to ensure prosthetic labs are operating effectively and economically as possible. we found that the va officials suspended their review of labs in january 2011 after reviewing only 9 of the 21 visions nationwide. because reviews of all visions were not conducted, prosthetic service was unaware of its inhouse fabrication capabilities or cost. vha lacked the information to know if its labs are operating effectively or efficiently. we were never trying to draw a cost comparison between the numbers in the report. those were the only numbers available at the time, and we clearly recognize it was not an apples to apples comparison. it is footnoted in the report to talk of the costs that are not in the vacost where you would

have profit and overhead of a contract vendor. we also in our second report we address va's prosthetic supply inventory management and offered a comprehensive perspective of the suitability of vha's prosthetic management supplies and procedures. we also recommended vha replace its current inventory systems with a modern inventory system. we reported that strengthening va's management of prosthetic supplies inventories in its va medical centers will reduce costs and minimize the risks of supply expiration and disruption to patient care due to supply shortages. for almost 60% of the inventoried prosthetic items, va mcs did not maintain optimal inventory levels. for almost 93,000 envenn toirin

items, inventories exceeded current needs for approximately 43,000 items for the inventories were too low for 10,000 items. further, we saw that documentation for an annual required wall to wall physical inventory had not been performed. this occurred because va mcs did not consistently apply basic inventory practices or techniques. for example, va mcs did not set normal reorder or emergency stock levels in their automated inventory system. for over 90% of the prosthetic items. weak and often ineffective inventory processes led to va mcs spending about $35 million to purchase prosthetic supplies in excess of their needs and that clearly increased the risk of supply expiration, theft, and shortages.

in fact, the controls are so weak, the losses associated with any diversion could go undetected. improvements in inventory practices and accountability, over prosthetic inventory, is still needed. vha must improve its inventory management systems and remain committed to replacing its pivoting inventory systems by 2015. we are pleased to see that va is adopting practices to achieve greater savings. along with providing more attention to ensuring the fiscal stewardship and contract administration of the funding needed for prosthetic care in response to the issues we reported on. we'll be happy to take any questions. >> thank you, miss halliday. dr. day? >> members of the committee, it's an honor to be here to speak to you on our report on prosthetic limb care in the va.

we've done a series of reports on when what i would call transition to care. and in those reports, we have allied ourself with the dod dj, access to dod data. also we've used dr. kleg in my office, a biostatistician who get it right. tbi, access to mental health in montana, combat stress, veterans. this report on prosthetics and one when just published on homelessness in this population. this issue of transition to care is important to us, and, again, we thank you and your staff's support for this work. we looked at two populations in this report. one is a population of about 500,000 veterans who left dod and became veterans in the 2005/2006 timeframe. and we were then able to follow those veterans as they transitioned through va and received several years of va care. and there were a couple of

outcomes from that data that i think are worth noting. one was it was surprising to me, maybe not to those who work with this population all the time, that it wasn't just the limb that was affected in these patients. every organ system you looked at, by diagnostic category, had significantly elevated disability or medical disease burden in this population. so whether it's that the blast injury they suffer at the time that they're injured or the other circumstances of trauma and recovery on the battlefield are unclear, but this is a population that has quite a significant disease burden beyond those that you would think of. the second feature that stood out from that analysis was the problem of pain management and substance use disorders. i mean, in addition to the normal mental health issues that this population will be expected to have, again, i can't speak

out enough the difficulty that this population has with these disorders and the difficulty that va currently has and society has in dealing with these issues. the second population that we looked at we got with the help of dr. paul at walter reed, both the older water reid and the new bethesda campus, he's. and they provided us their data set of combat injured veterans from the recent wars who had major amputation. at the time that we got our data, there were 1,506 major amputations. of that number, 180 were not traumatic. they were related to some other feature. 38 of those individuals were dead which left us with 1,288 individuals with combat-related major amputations. of that number, about 450

remained on active duty. some of whom were employed. and some of whom it appears to us were severely medically ill and dod seemed to be keeping them to make sure that they were in a better condition when discharged from dod. that left us with about 838, again, traumatic, major amputations of the upper, lower extremities that we tried to assess. if you take that number, divide it by 150 medical centers, and we did plot out addresses for these folks, you find out that this population, they're everywhere in the united states. so there is a simple problem of having, you know, ten or less on average without knowing specifically patients who have these problems across the va. just as a point of reference. whereas when you look at the elder population the va normally takes care of, where it looks to us, they have several thousand amputations a year. major amputations a year. that's mostly older gentlemen who have diabetes or other

vascular disease. so there is a significant difference there. we also went out and telephoned, surveyed and visited in person these returnees from the war, trying to get a feeling of whether what we were seeing on tv and in the press was an accurate reflection of how well these gentlemen and women were doing. it's the same ten people we were seeing playing softball all the time? or in general are these folks doing very well? and i would say that we are very, very impressed that this population, which entered the military with a can-do and follow-me attitude has really m manmaintained that. in general, this population is doing extremely well. there's one caveat to that. the folks at walter reed were very concerned about the 33 veterans at the time, that i give you the number, 1,500, who

had three or four limb amputations. and that population we were unable to see enough of to get a clear feeling of how they're doing, but i do believe that they are significantly more impacted in a total body sense from those who have one or two amputations. enough to be really, i think, a different category of disease. i think that also heard in our interviews and in our discussions with these, the discussions you've heard from the previous two panels. i won't go through those except people wanted to know why they wouldn't take a picture of their broken extremity and send it in by e-mail and try to expedite the paperwork involved in trying to get the billing process and the bureaucracy of things done. we have had conversations with dr. beck and her staff, they're well aware of these issues and i

think, i'm confident that they're thinking about how to best deal with these issues and they'll be on the next panel to discuss the changes that they would propose. but we've been very cooperative, i think, in trying to come up with what the right answer is. we made three recommendations. one was we asked va to consider this data set which i think is really previously not been available in the detail we've published it and i think va has done that in trying to tailor their care. we do believe the upper extremity veterans both in the surveys we've done have for a variety of reasons a great deal more difficulty than those with lower extremity. we urge the resource be done and the appropriate level of effort be made to get those upper extremity prosthetics up to speed. and thirdly, we ask va to deal with the bureaucracy. that is the contract complaints in the way that would lesson the

aggravation that veterans who have the difficultiy ies have i trying to make their way through the system. with that, i'll end my testimony and be glad to answer any questions you may have. thank you. >> i thank the panel. i have a couple observations. we appreciate you being here and testifying today. miss halliday, on the -- it doesn't look like a huge issue, but there, just with the simple changes in contracting, i certainly understood what you were saying. this doesn't change the quality of the prosthesis at all. it pmay be the same one, if you just negotiate a lower price with the same -- am i correct? is that what you were saying? >> you are definitely correct. what we were concerned, if we have an existing contract with a vendor, and it says that you're going to charge $10 for an attem attemitem, you're really charged $15 or

$20, that's the point we wanted to see the savings. that could be money, could be reprogrammed to prosthetics care. >> that shouldn't be a big issue. that's not a -- money-wise, it's a significant amount of money that could be spent, because as captain pruden or whoever said a minute ago, there were i think $54 million in the va budget. that's not a lot of money that's spent on all this prosthetic. so it, i guess the savings would be fairly significant. and prosthesis, i think we as -- i state myself as a layperson, in the va terminology, we would think of it as a limb. it could be a hearing aid, a wheelchair, a crutch. am i correct on that? >> it was, but this report thatby issued looked at the limbs. >> okay. just at the limbs. >> yes. >> you also agree that this was not an apples to apples -- when you were looking at it -- not really sure what that $2,900 -- >> we absolutely agree with that. it was the only cost information

available. we put it in the report and clearly said it wasn't apples to apples in our footnote there. the fact was va did not have good information on whether it should have labs, whether the labs could provide these items at a more economical cost and the same quality. they just did not have that type of information when my audit team went out. >> doctor, as fascinating data you had that you presented, did i hear right that there were 33 that had 3 amputations, more than 2? >> yes, sir. it was roughly 30 -- i believe the number we had in the report was 33 individuals who had 3 or 4 limb amputations who were alive at the time we did this report. >> i think the challenge is now, and i'll just be very brief here, but we went to afghanistan together three years ago and i went again in october of this

past year and just from a physicians viewpoint, the treatment of trauma care has changed dramatically from the time i was in the service. and you an see the results. and the results are a lot of people are surviving horrific injuries. if you don't die of your injury on the battlefield, you have about a 95% chance of surviving the injury as opposed to when mr. reyes was in vietnam which was a lot less than that i can tell you. we're going to have to deal with these issues going forward and we should. i guess the question i have for you is, do you agree with what captain pruden said a moment ago about if the va changes its procurement and so forth this will be detrimental to -- in other words, should we just keep doing what we're doing? and tighten up on what miss halliday said? that's not a -- inventory, walmart can tell you when a tube of tooth paste went out the door. they can replace it. we should be able to do that. the va, it sounds like by 2015,

should be implementied. you agree with -- >> well, sir, i didn't look at the business practices by which these prosthetics are determined, which is appropriate and procured. 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 the effectiveness of one prosthetic over another or, you know, the cost effectiveness of different measures. i don't have a comment on that, sir. >> i think the other thing you said just to make sure we all understand it is that the cohorts in this study had multiple co-morbidities. it wasn't just i lost my leg below the knee and that's the only thing wrong with me. am i correct there? >> it was impressive to me the total body injury the men and women had sustained, which is

the outward appearance would mostly be looked at as a prosthetic arm or leg. >> i yield now. >> thank you very much, mr. chairman. my question is, one of your recommendations, and i quote, consider veterans concerns with the approval process of fee-based and va contract care for prosthetic service to meet the needs of veterans with amputations, end of quote. would you expound a little bit more on that recommendation in details? is the reason why you came up with that because you were finding that veterans were being denied care or un-dually delayed in receiving care? >> what we found in interviews were veterans were complaints similar to what the first panel expressed. that was these men and women are active. they're going to school. they have families.

they have lives. if their prosthetic breaks, they want it fixed immediately. they don't want to have to get in their car and drive some place to have an examination done or to get the paperwork, you know, accomplished appropriately. we in our work did not analyze the business practices of making that happen. so i was -- didn't feel i was in a position to offer advice how to fix that problem, but we did sit down and have discussions with dr. beck and others to lay out what we thought the problem wases. dr. yang and others gave comments directly as to what we heard. we asked vha to consider how they're going their work and see if they can't improve that. at this point, i'm not knowledgeable enough unfortunately to give you advice on exactly what i think they should do different. i wish i could, but i don't have that information. >> there has been discussion, and clarified as far as the cost and the savings, comparing apples to apples and the

management of the inventory. have you or your sister agency ever done a report within the department of defense to find out what the cost, comparing dod to va, is the cost equal, number one? and secondly, you talked about the inventory management. is your recommendation consistent with what actually the department of defense is doing? do they have the same problems that va has in regards to cost and inventory management? >> with respect to the provision of care and the way va and dod are different, i think is that dod has, i believe, focused the care of patients who are badly injured from war at several discreet centers. and by then getting a large enough group of patients continuously there, they're able to put the resources in those

select several places, d.c., maybe san diego, bethesda, snoen wroe, maybe one or two others and provide cost effective state of the art care. va is a much more diverse organization. the veterans have already been through the acute trauma. they're up and about. so it's a little bit of a digit problem. to answer the second question, we have done no work on the cost of dod to compare it to va on providing the same level of care. >> when you talk about the wounded warrior, utilizing the dod versus the va, the numbers are higher in dod. do you know how many veterans the newer generation veterans are still utilizing the department of defense? versus going into the va because

they feel more, you know, they feel like they get better service at dod? and how many veterans are 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 vha is actually funding and how they're dealing with that. 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 for the veterans health administration for the united states department of veteran affairs. dr. beck 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, all of which are 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 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 orthostists and 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 pordorthics, 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.