veterans are using dod versus the va? >> we have found in looking at transition to care that there is a flow back and forth between dod and va for veterans. some veterans have dod disability that allows them to go to a dod facility or who are -- or they are retired and therefore, are able to use dod facilities. in our report, we show that the veterans transferred with prosthetic issues transferred to va fairly quickly, and in much larger numbers than the average veteran who left dod did, and i was actually, when we started this study, concerned that dod might hold on to or that those veterans might reside around the cities where these areas of the

dod areas of expertise i've highlighted but i think we found that really, they've not stuck there. they've transitioned very quickly to va which was somewhat of a surprise to me. i could get back with specific numbers at specific times but there's a nice chart that shows over four or five years they're almost all in the va. >> great. thank you very much. >> mr. reyes. >> thank you, mr. chairman. i apologize for being late. as you know, we have competing hearings taking place. in the regard of -- in fort bliss we have the wounded warrior transition center and one of the -- one of the questions that i get asked is the research and development that is going on in the area of prosthetics. can any of you comment on what

kind of r & d is going on? because i know just seeing the kinds of prosthetics that are being used today from my viewpoint, it's phenomenal, but i'm not sure that i understand where that r & d's taking place for prosthetics. >> sir, i apologize, i don't know the answer to that in detail that you need. i could get it for you. again, dr. beck may be able to, the next panel, explain what dha is actually funding. i can't give you a good view of that, sir. >> the other question i have, there have been many concerns expressed about the proposed changes to the procurement. i'm not sure i understood the issue and the concern from

veterans that there might be a further delay in getting their service for the prosthetics. can you comment on whether or not that's a valid concern on the part of veterans using the va? >> to some extent, 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 with strengthening the contract administration process that we found problems with. my concern is that it really requires communications between the prosthetic assistance and the contracting people so that the veterans' needs are truly met when they're needed. in the past, va has had some communication issues between

these offices. i think the new leadership is working very hard to fix those and i can't comment to whether the veterans will experience delays. va has just put a pilot in place to look at this new model, but they have not shared that information with us, nor have i had an opportunity to see it in practice to really measure its effectiveness. i think the question should also go to va. >> okay. so can you comment on whether or not there's either going to be or there is a process of providing feedback? >> i can't comment on that. i think that's a question for va. >> okay. thank you. >> with that, if there's no more questions from the committee, we thank you very much for your testimony this morning and we will now invite the fourth and final panel to come to the witness table.

joining us this morning in our fourth panel is dr. lucille beck. dr. beck is the acting chief consultant for the prosthetic and sensory aid service. she is accompanied by dr. joe webster, national director for the amputation system of care. dr. joe miller, national program director for the orthotic and prosthetic services and norbert doyle, chief procurement and logistics officer, for the department of veteran affairs. thank you very much for being here this morning. i guess it's afternoon now. dr. beck, if you would proceed. thank you. >> thank you. good morning, chairman buerkle,

ranking member michaud 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'm accompanied today by dr. webster, our director of the amputation system of care, dr. miller, our national program director for orthotic and prosthetic services and mr. norbert doyle, who is vha's chief procurement and logistics officer. va's prosthetics and sensory aid service is the largest and most comprehensive provider of prosthetic devices and sensory aids in the world, offering a full range of equipment and services. all enrolled veterans may receive any prosthetic item prescribed by a va clinician without regard to service connection when it is determined to promote, preserve 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 under way to

improve the quality and availability of amputation care. these fall under five general headings, staffing and community partnerships, accreditation of va laboratories, improved training for va staff, greater research into amputation and clinical issues, and collaborations with the department of defense. first, va's prosthetic and sensory aid service has a robust clinical staff of prosthetists as more than 75 locations and also partners with the private sector to provide custom fabrication and fitting of state of the art orthotic and prosthetic devices. va maintains local contracts with more than 600 accredited o & p providers to help deliver care closer to home. commercial partners help fabricate and fit prosthetic limbs for veterans across the country. since its creation in 2009, va's

amputation system of care has expanded to deliver more accessible high quality amputation care and rehabilitation to veterans across the country. this system of care utilizes an integrated system of va physicians, therapists and prosthetists working together to provide the best devices and state of the art care. second, va promotes the highest standards of professional expertise for its work force of more than 300 certified fitters. each va lab that is eligible for accreditation is accredited by the american board for certification in orthotics, prosthetics and also, the board of certification accreditation 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, va has developed a robust staff training program.

we offer clinical education, technical evaluation and business process and policy education in addition to specialty product training to help our staff provide better services to veterans. further, va has one of the largest orthotics and prosthetics residency education programs in the nation, with 18 paid residency positions at 11 locations across the country. fourth, va's office of research and development is investing heavily in prosthetics and amputation health care research. it is issuing requests for applications for studies to investigate a variety of upper limb amputation technologies and applications. va also works with the department of defense to support joint research initiatives to determine the efficacy and incorporation of new technological advances. finally, the partnership between va and dod extends further to provide a combined collaborative approach to amputation care by

developing a shared amputation rehabilitation clinical practice guideline for care following lower limb amputation. va is also supporting the department of defense by collaborating on the establishment of the extremity trauma and amputation center of excellence. the mission of this center is clinical care, including outreach, education and 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 capacity by the end of this fiscal year. in summary, va supports high quality amputation and prosthetics care by supporting ground wi groundbreaking research into new technologies, training a highly qualified cadre of staff and pursuing accreditation of all eligible prosthetic laboratories in va's amputation system of

care. we are improving our oversight and management of prosthetics purchasing and inventory management to better utilize resources that we have been appropriated by 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. 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 the veterans service organizations. i think they provide for us a reliable source of information and they identify needs for us. my first question is 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

veterans service organizations and/or veterans? who did you talk to to make this change? >> the impetus for the change is an impetus from the department to assure compliance with federal acquisition regulations. i have with me mr. norbert doyle, who is vha's chief procurement logistics officer today. we were anticipating some of these questions and he's available to provide more information about the change and what's happening. >> just if you would, before you start, so does that mean here - heretofore, the va was not compliant, if that's the basis of your change that compliance was an issue, maybe you could make that clear to us. >> yes, ma'am. thank you, dr. beck. ma'am, yes, the impetus was to include contracting to bring vha

and all the other va contracting organizations in better alignment with the federal acquisition regulations. we also, it's my understanding the department recognized several years ago actually that they were weak in certain areas, in contract administration and awarding of contracts, and this was also to bring it in house to ensure proper stewardship of the government dollars. in reference your question did we talk with veteran service organizations, actually, i don't believe we did before we started the process. however, last week, and i'm happy to meet with any organization to discuss what we're doing, i heard the complaints of the veterans service organizations that they feel out of the loop, i met last week with dr. beck with the secretary's advisory committee on prosthetics and special disabilities. we spent a great deal of time with them and i think that group has representative from many veterans service organizations, to address their concerns that they may have.

again, i make that offer that i will be happy to meet with any group to discuss these. >> thank you. i think it would be in the best interest as we go forward to do what's best for our veterans and to hear from the veterans service organizations and from the veterans themselves, and from those who have gone through this process who understand intimately, as did the first two panelists, that it would seem very basic to talk with them and have them identify needs and concerns. you heard wounded warriors say we're asking you, congress, to please freeze this change until and the other point i wanted to bring up was the pilot. you heard paralyzed veterans, their organization mentioned a pilot. have you done a pilot? if so, what were the findings, does that -- is that the justification for this change? >> yes, ma'am. i actually have a number of issues to address along this

line. first, to put it in context and granted, we're talking about the more expensive items that we're talking about today, the transfer of the contracting authority from prosthetics to contracting only impacts those procurements above $3,000, which is the mandated federal acquisition or federal micropurchase threshold. so only 3% of orders that we estimate fall in that realm so 97% of prosthetic orders will stay with prosthetics. as i said, we are doing this to bring us more in line with federal acquisition regulations and also to address many of the issues that the i.g. has mentioned although those were identified i think previously. i want to assure everybody that if a clinician specifies a specific product for a veteran, contracting will get that product for that individual. i do not, as the chief -- as the chief contracting person in the

veterans health administration, i do not want my contracting officers making a decision as to what goes in the veteran's body or gets appended to it. that is clearly a clinician decision. how are we going to get that product that the clinician specifies for the veteran? we're going to do it under the auspices of the federal acquisition regulations who are going to cite the authorities of 8123 which is one individual mentioned that the broad latitude given by congress to the veteran -- to the veterans administration. we're going to do that by properly preparing justification and approvals for sole source, citing in paragraph four the authorities granted under 8123. there are seven exceptions in part six to full and open competition, exception five is the one that as authorized by statute and that's what we will use. we have gone through great pains to ensure success in this transfer. a little bit of history, even

starting last summer, when we started this process under the direction of the department, dr. beck's and my folks, we formed a team and that team included field personnel, both prosthetics and contracting, which we thought was critical. they developed a plan on the -- for the transfer. it was a very detailed plan. the plan actually as we got into it got more detailed as we went, as we identified other issues. we then worked with our union partners to ensure that they did not have issues and that we could proceed successfully. there were pilots as part of the plan which is probably the best part, other than bringing field people in to the planning process. the pilots was a great aspect. we did pilot in three visions, 6, 11 and 20, virginia/north carolina area, the michigan area and the pacific northwest. we piloted beginning in january for about 60 days. those pilots concluded in march. we did learn from those pilots

and were implementing changes to ensure that care is not impacted. some of the things we learned is that our staffing models were incorrect. the number of procurements that we could do in a day in the contracting office. we are hiring, we received approval to hire additional people to ensure we can keep up. we are streamlining the process by, i mentioned justification approvals, by templating that process so it becomes more fill in the blank with the clinician's prescription. those are the type processes. we are slowly now implementing and the rest of the veterans health administration, i think four more are starting that process now and the rest will be coming on in june and july. the goal is to have all this done by the end of july. there is a contingency plan we have discussed. we still have the legacy procurement system if something does not go right or something unexpected happens that we can fall back on.

but we don't expect that to happen. >> i would like to add that this has been a very strong collaboration and partnership, prosthetics and sensory aid service is very concerned that we can continue to provide the services to the veterans that they deserve and that we have always been able to do, and so our prosthetics organizations at our local medical centers and division levels remain the eyes and ears so all orders come through prosthetics, prosthetics is managing them and working with contracting officers to achieve the placement of the order as is required to be meeting all of our acquisition requirements and we are, as mr. doyle has said, very aware of

the ability to use 8123 and have spent a significant amount of time developing justifications and approvals that allow us to use that and really reflect the needs, the individualized rehab needs of our veterans. we are very much aware that we customize these products and services, that they are selected based on an individual veteran's needs and that has been our goal as we have managed this transition. we're coming into a critical time as we move the transition forward and extend it to other visions and we have very well developed and exact procedures in place to monitor this as we go and we are prepared, i think, mr. doyle and i, as a team to -- and our offices as teams to review this very carefully and

make recommendations as the way forward based on how this process affects veterans. >> i'm sorry, ma'am. >> go ahead. >> may i add that when i met with the advisory committee on prosthetics and special disabilities last week, they had many of these very same concerns. i think after spending some degree of time with them, they at least understood what we were doing. they're still very interested in ensuring we do achieve success. i'll let dr. beck comment. i don't think we left there with a burning issue. at least i did not, that we needed to address. also, as a veteran myself, who made several trips to iraq and afghanistan both in a military and a civilian capacity, i'm very sympathetic to the needs of the veteran population, and i can assure you i will do nothing that hurts the veterans. there but for the grace of god go i, actually. that's the way i look at it. >> thank you. my time is way run over.

however, if my colleagues will indulge me, i have a couple follow-up questions and i will allow you to have as much time as you need. my first concern is you said with procurements, it just only pertains to those over $3,000 and you said only 3% of the orders are over $3,000. how many requests do you have? >> that is still not an insignificant number. based on our planning estimate, our planning figures for fiscal year '10 in which we planned the transfer over, was 3% of the orders equals roughly 97,000 orders. >> so i would suggest that because we're talking about 1500 warriors with amputations that probably are in need of prosthetic, that that is going to be a small percentage of what you're doing. however, all of those are going to exceed that $3,000 threshold. we heard earlier about a $12,000 limb and if it's $25,000, that doesn't matter because the veterans need prosthetics and they need state of the art prosthetics.

so that concerns me, that piece right there. the other thing that concerns me is you mentioned that you talked with your union partners. it would seem to me more appropriate to talk to your veteran partners and to the veterans who have gone through this and be more concerned with their thoughts about this being a program that works versus talking to the union partners. lastly, the pilot information, the results of those pilots, if i could respectfully request that you provide us with -- i think you said you did three, if you could provide us with the findings from those pilot programs, i would appreciate it. thank you. i now yield to the ranking member, mr. michaud. >> thank you very much, madam chair. i just want to follow up, mr. doyle, on your comment that you made where you mentioned that contracting officers do not change what the clinician prescribed but actually, in testimony we heard earlier from pva, that is not the case, that

their testimony states that contract officers when they do receive the orders, the request for the devices is modified and even denied in cases because of the cost. so that is a huge concern. there seem to be a disconnect from what you're hearing versus what the vsos are hearing because that is not the case. the cost is a factor. it's not the veterans' health care. so do you want to comment on that? >> yes, sir. thank you. first of all, contracting officers, all contracting officers do have a mandate under federal acquisition regulations to ensure that there's a price reasonableness aspect to the cost we are providing. i don't know if that is a concern or not. can't really speak to what may have happened before but i have put out to the contracting community that under 8123, if a

contract -- if the contracting office receives a physician's consult for a specific product, we will do due diligence to ensure we pay a fair and reasonable price for that product but we are going to get that product for that individual. so i don't know if it's a concern that again, i'll take full blame for not bringing the veterans service organizations into the loop into this discussion and we can fix that, but i don't know if that's part of the issue there, why that concern was being raised. >> well, it's very clear from the vsos, some of their statements, that it's not uncommon for clinicians to prescribe something and it's being modified by contracting officers and primarily because of cost. that's a big concern that i would have. my other question is mr. orris talked about older veterans at his practice complaining that

there appears to be a new administrative hurdle to prevent their continuing to receive c e care. the va has assured veterans that they may choose their own prosthetists, yet veterans who wish to use community-based providers report widespread administrative hurdles and other pressures to choose in-house va care. how would you explain the perception among the veterans in the community-based providers? there seemed to be a disconnect here as well as far as what you have told us versus what's actually happening out there. >> yes, sir. i'll start and we do have contracts with 600 providers,

approximately 600 providers. we do offer choice to our veterans and when our -- in our amputee clinics, when we initiate the process for the multi disciplinary care that we provide, we have our physicians and our clinicians and our prosthetists there. we also have our vendors, our contracted community partners or contracted prosthetic vendors from the community are there as well. the veterans do have that choice, that's part of our policy, and we, as we become aware of, we will reaffirm that policy with the field based on what we have heard from our veterans today, and -- and we are improving the processes. i think the inspector general report pointed out that there

are some contract administration initiatives that we need to undertake, including streamlining the way we do our quote reviews so that they happen in a more timely fashion, and that they really clarify the presiptive elements for fabrication of the leg, and we are doing that, or fabrication of the limb, and we are doing that. the second thing we are doing, we are making sure that our contracting officers and their technical representatives who have as part of their responsibility to review those quotes and certify that they are doing that regularly and in a timely fashion. there's guidance that is being prepared even now with -- to reinstruct the field and educate them on that. and the third thing that we are doing is we are taking a contracted, what we call contracted templates where we are developing policy and guidance that can actually go

into our contracts so that it is clearly specified for the contracted provider and the va exactly what the requirements are and the timelines. so we have taken the report that we have from the inspector general about the need to improve contract administration to support our veterans seriously and we are making those corrections and have been doing that over the last several months. >> do you feel that with the new changes that you're providing gets back to my original question, that the clinicians will have final say in what a veteran receives versus a contracting officer who has to look at contracts and saving costs which i believe that we have to do, but the bottom line for me is to make sure that the veterans get the adequate prosthets