquisition, not a physician, not clinician who has the patient's best interest at heart and that is the real concern. the va was given wide discretion like congress to provide without consideration of the political acquisition regulation years ago because congress recognized this

very special world in the prosthetics for providing careful -- care for the warriors and unfortunately this seems to be a step in the opposite direction tuthill had tuthill. >> meeting for the whole panel lets address this specifically what are the quality-of-life and health issues that could arise from these delays if anybody would like. >> i am personally experienced this through the natural inappropriate delays that occurred in the time to break a prosthetic foot to the time i need a new one. but my quality-of-life is hindered. my ability to go on walks with my kids and ability to do some aspects of my jobs are directly hindered that have been stuck in wheelchairs' have gained weight and had subsequent health issues due to the inability to get on the prosthetic limbs.

a buddy of mine mentioned the tebeau team that lost both his legs in iraq and a clinician that worked with him was able to use some discretion and latitude to get him the appropriate device is in a timely manner recently come and the same physician told me i am concerned if this goes through i would not have been able to do that. he would still be in his wheelchair today because he wouldn't have been able to scratch and go outside to take care of the sadr and that's the last thing we want to see happen. the hearings in the past several years take care of the veteran first and foremost that is the end goal in sure they receive the devices they need stepping back from that. >> what about maybe the mental health issues as a result of these delays? anyone want to comment on that?

we have a number of things in washington, d.c. local area that our prospects users that have been longtime users and certainly when something goes wrong when they have to offer a vision with it there's a broken foot or some sort of issue there prosthetic appliances is absolutely critical, and you can just see how frustrated they are to be able to do the things they are used to doing. if there's a delay in getting those items fixed and getting to their choosing the person that's worked with them over years and years, so i think it definitely can impact their mental health we wanted able to function. >> thank you. anyone else? >> my colleagues have discussed quality-of-life and mental

health. quality-of-care is often an issue. oftentimes when there are delays there are sometimes quick fixes and other times it could be larger issues but veterans are able to step in and figure out what the issues are and kind of interrupt the process that could extend the delay. when it comes to acquisitions understand it's not an office that generally sees many veterans that they can call and see what is going on or the representative can call. with regard to the reform moving over to acquisition systems must be put in place that will allow the veterans to know the exact process in which the order will be going. so that when there is a believe they can call and say there's been a delay. what is the problem and then hopefully the problem can be fixed. >> i appreciate and yelled back to the estimate i recognize the gentleman from for the. 64 madam share. let me welcome the panel, and i understand you went to the

university of florida? that's good. >> go gators. as i opportunity to welcome and to come over here any time i have committees of the same time, but i want to especially be here to welcome you personally and to thank you for your service and to just add my ear your ability and leadership in testifying and presenting to the american people the problems of the wounded warrior spirit i think when asking is sort of an overview. a understand you are one of the first improvised explosive devices casualties of operation iraqi freedom. is that true? >> you also testified before the oversight subcommittee on the seamless transition issues in 2010. have you discussed any of your concerns raised in your testimony with the va clinicians' or other va

officials. >> i certainly have, sir. i've had the opportunity to speak with numerous current va physicians and prosthetic chiefs with several candles record discussions, and all of them have real concerns about this process and about us moving forward changing our procurement requirements and in the hands of our commissions and him during the delivery time for the veterans. >> i guess particularly the members here in the va subcommittee which have served for 24 years i guess with a growing population of wounded veterans do you feel confident that the transition we are making will encounter greater delays perhaps in the veterans receiving the care they need in the prosthetics the need? >> i would certainly feel that that is a danger, and that's why we are asking the committee to

stop the implementation of this until either we are assured that there are safeguards in place that won't cause this to happen, or just find another way to find savings. the ig report that was cited several times here today in no means does it call for the use of federal law acquisition personnel in procuring the devices. it ads for strict cost controls and certain control measures and we are all full of fiscal responsibility and, you know saving taxpayers' money but not on the backs of injured. estimate a look at the statistics my staff provided in this is as of march there were 1,288 service members experiencing -- experienced major flem loss and the number three and 59 lost more than one, and that's just this past month. at walter reed medical center

received to a quadruple amputee. this is sort of mind-boggling to think that there is that many. do you think that with that number should we organize all these people together in a type of grouping to work with them and a focused way rather than sort of a broad way? is their something we can identify these people? we know the problems they're going to have and the enormous challenges the half. shouldn't we try to single out these folks and try to have a very special program? >> sir, i think that would be appropriate, and what you are hitting on is that it is a real challenge and actually, the number i got this morning is i think 1458 new amputee's from

iraq and afghanistan. it is a challenge. i had the honor of being on an expert panel that made some recommendations about the npt system of care and va to their credit has implemented that system of care in large measure, but it's not there yet. it hasn't met its objectors and certainly we want to encourage the committee to provide oversight and support as needed for prosthetic services to continue that program of enhancing care for the war years. these are professionals doing a good job, but certainly there is need for oversight and we certainly don't want to see baker tail and all of the advances made in the last years. >> i would think the committee might just think about this since we can't define who these people are, we should get

advantage in the job market for these people. it is through the tax credits or tell the employer if you hire one of these people, you are going to get advanced appreciation on your capital assets or your costs are going to get write-offs or incentives for them to hire these people so that all of these people get a job. because in the end the challenge they have mentally and physically is so enormous it can be overcome if the had the job they feel they have strong self-esteem, and they are self-sufficient and independent and they need this job more than anything else. would you agree with that? >> that is an excellent idea and a principal and certainly agree with it, yes, sir. >> those employers that hire the people should be singled out with merit and recognize some help in their corporation of the designation that they are hiring these roughly, you know, 14,

1400 people across america everywhere we go a person could look and say that is a company that is doing a great service for our veterans and for this nation. so, kafta might want to thank you for your service and sacrifice and it is truly a pleasure for me to represent you and the folks in gainesville. thank you. >> captain, i wasn't going to cut you some slack until we found out he went to the university of florida sue ulin dahlia are probably guinn to have to go head-to-head. kidding aside i want to talk about something i want to do privately with wounded warriors. i think what i have heard from surgeon vv prosthesis a and the limb loss and the care the veterans need is the relationship with their provider is very important and may handle on for a lifetime either in private practice or with the va.

i would like to have your comment about -- i can understand about saving taxpayers money with captain i couldn't agree more, we are not going to balance this budget on the back of lost limbs in the services of the country with its going to the va or wherever they need to go they need to get the best care wherever it is, and i think we need to measure apples to apples too because i don't think that $3,000 looks up the cost of the light bill, the water bill. if you dig down into it my bet is it is the cost of the actual prosthesis' materials and putting it together which isn't anywhere near the cost the overhead a person doing insurance, retirement, all the things going into this and i think what i heard you say i simply agree with the captain about we could set this back if

we do with the va is going to do to delay and what was said before, it's not just an inconvenience. you can't go out or whatever function it may be. with congressman stearns, what i see with a lot of these wounded warriors, they want to go back to the regular life and use this prosthesis and not have any advantages but just be able to do what they did before they went into the military. am i wrong on that or not? >> i think the employment issue is obviously important for many veterans but it all comes down to begin their ability to be able to do what they want to do to regain their function to live to have a quality-of-life. that comes down to the care they are going to get at the va and maintaining a fair press that

the items and getting them in a timely manner. >> to stay for example. i have been here for probably six months. this is only my second term. i've been to walter reed and was walking down the steps. you remember he was a major that lost -- i didn't know he was an amputee until i saw him put on the steps. he had returned to duty and was carrying on exactly like he always had. when i saw him and we sat down and had a talk about that that was amazing to me that he was able to do that and for months i saw him walking out of here and i didn't even know he was an amputee. that is the kind of return to duty that people want and when they've lost an extremity and so obviously are more herseth than others, but i believe that is the goal of every wounded warrior is to be all to go back to what they did and assumed a life they had before they signed on. >> i appreciate your testimony, and certainly every one of you service to the nation and i will

now call on the next panel. >> thank you all. china offered panel is linda hall the assistant inspector general for audits and evaluations for the office of inspector general of eg for the u.s. department of veterans affairs. it is always accompanied by nicholas stultz director of the bedford office of audits and evaluations for the ig. the director of the atlanta office for audits and

evaluations and we are also joined with the assistant inspector general for health inspections. accompanied with a physician for the office of health care inspections. thank you all for being here today and to share your expertise. we will begin with you. >> okay. >> representative, ranking member and members of the subcommittee, thank you for the opportunity to discuss the results of the recent reports on the vha management and acquisition of prosthetic limbs and the management of prosthetics supply inventories. we conducted our work at the request of the house veterans affairs. today i will discuss our efforts to evaluate the va capabilities to deliver state of the art prosthetic care and managed prosthetic supply inventories in its medical centers. and our first report, we examine the procurement practices and the costs paid for prosthetic

limbs. we identified opportunities for the vha to improve payment controls to avoid overpaying for prosthetic limbs and approve contract negotiations to obtain the best value for prosthetic limbs purchased from contract vendors. with regard to the cost comparisons in the report addressing the va fabricating prosthetic limbs or processing via contract our report concluded they lacked information to make the decisions it needs to make to know whether it should continue with the use of the labs or to rely on contracts to provide these limbs. in know whether we did we address cutting the quality of the requirements to purchase a limb. this was the focus was on the contract administration peace

and the contract administration is that the va entered into contracts with vendors to provide the lambs at certain prices. what we have looked at was that the invoices were coming in, they lacked an adequate review process to the certification for payment in which case resulted in overpayments. that's a contract administration issue and i want to be very clear we didn't say cut the quality of a prosthetic limb for any of these veterans. but clearly it is an opportunity if you can fix this control you can reprogram the funds saved to provide for prosthetic care for veterans. the overpayment for prosthetic limbs or a systemic issue in 21 veteran integrated service that works. that's where we identified

overpayments and 23% of all the transactions paid in 2010. the overpayments generally occur because the invoice is received from vendors lack adequate review and as a result the vendor invoices were just processed with charges in excess of the prices in the vendor contracts. we've reported continued overpaid prosthetic limbs for about 8.6 million over the next four years if it didn't take the action to strengthen these controls. we also found that contract and offices were not always negotiating to attain a better discount rate with vendors without negotiations for the discount rates untenable, they cannot be assured that it receives the best value for the funds that spends to buy plastic limbs. we noted that taking action to

ensure contract and officers consistently negotiate a better discount rates in no way compromises the quality of the prosthetic limbs the va pious. we also found and a very clear point in the report that the vha guide should periodically conduct evaluations to ensure the labs are operating effectively in the economically as possible. we found that the officials suspended the review of the labs in january, 2011 after receiving only nine of the 21 businesses nationwide. because the refusal business were not conducted, prosthetic service was unaware of its in-house fabrication capabilities or costs. the vha lacked the information to know if the labs were operating effectively or efficiently. we were never trying to draw

cost comparisons between the numbers in the report. those were the only numbers available at the time and we clearly recognized it wasn't an apples to apples comparison. as foot noted in the report to talk about the costs that are not in the costs where you'd have profit and overhead of a contract under. we also in the second report address the prosthetic supply inventory management and offer a comprehensive perspective of the suitability of the prosthetic management supplies and procedures. we also recommended that replace the current inventory systems with a modern inventory system. we've reported strengthening the management of prosthetics applies inventory in its medical centers will reduce costs and minimize the risk of supply and exploration and disruption to

patient care deutsch to the supply shortages. for almost 60% of the inventory prostatic items the v-8 emcees didn't maintain optimum levels. for almost 93,000 inventory items we estimated va inventory either exceeded the current needs for approximately 43,000 items or the inventory was too low for 10,000 items. further, we saw the documentation for an annual required wall-to-wall physical inventory have not been performed. this occurred because they did not consistently apply basic inventory practices or techniques. for example, they didn't fit the normal emergency stock levels in their automated inventory system for over 90% of the prosthetic

items. we often offer practices led to them spending about $35 million to purchase prosthetic supplies in excess of their needs, and that clearly increases the risk of supply exploration, theft and shortages. in fact, the controls are so weak the losses associated with any diversion could go undetected. in prince and inventory practices and accountability over prostatic inventory is still needed. vha must approve its inventory management systems and remain committed to replacing its existing inventory systems by 2015. we are pleased to see they are adopting practice is to achieve greater savings to be along with providing more attention to ensuring the fiscal stewardship and contract administration of the funding needed for the

prosthetic care in response to the issues the we reported on. we would be happy to take any questions. >> thank you. dr. de? >> members of the committee, it is an honor to be here to speak with you on the report on prosthetic care in the va. we've done a series of reports on what i would call transition to care and in those reports we have aligned ourselves the alliance member that helped us gain access to the data. also we have used the doctor in my office is to try to get the metrics right and he's quite an expert on population health. we've reported on the moderate access to mental health and montana, combat stress and women veterans. this report on prosthetics and one we just published on homelessness is populations of the issue of transitioning to care is important to us and again we think you and your stuff support for this work.

we will get to populations in the report. one is the population of about 500,000 veterans who left the dod and became veterans in the 2005, 2006 time frame and we are then able to follow the veterans as they transition through the va and then received several years of care and there were a couple of outcomes. one is that it was surprising to me, maybe not those that work in the population of the time and that it wasn't just the limb that was affected in these patients. every system you looked at by a diagnostic category had significantly elevated disability or medical disease burden in this population. so whether it is the injury that they suffered at the time that they were injured, or the other circumstances trauma and recovering on the battlefield were unclear but this is a

population that has quite a significant disease burden beyond what you'd think. the second feature that stood out from the analysis is pain management and substance eustis orders. in addition to the normal mental health issues the population be expected to have, again, i can't speak out and of the difficulty that this population has with these disorders and the difficulty that the va currently has and the society has in dealing with these issues. the second population that we looked at we got with the help at walter reed, both of the old walter reed and the bethesda campus is and he was in charge of the prosthetic program i believe. and they provided their data set of combat injured veterans from the recent war who had major amputations. at that time we got the data

there were 1506 major imputations of that number 180 were not dramatic work related to some of the feature. city of the individuals were dead which left us with 1288 individuals with combat related major amputations. of that number, about 450 remained on active duty some of whom were employed in some of whom it appears to us were severely medically ill and the dod seem to be keeping them to make sure that they were in better position when discharged. that left us with about 848 again traumatic major imputations that the extremities we tried to assess carried to take that number and slash 150 medical centers, and we did what addresses for these folks and find out that the their everywhere in the united states. there is a simple problem of having ten or less on average without knowing specifically

patients who have the problems just as a point of reference whereas when you look at the older population that normally takes care of where it looks to us they have several thousand institutions, major and petitions a year that's mostly older gentleman who have diabetes or other vascular disease, so there is a significant difference. we also went out and telephone survey and visited in person these returning from the war chongging to get a feeling of what they're what we were seeing on tv and the press was an accurate reflection of how well the gentleman and the women were doing. the same people we were seeing playing softball all the time were these folks doing generally well. i would say we are very, very impressed that this population which entered the military with a can-do attitude has maintained

that, and i don't believe that what we see on tv is in operation. i think they are doing extremely well. there's one caveat to that. the folks at walter reed were very concerned about the 43 veterans at the time that i gave you the number 1500 who had three or four limb amputations and at that time we were unable to see enough to get a clear feeling of how they were doing but i do believe that if they are significantly more impacted in a total sense from those that have one or or to imputations to be a different category of disease. i think that we also heard in our interviews and in our discussions essentially the same comments that you heard from the previous panels, and i won't go through those except to say that

people wanted to know why they couldn't take it after of the broken extremity and send it by e-mail and try to expedite the paperwork involved in trying to get the billing process from the bureaucracy done. we had conversations with dr. brackett at stuff khator aware of these issues and i am confident that they're thinking about how to best deal with these issues and will be on the next panel to discuss the changes they would propose, but they've been three culprits if i think in trying to come up with with the right answer is. we made three recommendations. one was to consider this data that i think as previously not been as able in the detail and to publish and i think they've done that am trying to tailor their care. we do believe that the upper extremity veterans with in the surveys that we have done half for a variety of reasons a great deal more difficulty than those

with lower extremity and we urge that the research would be done and the appropriate level of effort would be made to get those upper extremity prosthetics up to speed. third, we ask them to deal with of the bureaucracy for the contract complaints and a that would sort of lesson the aggravation of the veterans that have these difficulties in trying to make their way through the system. with that, i will end my testimony and be glad to answer any questions that you have. >> i think the panel and have a couple of observations and of course we appreciate you being here testifying today. on the -- it doesn't look like a huge issue but there were the simple changes in contract and i certainly understood where you're saying this doesn't change the quality of the prosthesis at all. it may be the same one that you just negotiate a lower price. am i correct on that is that what you're saying?

>> you were definitely correct. if we have existing contracts with the vendors and this is you were quick to charge $10 for an item, and the invoice starts to come in if they are not reviewed and you are really charged 15 or $20, that's the point that we want to see the savings. that money could be reprogrammed to prosthetics care. >> it shouldn't be a big issue. that's not -- i mean, money why is it is a significant amount that could be spent because whoever said a minute ago that there were i think $54 million in the budget that's not a lot of money spent on all of these prospects, so i guess the savings would be fairly significant and the prosthesis i think that we as i sit myself as a layperson in the va terminology we would think of it as a limb. it could be a hearing aid or a wheelchair. am i correct on that?

>> this report be issued looked up the limbs. >> and you also agree this wasn't an apples to apples you were not sure what $2,900 -- >> we absolutely agree with that. it is the only cost information available. we put it in the report and clearly said it was apples to apples and or foot node. the fact was they didn't have good information to make decisions on whether it should have, whether they could provide these items and more economical cost and the same quality. they just didn't have that same information when my team who went out. >> as fascinating data that you had that he presented and did i hear right that there were 33 that had three imputations, more than two? >> yes, sir it was roughly i

believe the number we had in the report was 33 individuals who had three or four amputations who were alive at the time the we did this report. >> i think the challenge is now and i just very brief, but we went to afghanistan together three years ago and i went again in october this past year and just from a physician who viewpoint the treatment of care has changed dramatically from the time i was in service and you can see the results. a lot of people are survive the two surviving a horrific injuries and you don't die if your entry on the battlefield to have about a 95% chance now of surviving as opposed to when mr. reyes was in vietnam which was a lot less than that i can tell you. so we are going to have to deal with these issues going forward, and we should. i guess the question that i have for you is do you agree with the captains and ago if the va changes its procurement and so

forth this will be detrimental to in other words should we keep doing what we are doing and then tighten up on what they said? that isn't at the heart of the inventory. wal-mart can tell you when you to put toothpaste went out the door, so we should be able to do that and it sounds like the va in 2015 that should be implemented. >> do you agree? >> i didn't look at the business practices by which these prosthetics are determined what is appropriate. we simply in this report looked at the populations that existed and tried to understand who they were and what was going on with them. similarly to the gentleman on the second panel, we didn't look at effectiveness of one prostatic over another or, you know, the cost effectiveness of the different measures. we simply did a population study. so, i don't have a comment on that, sir.

>> i think the everything the that you said, just to make sure that we all understand it, that the code words in the study had multiple, but goodies. it wasn't just a i lost my leg below the knee and that is the only thing wrong with me. am i correct? >> it was very impressive to me that the total body injury that these men and women had sustained, which to the outward appearance would mostly be looked at as and prosthetic arm or leg. >> i yield now. >> thank you very much mr. chairman. my question is what are your recommendations come and i will quote considering veterans' concerns with the approval process of the feet bases in the contract care prosthetics service to meet the needs. could you expand a little bit more on that recommendation in detail, is the reason you came up with that that you're finding

that veterans are being denied care war are unduly delayed in receiving care? >> what we found in the interviews with veterans were complaints similar to what first panel expressed come and that was these men and women are active. they are going to school, the families, the of lives. if they're prosthetic breaks the one to fix immediately they don't want to have to get in the car and drive someplace to have an examination done to get the paperwork accomplished appropriately. we in our work didn't analyze the business practices of making that happen. i didn't feel i was in the position to offer advice on how to fix that problem we did sit down and have discussions with others to lay out what we felt the problem was. dr. yang and others, strictly as to what we heard and we ask the vha to do their work and sees

the canton prove that. at this point in time i'm not knowledgeable enough unfortunately to give you the advice on exactly what i think they should do different. i wish i could but i don't have that affirmation. estimate clarified as far as the cost and the savings comparing apples to apples. have you or your sister agency ever done any report within the department of defense to find out what the cost comparing the dod with the va is a cost equal number one and second you talk about the inventory management is your recommendation consistent with what is actually the department of defense's dillinger or do they have the same problems the va has in regards to cost and inventory management. >> petraeus began the way that

the va and the dod are different. the dod as i believe focused the care of patients that were badly injured from the war and several discrete centers and by then getting a large enough progress but patience continuously their. they're able to put the resources and select several places d.c. may be santiago san antonio maybe one or two others, and then provide cost-effective state-of-the-art care. the va is a much more dispersed organization and the veterans live throughout the country. they've already been through the trauma. the are of and about, so it is a little bit of a different problem. as for the second question, we have done no work on the cost of the dod compared to the va providing the same level of care

>> when you talk about the wounded warrior utilizing the dod horses the va, the numbers are higher. you know how much of the new generations are still utilizing the department of defense versus going into the va. do you feel they get better service and how many veterans are using dod versus the va? >> we've found looking at the transition to care that there is a flow back and forth between the dod and the va for veterans. some allow them to go to the dod facility and who are or who are retired and therefore retired in able to use those facilities in

the report will show that the veterans transfer with prosthetic issues transferred to the va very quickly and much larger numbers than the larger veteran who left did and i was actually when we started the study confirmed that -- concerned that the dod might hold onto or they might reside around the cities in these areas in the dod areas of expertise have violated the fair really they've not stop there. they are transitioned very quickly which was somewhat of a surprise to me. i could get back with specific numbers and specific times, but there is a nice chart that shows over four or five years almost all in the va to >> thank you very much. >> thank you mr. sherman. as you know, we have competing hearings taking place.

with regards we have in fort bliss the wounded warrior transition senator and one of the questions i get asked is the research and development that is going on in the area of prosthetics. can and if you comment on because i know just seeing the kind of prosthetics for being used today from my viewpoint is phenomenal where that is taking place for the prosthetics. >> i apologize i don't know the answer to that in detail. i could get it to you and again

you can explain what they are actually funding and how they are dealing with it. i can't give you a good view of that. >> the other question i have to have been many concerns expressed on the proposed changes to the procurement i'm not sure i'd understood the issue and the concern for veterans that there might be a further delay in getting their service for the prosthetics. can you comment on whether or not it is a valid concern on the part of the veterans using the va? >> i can offer some comments on that. the va is changing its procurement practice bringing in involvement to contracting officers, which i think will help strengthening the contract

administration process but we found problems with my concern is that requires communications between the prostatic assistance and the contacting people so that the veterans need are truly met when they are needed. in the past, the va has had some communication issues between these offices i think the new leadership is working very hard to fix these and i can't comment to whether the veterans will experience delays. they've put a pilot in place to look at this new model but they haven't shared that information with us nor have i had an opportunity to see it in practice to measure its effectiveness. the question should also go to the va. islamic can you comment on whether or not there is either

going to be or there is process of providing feedback. >> i can't comment on that. that is a question for the va. >> thank you, madame share. >> thank you. if there is no more questions from the committee, we thank you very much for your testimony this morning we will invite the fourth and final panel to come to the witness table. >> joining us this morning on the fourth panel is dr. lucille, dr. beck is the acting chief consultant for the prospect service called attrition for the united states the part of veterans affairs. dr. beck is accompanied by

dr. jobe steel for the system of care. dr. joe miller the national program director for the republican press that it services chief procurement logistics officer all of which are within the va administration for the department of veterans affairs. thank you all very much for being with us this morning. i guess it's the afternoon now. dr. beck, if he would proceed. thank you. >> thank you. good morning. chairman, ranking member and members of the subcommittee. thank you for the opportunity to speak about the department of veterans affairs ability to deliver state of the art care to veterans with amputations. i am accompanied today by dr. webster, our director of the amputation system of care, dr. miller, our national program director for orthotics and prosthetics surfaces, and mr. norbert baliles who is the chief procurement logistics officer to read the va prosthetics sensory service is the largest and most

comprehensive provider of plastic devices in the world offering a full range of equipment and services. all enrolled veterans may be seeing any price that items prescribed by aba commission without regard to service connection when it is determined to provide or restore the health of the individual and is in accord with generally accepted standards of medical practice. i will briefly summarize the major initiatives underway to improve the quality and availability of amputation care. these fall under five general headings, staffing and community partnerships, accreditation of the laboratories, improved training for the va staff, a great research and and petition and clinical issues and collaborations with the department of defense. first, the va prosthetics sensory service has a robust clinical staff at more than 75 locations and also partners with

the private sector to provide custom fabrication and sitting of state of the art or fought and prosthetic devices. the fda maintains local contracts with more than 600 accredited providers to help deliver care at home. commercial partners helped fabricate and fit prosthetic limbs for the veterans across the country. since its creation in 2000 mine, and he and system of care has expanded to deliver more accessible high quality of duties and care and rehabilitation to the veterans across the country. the system of care utilizes an integrated system of the va physicians and therapists and prosthetists working together to provide the best state of the art care. second, va promotes the highest standards of professional expertise for its work force of more than 300 certified prosthetists, or this and

fitters. each lab that is eligible for accreditation is accredited by the american board for certification and orthotics, prosthetics and put or fix and also the board certification degradation international or both. this accreditation process ensures quality care and services are provided by trained and educated practitioners. third, to support the continued delivery of high quality care the va has developed a robust staff training program. we offer clinical the education cuts technical evaluation and business process and policy education in addition to specialty product training to held our staff provide better services to veterans to give further, the va has one of the largest orthotics and prosthetics residency education programs in the nation with 18. presidency physicians at 11 locations across the country. fourth, the office of research and development is investing heavily in prosthetics and a

petition health care research. it's issuing requests for applications for studies to investigate a variety of upper limb amputation technologies and applications. the va also works with the department of defense to support joint research initiatives to turn the efficacy and incorporation of new technological what chances. finally, the partnership between the va and the dod extends further to provide a combined kuhl leverett approached and petition care by developing a shared amputation rehabilitation clinical practice guideline for care following the lower limb amputation. the va is also supporting the department of defense department collaborating on the establishment of the extremities, amputation center of excellence. the mission of this center is clinical care including outreach and clinical education research and is designed to be a lead organization for direction and

oversight in each of these areas. the center is currently being implemented and will obtain initial operating capacities by the end of this fiscal year. in summary, a high-quality invitation prosthetics by supporting ground-breaking research into new technologies, training a highly qualified cadres of staff and pursuing accreditation of all eligible prosthetics laboratories in the invitation system of care. we are increasing our oversight management of prosthetics purchasing inventory management to better utilize resources we have been appropriated with bye congress and to serve america's veterans. we appreciate the opportunity to appear before you today to discuss this important program my colleagues and i are prepared to answer your questions. thank you. >> thank you, dr. beck, and for your testimony and for being here today. i have a number of questions a

lot of it is based on what we heard from the three previous panels especially the veterans and veterans' services organization. i think they've provided a reliable source of information and to identify needs for us. the first question knows what was the impetus behind the change? you heard the concern from the previous panels. what was the impetus behind the change in the procurement policy and did you consult with the veteran service organization or veterans who did you talk to to make this change? >> the impetus for the change is an impetus from the department to insure compliance with federal acquisition regulation. i have with me mr. norbert leal, the chief procurement logistics officer today. we were anticipating some of these questions. he is available to provide more

information about the change and what's happening. >> gist if you would before we start, so does that mean heretofore the va was not compliant and if that is the basis for the change that compliance is an issue maybe you could make that clear to us? ..