that they need in a timely fashion. mr. mayor said it very well. it's inconvenient, no it affects how you live. you take one day off can't go to work because of your prosthesis it's not acceptable. in our budget 1500 and something was the last number of wounded warriors who have lost one or more extremities. we can't do enough of those warriors. the needs are going to go on. mr. mayor can tell you, mr. rich you will change as you get older. your leg changes. things just change. and gravity has a great effect on us. >> i am finding that out. >> you are finding that out. we have a commitment, i think to those wounded warriors. not for this great care now, but for a lifetime of great care. i can speak for the entire committee on that. we all feel that way.

again, i want to make sure that the care doesn't drop from the time you leave d.o.d. i've seen that facility out there multiple times. it's phenomenal to when they get to the v.a. i'm out of time. later if you get a chance i want to get on the answer about why you think the v.a.'s prosthesis is 2900 and you're out in the private sector it's 12,000. i agree with your analysis. i read your testimony. i yield back. >> thank you. i now recognize the gentlemen from new jersey. >> thank you both for your service to this country. >> whether with a private doctor or with the v.a., treatment

equal? yes. i have know from what i experienced at the three v.a.s i've gone to. there was one at the clinic in california. there was also one in virginia as well as the one in denver. i've received great care. >> because it kind of comes back to the things we discussed in this committee. and mr. mayor obviously stated we have a 900% increase in the need for prosthetic treatments. and moving forward in knowing there's a need out there. one thing we talked about here all the time is access to that care. when we move forward from this, obviously yourself wanting to get back into the athletic mode. when we look at the holistic approach of all this in avoiding jn society of things like diabetes by staying active and not compromising your health because you don't have the

actress to care whether you want to make the 70 mile tripe to denver or not. there's something to be said about seven minutes away versus 70 mile ace way. i think it really becomes an issue. i see in my district all the time veterans all the time, well, i'm not going to spend my whole day traveling to go get treatment until i really need it. i think that's something we really have to look at. as you just said, also, you don't see the -- you agree that the treatment on both the private side and the v.a. side are call, but at the same time i don't think we -- and you brought it up, you didn't see you're entitled to reimbursement for travel. at the end of the day also being another cost to the v.a. system where we could get that, that same cost to another veteran to help them along. and i just think, well i didn't have a lot of questions, i just wanted to make that. there is an access to care issue

here. i think as we've increased as mr. mayor said with the 900% increase it's a huge, huge issue. i want to throw that out there. i really didn't have any other questions. i yield back. >> madam chair, may i respond? >> sure. >> i would like to as a great observation i wanted to say what mr. mayor was talking about earlier and what you just said is that a lot of these veterans are finding that system of care and they're not moving away or they're moving back to where they found that quality. so for example, they may get their care they're often walking and going back to regular life, but they're not finding the care where they have moved to so they wind up coming back to san antonio because they have that system of care. they don't want to get away frit. it's not just about getting back into athletics. that just happened to be what i did. it's getting back into school, your families, it's walking your

daughter down the aisle. it's taking your son fishing. it's all those things that they had before that they want to get back to the high level of care. and having that in a centralized location where they don't have to travel so far to do it is paramount for that individual. >> thank you. i yield back. >> thank you very much. if anyone else has any further questions? with that, we want to say thank you to both of you for giving us the opportunity to thank you in person for your service and sacrifice to this nation. both then and now as you continue on. so thank you very much. you are both dismissed. >> thank you. >> i'd like to invite the second panel to the witness table.

good morning and thank you all for being here this morning. with us today is michael oros board member of the american orthodic and prosthetic organization. captain prudhomme retired southeast alumni manager for the wounded warrior project. and the associate director of health legislation for the paralyzed veterans of america. thank you all for being here in particular we would like to recognize the honorable service to our country. thank you both very much. she's a service connected disabled veteran who served as a combat medic in the united states army. the captain is a veteran of the united states army. he was severely injured when a

roadside bomb struck his humvee he was driving while serving in iraq in 2003. and subsequently he lost his right leg. thank you both for your honorable service and your very important advocacy efforts on behalf of all disabled veterans. i am eager to begin the discussion. you can proceed with opening statements. >> morning. thank you for holding this hearing for your work to ensure that veterans with limb loss receive the highest quality prosthetic care. i'm a board member of the american orthodic and prosthetic association. i'm a licensed pros the cyst. for me as a practicing clinician already four elements to high quality care. the first would be access. veterans receive their care in a timely basis without having to wait weeks or traveling hundreds of mile for the that care. second, trust. veterans receive care from a

provider they feel good about. one who listens to them and one who works with them. experience and expertise. clinicians serving veterans design, fit and adjust the best possible prosthetic device to address the veteran's complex challenges. finally positive outcomes. the result of high quality prosthetic care is greater comfort, higher activity levels, more independence, and greater restoration of function to those veterans. the potential quality of prosthetic and orth oddic care for veterans has never been higher. veterans experience of care is highly dependent on their able toy to advocate for themselves. several barriers seem to stand many the way of 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 guarantee

the veterans meaningful access to trusted clinician of their choice. currently 80% of all orth thoiding and prosthetic care is provided by community based providers in. new york city is majority of care is provided by v.a. employees. however in cities like chicago, even veterans who live close to a va medical center may choose to rev their care by independent contracted providers. those who have served and sacrificed for our country should be able to freely choose the provider who best meets their needs especially on an issue as personal as important as prosthetic and orthodic care. reports from the field suggest they're real and increasing administrative barriers to veterans choosing nonv.a. providers. it's been suggest that had the v. savmt is moving karin house because it's cheaper. we're disturbed by the allegations that the average cost of a prosthetic limb

fabricated in house by the v.a. is about 25% of that fabricated by an outside contractor. the costs quoted for the v.a. fabricated limbs omit the cost of v.a. salaries, benefits, facility costs and administration. we believe that a complete and accurate cost comparison would show that op contractors provide celebrity value to the veterans and our tax payers. the second agenda point would be to elevate the clinician expertise and experience. over the past decade the practice of orthodices and prosthetics has grown complex and the technology has grown increasingly sophisticated. in response -- there are only six institutions enrolling approximately eight to 12 students in master degree programs with a few more in the

credentialing process. this is simply an insufficient amount to meet the growing demand. we recommend the creation of small time limited competitive grant programs to offer brants to either create or expand the masters programs. we are grateful to the chairman for your work on this issue. and finally, demand evidence based practice to achieve optimum outcomes. it's important to hold all professionals accountable for the quality and cost of care delivered. this is a challenge for the v.a. evening frankly there is currently little body of objective compare ift out comes research to support evidence based practices. for example, 20 years ago if you had a back problem, there was no outcomes researched to guide you as to whether the right decision would be surge or physical therapy. today objective research

documents which treatment works best for which patients. the result better outcomes obtained more cost effectively. that's what we want for veterans who need prosthetic and ordottic care. a comparative portfolio in this would increase the care of veterans and others with limb loss while proekting tax payers. madam chairwoman thank you for your invitation to testify and i look forward to answering any questions. >> thank you very much. you may proceed. >> thank you. madam chair, ranking member and members of the subcommittee. i'm pleased to present the views to deliver care to veterans with amputations. many members have experienced limb loss due to combat trauma and are high intensity users of v.a. health care and its specialized services. v.a. is responsible for ensuring that veterans with these types of injuries have every opportunity to regain their

health, functions, overall well being and quality of life. as in previous generations of veterans our newest war veterans with amputations want to remain physically fit, highly active and participate in competitive sports. these expectations require a team of specialists and lifelong care. the v.a. inspector general recently issued three reports related to v.a. amputee care. we found that overall most veterans contacted ka contacted were pleased with the quality of v.a. care and service fs they received, but some have indicated that certain processes for obtaining prosthetic limbs should be more streamlined and simplified. in one report the personal comments from veterans related to amputation care provide v.a. with good feed back and can help to reduce identified bureaus and bureaucracy for routine maintenance and repair of prosthetic limbs. we urge v.a. to establish a permanent mechanism to receive

continuing comments from this population. v.a.'s extensive system for care and rehabilitation collectively delivers specialized expertise across the v.a. system in. our opinion this program is functions very wem and we urge v.a. to continue to evaluate these veterans over time to better understand the complex and evolving health care needs and when necessary to readjust v.a. services according toly. we also concluded that it had overpaid private vendors by $2.2 million in the year assessed and v.a. is not getting the best value for these purchased items. we agreed with the recommendations and it appears that procurement reform and new policies to better manager functions are underway. however, dav is very concerned that during the transition v.a. services should retain

appropriate staff to ensure a strong connection between veterans and clinical components of care. contracting will always be a dominant aspect of supply, the determination of what type of appliance is appropriate should remain with the physical medicine and rehabilitation specialists aided by prosthetic representatives in conjunction with direct involvement of disabled veterans being sevened. one of our commenters put it best. without guidance, veterans could experience unnecessary delays as they would be invoice numbers rather than patients with unique needs. v.a. could expand the in-house manufacturing, costs should not be the sole factor for an expansion of in house fabrication of limbs. in our opinion the most important aspect of am pew tea care is maintaining options for a veterans preference of selecting a qualified doctor they feel most comfortable with

and the convenience of those services. current authority provides v.a. the authority to flexibility to manufacture and procure devices to wounded war veterans without any other provision of law including cost. we believe this authority should be used to provide patient centered care and timely delivery of prosthetic items, we do urge v.a. to focus on improving its business relationships with private fabricators and work to internally improve controls, prosthetic training, certification and inventory management. a third report we reviewed evaluated the effectiveness of v.a. medical zr management of the inventories. dav was disappointed to learn of the findings, we understand that prosthetic services has been waiting a number of years for the development of an integrated technology solution for managing prosthetic inventories which is yet to be approved by v.a.'s

office of information technology. we urge v.a. to expedite development of an i.t. solution and take other necessary actions to resolve this issue. in closing, while d.a.v. agrees it's an expensive area of operations and changes can and should be made to improve and leverage purchasing power, these expenditures are well worth their cost to partially repay the cost of veterans. and they are an integral component of holistic health care to veterans in general. that completes my statement. thank you very much. you may proceed. >> chairwoman burkle, and members of the subcommittee, thank you for inviting wounded warrior project to share its perspective on issues facing our amputees. as chairwoman mentioned i was wounded in 2003 while serving as a captain in iraq. i was one of the first ied casualties. i underwent 20 operations at

seven different hospitals including the amputation of my right leg. over the course of the past six years with the wounded warrior project i worked closely with thousands of wounded warriors many of them amputees and have observed both v.a. and d.o.d. care. my friend's earlier observation that prosthetics is at a crossroads is pektive and accurate. the path is clear for us. with over 1400 amputees many still adapting to life changing injuries it seems the v.a. is head down the wrong path and moving to institute changes that will set back care rather than improve it. we hope this hearing can alter their current course which may reverse years of progress towards appropriate and timely care for the amputees. currently the v.a. uses a process under which v.a. physicians see a veteran to determine what kind of prosthetic equipment is most important for that individual. with this individual the

prosthetics purchasing officer completes a purchase order to obtain the needed item. those purchasing officers are specialists who handle exclusively prosthetics. the veterans health administration intends to institute a major change on jewel 30th. under the change only an officer can procure an item costing more than $3,000. this policy would effect essential items including most limbs like mine and wheelchairs. it would require the use of a system designed for bulk procurement purchases that involves manually processing over 300 individual steps to develop a purchase order. the system may be great for buying cinder blocks and lightbulbs, but is certainly not appropriate for providing timely and appropriate medical care. equally troubling this change offers no promise of improving service to the warrior. instead it would mean greater delays. the change could realize modest savings, but at what cost.

a warrior needing a new leg or wheelchair should not have to wait longer than is absolutely necessary. i know warriors who have stayed from school, from work, can't play ball with their kids, live in chronic pain, while they wait for a new prosthesis. e know firsthand what it's like to not put my son into the crib when waiting for a prosthetic, my daughter asking once again, why can't daddy walk with us? on va moving ahead on changing procurement practice, wounded war wrors near the committee's help. prosthetics are specialized medical equipment that should be prescribed by a clinician and promptly delivered to the veteran. we urge this committee to direct va to stop implementation of this change in prosthetic procurement. beyond this immediate concern, our warriors face other challenges. war zone injuries that result in amputations are often complex and can prove difficult for later prosthetic fittings. it's apparent the paradigm shift

promised some years ago is far from complete and more progress is needed to realize va's vision for an amputee system of care. as a bottom line, we have real concerns about the direction of this program which appears to have lost the kind of focused advocacy it once enjoyed and fallen victim to a bureaucratization that lost sight of its customer, the veteran. today, vha seems intent on tossing out veteran center procurement so essential to timely and appropriate care. tomorrow, we fear centralized funding of prosthetics will be tossed out. we may end up, whereas jim mentioned earlier, where we were 20 years ago when fourth quarter meant all the money for hospitals, budget and spent, and you continue get a new limb or wheelchair until the next fiscal quarter. our goal is improved prosthetics care ands. to that end we offer the committee with a number of recommendations in our full statement. in closing let me highlight just a few areas in which the committee can make profound

difference. first, ensure through ongoing oversight, va's vision of amputee system of care is actually realized. second, press va to reestablish and re-energize the robust steering committee of experts to oversee and provide guidance in the direction and operation of va's prosthetics and orthotics program and finally, it is essential that va reestablish itself as a leader in prosthetics research and care. and maintain that position as a commitment to our wounded warriors. that concludes my testimony. thank you, and i welcome any questions. >> thank you very much. you may proceed. >> thank you. chairwoman berkel, ranking member, and members of the subcommittee, thank you for allowing paralyzed veterans of america to testify today concerning prosthetic services of the department of veterans affairs. ensuring that our nation's injured veteran population is able to receive state of the art prosthetic devices in a timely manner is an extremely important issue for pva. pva has more than 19,000 members

who all utilize va prosthetic services on a regular basis. in recent months the va office at the inspector general released numerous reports on va prosthetics and sensory aids, inventory management, acquisition of prosthetic limbs and prosthetic limb care. pva believes that the audits and investigations have identified many areas in need of improvement within psas and pva generally supports the oig recommendations. these recommendations provide not only an opportunity to improve upon prosthetic services for veterans for amputations but for all veterans who utilize va prosthetic services. the oig's key evaluations and assessments are taking place at a key turning point. the organization is undergoing a structural reorganization that directly impacts the delivery of prosthetic services to veterans. today i'll limit my remarks to this reorganization. under the current changes, va prosthetics will no longer be solely responsible for managing the purchases of prosthetic

items. rather the va is currently implementing a joint purchasing structure that includes making prosthetic purchases. while the va reports this change will result in increased oversight and review of prosthetic orders, pva is concerned the track has potential to create delays in the delivery of items to veterans. pva is further concerned the new system will lead to less va accountability for veterans during the ordering and delivering processes. when order for prosthetics is placed, at any point before the item is delivered veterans are oftentimes national service officers on behalf of a veteran is able to contact an employee with questions regarding an ordered device or status of delivery. now handling prosthetic purchases it is unclear which office will serve as a point of contact to provide veterans with timely assistance or questions or concerns that may arise. pva reached out to psasa

leadership on several occasions to identify the status of the reorganization and appreciates the opportunity to provide input. we've been informed the dual purchasing system was piloted in three veteran integrated service networks in the beginning of 2012 and implemented in additional areas in july 2012, we're not sure how va intends to make sure veterans are aware of the changes. pva encourages leadership to consult with veterans and families as well as stakeholders who regularly work with va prosthetic offices to provide input as they further develop the process for prosthetic purchases. pva further recommends the va regularly update this committee with the findings compiled as a result of the pilots it s impld in january 2012. lastly the office of procurement and logistics is governed by va policies of va acquisition to address the purchasing of

various items from many different offices in va. the change to the office of procurement and logistics managing the purchases of high cost prosthetics does not lead to the standardization of items particularly highly specialized prosthetics such as artificial limbs, specialized wheelchairs and surgical implants. pva strongly urges the va to continue to abide by va policy that adheres to tight 38 united states code section 8123. a statue that enables va to meet the unique prosthetic needs of veterans in a timely manner without limitations of cost saving measures such as standardization of items or contract bulk purchasing. veterans must have access to prosthetics that best fit their individual needs. for many years psas has done a good job of ensuring the number one consideration when ordering prosthetics is quality. the ability to meet the medical and personal needs of veterans. the va must make certain that the issuance and delivery of prosthetics continues to be provided based on the unique needs of veterans and help to

maximize their quality of life. again, pva thanks this committee for their attention to this important issue and encourages continued oversight. i'm happy to take any questions from the committee. >> thank you all very much. i will now yield myself five minutes for questions. mr. oros, in your opening statement, you mentioned the four very important tenets of trust, excess trust, experience and positive outcomes. as you look at the va prosthetic care, do you think that that encompasses those four tenets that you laid out for us this morning? >> i think it can. it's somewhat dependent on the veterans' ability to advocate for themselves. the outcomes piece, frankly, we're missing almost across the board. both inside and outside the system. >> can you give us some insights how we could -- how do we change that? how do we make the outcomes more

positive? how do we make sure these four tenets are -- >> specifically with outcomes there are validated instruments, tests that could be undertaken when prosthetic limbs are prescribed, so that are we truly getting, i'm going to use the word, the most bang for your buck, when it comes to prescribing a particular prosthetic foot or particular prosthetic need? and, you know, there simply right now are not research dollars allocated to studding comparative effectiveness when it comes to orthotics or prosthetics. in absence of that, we'll sort of continue to use our experience and our best judgment as to what we think are the best particular components for a veteran without any necessarily evidence to support that. >> do you have any information or knowledge as to why there hasn't been that kind of research done, like you say, compilation of data about the

outcomes? >> my suspicion is we're really just too small of a profession is really it. if it's not industry driven, it frankly has to come from the federal government. i can't explain beyond that. >> thank you. in your testimony, you talked about va prosthetics research has lagged in recent years. now, mr. oros talked about outcomes, but i think you're talking more generally in terms of the research. what impact do you -- and i shouldn't speak for you. i should let you say what research you were referring to. then if you could, after you tell us that piece, what impact has that had on veterans and the services that they need? >> va has stepped up in a number of capacities in the past few years, but as mr. mayer pointed out earlier, dod