walk fine, but it's difficult for him to do a lot of things. that's probably the satisfaction difference that you see, if you get back to jumping, running like you are, you feel pretty good about that. whether you have a prosthesis or not. and i think the other thing and you brought up a great point you brought up, it's very individual who you relate to. i know as a physician myself, when you have that relationship with your patient, you have great confidence in the fellow you work with as a person. and they know you, they know your leg, they know exactly about you. i'm just going say for myself, i think i can speak for most of the committee, i don't care what it costs for you to get the care you need for a wounded warrior to get the prosthesis that they need in a timely fashion, and mr. mayer said it very well, it's inconvenient, no, it effects how you live and you take one day off or three days that you can't do something, can't take care of your family, can't go to work, whatever, it's not acceptable. .

and in our budget, 1,500 wounded warriors who lost ex triments. we can't do enough and those needs are going to go on. and mr. mayer can tell you, mr. register, that you will change as you get older. your leg changes, things just change. gravity has a great effect on us. >> i'm finding that out. >> and so we have a commitment, i think, to those wounded warriors, not for this great care but for a lifetime of great care and i can speak for the entire committee. 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. because i have seen that facility out there multiple times and it is phenomenal when they get to the v.a. and i'm out of time. and later, if you get a chance, why do you think the v.a.'s

number -- i agree with your analysis, i read your testimony. i yield back. >> thank you. i now recognize the gentleman from new jersey. >> gentlemen, thank you both for your service to this country. just talking, mr. register, about whether it is contractor or fee-for-for based -- sorry. with a private doctor or with the v.a., treatment equal? >> yes. i have no, from what i have experienced at the three v.a.'s i have gone to. i was in a clinic in california. there was also one in virginia as well as the one in denver. i have received great care. >> it kind of comes back to a

lot of the things we discuss here in this committee and obviously, i think mr. mayer has stated that we have a 900% increase in the need for pros at the timeic -- prosthetic treatments. and one thing we talk about is access to that care. and when we move forward from this, obviously, yourself wanting to get back into the athletic mode. when we look at the approach of all this, and avoiding onset of things like diabetes and staying active and not compromising your health, whether you want to make the 70-that all members may have five legislative days to revise and extend their remarks -- 70 -mile trip. and i think it becomes an issue, because i see it in my district all the time. veterans say, i'm not going to

spend my whole day traveling to get treatment until i really need and that's something we have to look at. because as you said also, you don't see -- you agree that the treatment on both the private side and the v.a. side are equal, but at the same time, i don't think -- and you brought it up, you didn't say you are entitled to reimbursement for travel. at the end of the day being another cost to the v.a. system where we can get that same cost to another veteran to help them along. and i just think -- i don't have a lot of questions and i wanted to make that because there is an access to care issue here. and as mr. mayer said, 900% increase, it is a huge issue. i wanted to throw that out. i yield back. >> may i respond? >> i would like to -- that is a

great observation. what i wanted to say what mr. mayer was talking about earlier and what you just said, sir, a lot of these veterans are finding that system of care and they're not moving away or moving back to where they found that quality. they may get their care and walking and going back to regular life but not finding the care where they had moved to so they wind up coming back to san antonio and it's not getting back into athletics. that happened to be what i did. it's getting back into school and getting back with your families again. walking your daughter down the aisle and taking your son fishing, all those things they had before that they want to get back to to the high level of care. and having that in a location where they don't have to travel so far to do it is paramount for that individual. >> thank you, yield back.

>> anyone else have 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. thank you very much. you are both dismissed. thank you. i would like to invite the second table to the witness table. >> good morning and thank you all for being here this morning. with us is michael oros board member of the american orthotic

and pros thet particular association. joy ilem deputy national legislative director. jonathan pruden, retired, southeast alume nye manager for the wounded warrior project and alethea preed doe -- predeoux, associate director of health legislation, paralyzed veterans. ms. ilem served as a combat medic and captain pruden is a member of the united states army and injured when a roadside bomb struck his humvee while serving in iraq in 2003 and he lost his right leg. thank you for your service and very important advocacy efforts. i'm eager to begin our discussion and begin, mr. oros

and if you would like to proceed with your opening statement. >> thank you he holding this hearing to ensure that veterans receive the highest care. i'm a board member of the american orthotic and protthetic association. for me as a practicing doctor, there are four elements to high quality sare care. the first would be access. veterans receive their care on a timely basis without having to wait weeks or traveling hups of miles for 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 adjust the best possible prosthetic device to address the complex challenges and positive

outcomes. the result of high quality care is greater comfort, higher activity levels, more independence and greater restoration of function to those veterans. the potential quality of prosthetic and/or notic care for veterans has never been higher. veterans experience is dependent on their ability to advocate for themselves. several barriers stand in 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 that veterans meaningful access to a trusted clinician of their choice. 80% of all orthotic and prosthetic care are provided by community-based providers. in some places, majority of care is provided by v.a. employees.

however in cities like chicago, even veterans who are close to a v.a. medical center may choose to receive their care by independent contracted providers. those who have served and sacrificed for our country should be able to choose the provider who bests their needs especially on an issue as important as prosthetic care. reports from the field suggest they irreal and increasing administrative barriers to veterans choosing non-v.a. providers. it has been suggested that the v.a. is moving care in-house it is cheaper. the average cost of a prosthetic limb fabricated in-house is about 25% of that fabricated by an outside contractor. the costs quoted almost certainly omit the costs of like v.a. salaries, benefits, facility costs and administration. we believe that a complete and

accurate cost comparison would show that contractors provide slept value not only to the veterans but to our taxpayers. the second agenda point would be to elevate the clinician expertise and experience. over the past decade, the practice of prosthetics has grown increasingly complex and the technology has grown sophisticated. in response, the field has changed to the entry-level credentials, that of a masters degree. there are only six institutions enrolling eight to 12 students in master degree programs with a few more in the 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 grants to create or expand masters programs and we are

grateful that -- chairwoman, for your work on this issue. demand evidence-based practice to achieve maximum outcomes. it is important to hold all professionals accountable for the quality and cost of the care delivered. this is a challenge for the v.a. because there isn't a body of objective to support evidence-based practices that pertains to orthotics and prosthetics. 20 years ago, if you had a back problem there was no resevere to guide you whether the right decision would be surgery 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. comparative research outcomes portfolio. this would increase the quality of care for veterans and others with limb loss while protecting

taxpayers by ensuring that patients receive the most appropriate care. thank you for your invitation to testify. and i look forward to answering any questions. >> mrs. ilem, you may proceed. >> members of the subcommittee, i'm pleased to present the views on the capabilities of v.a. to deliver state of the art care. many members have experienced limb loss due to combat trauma and high intensity users. v.a. is responsible for ensuring that veterans with these types of injuries have every opportunity to regain their health, functioning, overall well-being and quality of life. as in previous generations of veterans, our newest war veterans to want to remain physically fit, highly active and participate in competitive sports post-injury. these expectations and interest require a team of health care

specialists and lifeline care. there are three reports related to v.a. amputee care and prosthetics and services. the i.g. found that most veterans contacted were pleased with the quality of v.a. care and services they received but some have indicated that certain processes for obtaining prosthetic limbs should be simplified. in one report the personal comments related to amputation care provided v.a. with good feedback and help to identify hurdles and buyer buyer for routine maintenance and repair. we urge v.a. to establish a permanent correspondence. this collectively delivers specialized expertise across the v.a. system. this program is functioning very well and we urge the v.a. to evaluate these veterans over time to better understand their complex and evolving health care

needs and when necessary to readjust v.a. services accordingly. the i.g. conducted an audit of acquisition processes and purchasing prosthetic limbs and concluded it overpaid vendors and that v.a. is not getting the best value for these purchased items. we agree with the i.g.'s recommendations and it appears that procurement reform and new policies to better manage prosthetic acquisition functions are under way, we are concerned that during the transition prosthetics, v.a. services should retain appropriate staff to have a strong connection between veterans and components of care. while contracting will be a dominant aspect, the determination of what type of prosthetic appliance is appropriate should remain with the physical medicine and rehabilitation specialist aided by prosthetic representatives in conjunction with direct

involvement of the disabled veterans being served. one put it best, without clinical precedents, veterans could experience unnecessary delays as they would simply be invoice numbers rather than patients with unique needs. while v.a. could expand its manufacturing with the i.g.'s cost-cutting views, costs should not be the sole factor. in our opinion, the most important aspect of amputee care is maintaining options for a veteran's preference of selecting a qualified doctor they feel most comfortable with and the convenience of those services. it provides the v.a. the flexibility to manufacture and procure devices to wounded war veterans without any other provision of war including costs. while we believe this authority should be used to provide patient-centered care, we do

urge v.a. to focus on improving its business relationships with private fabricators and improve controls in protthetic training and certification as recommended by the i.g. a third report we reviewed, evaluated the effectiveness of the medical centers management of its prosthetic inventories. while it 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 has yet to be imapproved. we urge v.a. development of an a solution and take actions to resolve this issue. while prosthetic services is an expensive area of operation and changes should be made to improve purchasing power, these expenditures partially repay the

costs that disabled veterans have made and an important component to patients in general. >> mr. pruden, you may proceed. >> chairwoman, ranking member and members of the subcommittee, thank you for inviting wounded warrior project. as chairwoman mentioned, i was wounded in 2003 as serving as an arm infantry captain in iraq. i underwent 20 operations at seven different hospitals and the amputation of my right leg. over the course of the past six years, i worked closely with thousands of wounded warriors, many of them amputees and my friend jim mayer's earlier observation that v.a. prosthetics is at a crossroads

is perceptive and accurate. the path that v.a. should take is clear, but with over 1,400 amputees, many adapting to their life changes, v.a. is headed down the wrong path and instituting changes that will set back prosthetic care rather than improve it. we hope this hearing can alter the current course which may reverse years of progress towards appropriate care for our amputees. currently, v.a. uses a process under which v.a. physicians see a veteran to determine what type of equipment is most appropriate for that individual. with this information, prosthetics purchasing officer completes a purchase order to object tape the needed item. those purchasing officers are specialists who handle exclusively prosthetics. the veterans health administration intends to institute a major change on july 30. under the change, only a

contracting officer could procure a prosthetic costing more than $3,000. this would affect limbs like mine and wheelchairs and would require the use of a system designed for bulk procurement purchases which is manually processing over 300 individual steps to develop a purchase order. this system may be great for buying sinder blocks and light bulbs but not appropriate for providing timely and appropriate medical care. equally troubling, this change offers no improvement. it would mean greater delays. the change could realize modest savings, but at what cost? a warrior needed a new leg or wheelchair shouldn't have to wait longer than necessary. i know warriors who have stayed home from events, from school, from work, can't play ball with their kids or live in chronic pain while they wait. i know first wand what it is like not to put my son in the

crib, to live in chronic pain and have my daughter at my wife, why can't daddy walk with us. with v.a. moving ahead, wounded warriors need this committee's help. a prosthetic limb is not mass produced. it is specialized and should be prescribed by a clinician and promptly delivered to the veteran. we urge v.a. to stop implementing this change. beyond this immediate concern, our warriors face other challenges. war-zone injuries are often complex and can prove difficult for prosthetic fittings but the paradigm shift promised some years ago is far from complete and more progress is needed to realize v.a.'s vision for a system of care. we have real concerns about the direction of this program, which a appears to have lost the focused advocacy it once enjoyed and fallen victim that has lost

sight of its customer, the veteran. it seems like it tosses out care. tomorrow, we fear central lised funding maybe tossed out and end up where we were 20 years ago and all the money for the budget had been spent and couldn't get a new limb or wheelchair until the next fiscal quarter. we offer the committee with a number of recommendations in our full statement. in closing, let me highlight a few areas which the committee can make a difference. first, ensure through ongoing oversight that v.a.'s vision of a system of care is realized. second, press v.a. to re-establish robust hearing of experts to oversee and provide guidance on the direction of v.a.'s program and finally, it

is essential that v.a. re-establish itself in 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. >> ms. predeoux you may proceed. >> thank you. thank you for allowing paralyzed veterans of america to testify concerning services and ensuring that our nation's injured population is able to receive prosthetic devices in a timely manner is an important issue. we have more than 19,000 members who all utilize prosthetic services on a regular basis. the v.a. office of the inspector general released numerous reports, inventory management and prosthetic limb care. we believe these internal audits

and investigations have identified many areas in need of improvement and we support the recommendations. these recommendations provide not only an opportunity to improve the prosthetic services but for all veterans that utilize prosthetic services. the evaluations and estimates are taking place during a critical turning point. the veterans health administration is undergoing a structural re-organization that directly impacts the delivery of prosthetic services to veterans. i will limit my remarks to this reorganization. it will not be solely responsible for managing the purchases of prosthetic items. the v.a. is implementing a joint purchasing structure making prosthetic purchases. while the v.a. reports that this change will result in increased oversight and review of orders, we are concerned that this track

has the track to create delay. we are further concerned that this new system will lead to less accountability during the ordering and delivery processes. when an order is placed at any point before the item is delivered, veterans are able to contact their employee with questions regarding an ordered device or the status of delivery. with the v.a. office now handling purchases, it is unclear which office will serve as a point of contact to provide veterans the timely assistance or questions or concerns that may arise. we have reached out to the leadership on several occasions to identify the status of the reorganization and appreciate the opportunity to provide input. while we have been informed that the dual purchasing system was pilotted in three service networks beginning in january, 2012 and will be further implemented in additional areas in july of 2012.

we are not aware of how v.a. is making veterans aware of these changes. we urge you to consult with veterans and their families to provide input as a further development for prosthetic purchases through the office of procurement and logistics. we recommend that the updates be implemented as well as future findings as plans move forward. lastly, the office of procurement and logistics is governed. such policies address things going on in v.a. and the change to office of procurement and logistics managing the purchasing does not lead to a standardization of items particularly highly specialized prosthetics, and we urge the

v.a. to continue to abide by v.a. policy. a statute that enables v.a. to meet the needs of veterans in a timely manner without cost savings measures such as standardization measures. veterans must have access to prosthetics. for many years, we have done a good job of ensuring that the number one consideration is quality, the ability to meet the medical and personal needs of veterans. the v.a. must make certain that theishance be provided based on the uniqueness of veterans and maximize their quality of life. we thank this committee for their attention to this important issue and encourage its continued oversight. i'm happy to take any questions from the committee. >> thank you all very much. i yield myself five minutes for questions. mr. oros in your opening

statement, you mentioned the four important ten events of access, trust, experience and positive outcomes. as you look at the v.a. prosthetic care, do you think that encompasses those four that you laid out for us this morning? >> i think it can, but it's dependent on the veterans ability to advocate for themselves. the outcomes piece we are missing across the board. both inside and outside the system. >> can you give us some insight -- how do we change that and make the outcomes more positive? how do we make sure these four tents are -- >> there are validated tests that could be undertaken. when prosthetic limbs are prescribed and are we truly

getting -- i'm going to use the most bang for your buck when procuring a particular prosthetic and there are not research dollars to studying comparative effectiveness when it comes to orthotics and prosthetics. in the absence of that, we will continue to use our experience and our best judgment as to what we think are the best particular components for a veteran without any evidence to support that. >> zouf any information or -- do you have any information or knowledge as to why there hasn't been any research done about the outcomes? >> my suspicion is we are really too small a professiois really it. if it's not industry-driven, it has to come from the federal government. and i can't explain beyond that.

>> mr. pruden, you talked about v.a. prosthetics research has lagged in recent years. mr. oros talked about outcomes but you are talking more generally in terms of the research. what impact -- and i shouldn't speak for you, i should let you say what research you were referring to. and after you tell us that piece, what impact has that had on veterans and the services that they need? >> the v.a. has stepped up in a number of exassyits in the past few -- capacities in the past few years, but d.o.d. has taken the lead on the development of the decka arm. in years past, v.a. has been one of its key roles and one of the reasons exists is to provide specialized medical equipment

for our combat wounded and for our veterans and v.a. needs to have the capacity and focus when d.o.d. and globe war on terror dollars go away. this ties into the discussion about centers of excellence at walter reed, brook army medical center. when these dollars go away, those d.o.d. facilities will scale back their capacity for rehabilitation and research. and what we are calling for is v.a. through the amputee system of care to be prepared to meet the needs as d.o.d. scales back. >> ms. predeoux, i'm extremely concerned about your comments about the filing system being outdated and the backlog that it creates. could you comment. >> in my written statement with the filing system, it refers to

medical records within one v.a. medical center and if a veteran were to relocate. for example, our director of benefits relocated to this area from san diego and took quite a bit of time for the medical records to be transferred from san diego to d.c. simply because there isn't one central system in which all the medical centers can locate and view the medical records of a veteran and it's not just the wait time but being able to become comfortable and actually be mobile. >> that was going to my question. when the records are not able to be transferred timely, that means the veteran does not have -- >> the records not being transferred for the medical provider to see them and get what is needed. could be a chair, could be a repair, those types of items. >> thank you very much.

i yield five minutes to the ranking member, mr. michigan add. >> thank -- michaud. >> thank you. mr. mayer from the first panel recommended that the committee ask the v.a. to freeze the pending reorganization until a full scale program to a new strategic program. do you agree with that as well? >> i'm not entirely familiar with the differentiation between what mr. mayer is asking to be done and the current system. >> do you think we should ask the v.a. to freeze the reorganization and bring

everything in-house? >> absolutely. absolutely. >> i'm happy to provide a comment on that. with regard to the reorganization, all of our concerns are provided in our written statement, but until i think we can answer that, it would be great to know the results and how things work in the pilots that are implemented in january. it is my understanding that within those pilots, different -- the reorganization was implemented in different ways. so it would be interesting to see how veterans were affected and the delivery of items, the timeliness, those issues, and access. >> how the different pilot programs -- they diverse? the diversity great or -- >> minor. administration of certain policies and how they handed off

items that needed to be handed off. that's my understanding. >> why should the v.a. undertake research and comparativeness outcomes. why couldn't this be done by other agencies, such as the department of defense or national institute of health? anyone who wishes to answer that? >> i would say that d.o.d.'s mission is to rehabilitate troops to their maximum potential and either return them to the line or send them on for further care. v.a.'s job is for long-standing, life-long care once they leave the service. d.o.d.'s service is on acute care and v.a. should be on long-term outcomes and long-term care for our warriors and certainly, if possible, should

be done in partnership with n.i.h. and d.o.d., but v.a. should be looking at long-term care for amputees. >> i concur with that. i think that is absolutely essential for v.a. because of the paradigm shift that occurred within d.o.d. and providing this up front amputee care, but as a transition into v.a., that is the lifelong care and they are focused on effective care and good outcomes. so that would be within their portfolio. >> i guess this would be for mr. oros or anyone else, there has been some discussion about the cost in the private sector versus the v.a. has anyone done an analysis of what the cost is within the department of defense? >> we haven't, but i think the

comments that mr. oros made were really pertinent. the first thing we thought when we saw the report and the difference between the two cost comparisons was, you know, not factoring in a number of other things. maybe that was just material. so we would like to see a better analysis of that. >> may i say that $2.2 million while it seems like a lot of money, for us to allow our most severely injured are blind, wheel-chair bound and bearing the burden of cost savings at $2 million even assuming those savings can be realized, i think is unconscionable and that's where i stand on that. >> well taken and i agree with your point. we will be asking the i.g. and

v.a. as to how do they come up with the cost comparisons because sometimes they aren't comparing apples to apples which will give you that deviation but as well as d.o.d. it would seem to me that the costs should be similar to the v.a. as far as the v.a. and d.o.d. costs are the same, probably the methodology is correct. if it's not, i would be interested in seeing that as well. i yield become. >> i now yield to the gentleman from florida, mr. bilirakis. >> i thank the entire panel for their system today. my first question is for mr. pruden, first of all, thank you for your service to our country. you mentioned in your testimony your concerns about the v.a.'s planned changes in the

prosthetics acquisition process. will you elaborate on the real world implications that this will have on our veterans, specifically from the time a prosthetic is ordered, how long does it typically take to arrive under the v.a.'s 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 these delays? >> under the current system there are safeguards in place to ensure that v.a. is being fiscally responsible and can take a month, two months. some of this is predicated on the clinical needs of the patient and availability of the product in their area, which is appropriate. our real concerns is that with the new system, it would be

supposition, but may take months and months longer to get purchase orders for needed equipment and veterans shouldn't have to wait and the clinician's hands shouldn't be tied. if they feel the device is appropriate and going to provide the best care for a warrior. i had the opportunity to speak with over a dozen v.a. clinicians who are serving and every single one of them said they share our concerns about the ability to remain timely and potential delays in veterans receiving needed prosthetic devices under this new system. and dr. beck will come up in a few minutes and will say that one of the things we're going to consider is if a device is generally available and interchangeable, then it will fall under the federal acquisition regulations. who is determining what is generally available and

interchangeable. someone in acquisition, not a physician or clinician that has the patient's best interest at heart. that is our concern. v.a. was given wide discretion by congress to provide prosthetic devices without consideration of applicable federal regulations years ago because congress recognized this special, unique role in prosthetics in providing care for our warriors. and unfortunately, this seems to be a step in the opposite direction. >> maybe for the entire panel, let's address this specifically, where are the quality of life and health issues that could arise from these delays? if anybody would like to testify on that. >> well, i'll state it again that i have personally experienced this through the appropriate delays that occur from the time i 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 do some aspects of my job and i can tell you story after story about warriors who are stuck in wheelchairs, gained weight and subsequent health shoes due to the inability to get up on their prosthetic limbs. a buddy of mine is an amputee who lost both his legs in iraq and clinician that worked with him was able to use discretion to get him the appropriate devices in a timely manner recently. and that same physician told me that this goes throo i wouldn't be able to do that for him. he would still be in his wheelchair today. and that's the last thing we want to see happen. the hearings in the past several years has been take care of the

veteran first and foremost, ensure they receive the devices they need. and it is a concern to see us stepping back from that. >> what about mental health issues as a result of these delays? anyone want to comment on that? >> i think from our perspective, we have a number of members and people we work with on our staff in washington, d.c., and local areas that are prosthetic users that have been long time users and when something goes wrong, is there a broken foot or some sort of issue with the prosthetic appliance, it's absolutely critical and you can just see it in them how frustrated they are not being able to do the things they are used to doing. if there is a delay in getting those items fixed and getting to a clinician of their choosing

that a person who has worked with them over years and years. it definitely can impact on their mental health. and they want to be functioning in all that they can. >> thank you. anyone else? >> my colleagues have discussed quality of life and mental health. quality of care is an issue. when there are delays, sometimes there are quick fixes and other times they could be larger issues, but veterans are able to step in and figure out what the issues are and kind of interrupt that process that could extend the delay. when it comes to acquisitions, as it stands, it's not an office that veterans can see or call or their representative can call. so with regard to their -- the reform and moving over to acquisitions, systems must be put in place so veterans know the exact order, so when there

is a delay they can call and say there has been a delay, what is the problem and hopefully the problem can be fixed. >> thank you. i yield back. >> i recognize the gentleman from florida. >> let me welcome the panel and i understand you went to the university of florida. >> go gators. >> it's my honor to represent the university of florida here in congress and i'm delighted that i can come over here in time. i have two other committees at the same time but i wanted to be here to welcome you personally and thank you for your service and thank you and just admire your ability and leadership here in testifying and presenting to the american people some of the problems for the wounded warriors. i think what i'm asking is sort of an overview. i understand you are one of the one of the first i.e.d.

casualties of iraqi freedom, is that true? >> yes, sir. >> you testified before the oversight subcommittee on seamless transition issues in 2010. >> yes, sir. >> have you discussed any of your concerns raised in your testimony with the v.a. clinicians or other v.a. officials? >> i certainly have. i had the opportunity to speak with numerous current v.a. physicians and prosthetic chiefs. several candid off-record discussions and all of them had real concerns about this process and about us moving forward in changing our procurement requirements and potentially tying the hands of our clinicians and hampering the delivery time for our veterans. >> particularly the members here on the v.a. committee, i guess with the growing population of wounded veterans, do you feel

confident that transition that we're making will not encounter greater delays perhaps in veterans receiving the care they need and the prosthetics they need? >> sir, i certainly feel that this is a real danger. and that's why we've -- we're asking the committee to stop the implementation of this until either -- assured there are safe roads in place that won't cause this to happen or just find another way to find savings. the i.g. report that was cited several times here today in no means, no wherein the report does it call for the use of federal acquisition personnel in procuring these assisted devices. it asked for stricter cost controls and certain measures and we are all for fiscal responsibility and for saving taxpayer money, but not on the backs of our most severely

injured. >> some of the statistics my staff provided, as of march, 1,288 service members experienced major limb loss and of that number, 359 lost more than one limb and that's just this past month. what ther reed medical center, two quadruple amputees. this is mind boggling to think there is that many. do you think that with that number -- should we organize all these people together in a en masse type of grouping rather in a focused way rather than a broadway. we know the problems they are going to have and enormous

challenges. 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, it is a real challenge and the number i got this morning is 1,458 new amputees from iraq and afghanistan. and it is a challenge. i had the honor of being on a 27-member expert panel that made some recommendations about the amputee system of care and v.a. to its credit has implemented that amputee system of care in large measure, but it's not there yet. it hasn't met all the stated objectives and we want to encourage the committee to provide oversight, to continue that program of enhancing care for our warriors. dr. beck and dr. miller, these are professionals and they're

doing a good job, but certainly, there is need for oversight and we don't want to see penny pinching, curtailed, all the advancements that have been made in the past 20 years. >> madam chair, i would think that the committee might think about this, since we can define who these peopler we should in the job market, either through tax credits or tell the employer that if you hire one of these people, you are going to get advanced depreciation on your capital assets or possibly going to get write-office or incentives to hire these people. because in the end, the challenge that they have mentally and physically is so enormous, it can be overcome if they have a job that they feel they have strong self-esteem and self-sufficient and need this job more than anything else.

would you agree with that? >> that is an excellent idea. in principle, i certainly agree with it. >> and so, in fact those pliers that hire these people should be singled out with merit and recognized somehow in their corporation with a designation that they are hiring these roughly 13, 1 housm 400 people. across america, a person can look and see a company doing great service for our veterans and for this nation. captain, i thank you for your service and sacrifice. it is a pleasure for me to represent you and the folks in gainesville. thank you. >> i was going to cut you some slack but having found out you went to the university of florida. all kidding aside, i want to talk to you about something i want to do privately with wounded warriors.

i think what i have heard from certainly with the prosthesis and with limb loss and so on are the very individual care that veterans need and that relationship they have with their provider is very important and may go on a lifetime as that person is in private practice or with the v.a. and i would like to have you all's comment but captain, i couldn't agree more, we aren't going to balance this budget on the backs of people who lost limbs in service to this country, whether going to a private clinician or v.a., they need the best care. and i think we need to see if we are measuring apples to apples because i don't think $3,000 looks at the cost of a light bill, water bill. if you dig into it, my bet is, it's the actual cost of the pros

theet is and materials putting it together. if you are running a business, the overhead of the person doing the insurance, all the things that go into just running a business. and i think what i heard you say, i completely agree with about we could set this back if we do what the v.a. is going to do and delay and what was said by mr. mayer right before you, it's not just an inconvenience, it's like you said, you can't go out and walk your daughter or whatever function you may have. the other thing i would argue a little bit -- i wouldn't argue but to comment on congressman stearns, when i see wounded warriors, they want to go back to regular life and use the prosthesis. and do what they did before going into the military. >> i think, too, and the

employment issue is obviously important for many veterans but it all comes down to again, their ability to be able to do what they want to do to regain their function, to live, to have quality of life and that comes down to the care they are going to get at v.a. and maintaining their prosthetic items and getting them in a timely manner. >> i have been here probably six months in congress and this is my second term and been to walter reed and walking down the steps, spanky was a major -- i didn't know he was an amputee. he had returned to duty and was carrying on exactly like he always had. when i saw him and had a little talk about that, but that was amazing that he was able to do that. and i saw him walk and out of here and didn't know he was an amputee. that's the return to duty people

want. when they have lost an ex treatment, i believe that's the -- ex triment, i believe that's what they want. i appreciate your testimony and certainly your service to our nation and i will call on our next panel.

>> joining us is linda halliday, assistant inspector general, i.d. for the u.s. department of veterans affairs. and nicholas dahl, director of the bedford office of awed its and he valuation for the i.g., director of the atlanta office. and also joined by dr. john day. dr. day is accompanied by dr. yang a physician for the office of health care inspections for the i.g. thank you for being here. ms. halliday, we'll begin with you. >> members of the subcommittee, thank you for the opportunity to discuss the results of our two recent reports on v.h.a.'s management and acquisition of prosthetic limbs in the management of supply inventories. we conducted our work at the

request of the house veterans affairs. i'll discuss our efforts to to deliver prosthetic limb care and manage supply inventories in its medical centers. in our first report, we examined the procurement practices and the costs of prosthetic limbs. we identified opportunities to improve payment controls to avoid overpaying for prosthetic limbs and to improve contract negotiations to obtain the best value for prosthetic limbs purchased from contract vendors. with regard to the cost comparisons in our report addressing v.a. fabricating the prosthetic limbs or processing these limbs via contract, our report concluded v.a. 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 no way did we address cutting the quality of the requirements to purchase a limb. this was the focus was on the contract administration piece. and the contract administration piece is that v.a. entered into contracts with vendors to provide limbs at certain prices. what we looked at was that the invoices were coming in. they lacked an adequate review process prior to certification for payment, in which case, resulted in overpayments. that's a contract administration issue. and i want to be very clear. we did not say cut the quality of a prosthetic limb for any of these veterans. but clearly, it is an

opportunity to if you can fix this control, you can then reprogram the funds saved to provide more prosthetic care for veterans. the overpayments for prosthetic limbs were a systemic issue in 21 integrated service networks and that's where we identified overpayments in 23% of all transactions paid in 2010. the overpayments germly occurred because invoices received from vendors, they lacked adequate review. as a result the vendor invoices were processed with charges in excess of the prices in the vendor contracts. we reported v. hmple a. would continue to overpay prosthetic limbs for about $8.6 million if it did not take action to strengthen these controls. we also found that visn

contracting officers were not always negotiating to obtain a better discount rate with vendors. without negotiations for the best discount rates obtainable, v.a. cannot be assured for the funds it ex pends to buy prosthetic limbs. we noted taking with noted that contracting officers consistently negotiating a better rate in no way compromises the quality of the limbs the v.a. buys. we also report that the v.h.a. guidance says the service should periodically conduct evaluations to ensure that prosthetic labs are operating as effectively as possible. we found the v.a. officials suspended their review of labs in january, 2011, after reviewing only nine of the 1

businesses nationwide. because of -- because review of all businesses were not conducted, prosthetic service was not aair ware of the in-house capabilities or costs. v.h.a. 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 cost not in the v.a. cost where you would have profit and overhead of a contract vendor. we also, in our second report, we addressed v.a.'s prosthetic supply inventory management and offered a comprehensive perspective of their prosthetic management supplies and

procedures. we also recommended v.h.a. replace its current inventory systems with a modern inventory system. we reported that strengthening v.a.'s management of prosthetic supply inventories in its v.a. 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, vamc's did not maintain optimal inventory levels. for almost 93,000 inventory items we estimated that v.a. inventories exceeded current needs for approximately 43,000 items, or the inventories were too low for 0,000 items. further we saw that dumontation for an annual required

wall-to-wall physical inventory had not been performed. this occurred because v.a. -- vamc's did not consistently apply basic inventory practice or techniques. for example, they did not set normal reorder or emergency stock levels in their out -- automated inventory system for over 90% of the prosthetic items. weak and ineffective practices led to them spending about $35 million to purchase prosthetic supplies in excess of their needs and that clearly encreased the risk of supply expiration, theft, and shortages. in fact, controls are so weak the losses associated with any diversion could go undetected. improvements in in-- in inventory practices and accountability over prosthetic inventory is still needed. v.h.a. must improve its inventory management systems

and remain committed to replacing its existing inventory systems by 2015. we are pleased to see that v.a. 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. dr. day. >> it's an honor to be here to speak with you. we have a series of reports on care and we have alied ourselves with the dodig, specifically a member who helped us gain access to d.o.d. data and we've used a

statistician in my district to help us get the numbers right. this report on prosthetics, one on women veterans and others, so this issue of transition to care is important to us and again we thank you and your staff for your work. we looked at two populations in this work. one is a population of about 500,000 veterans who left d.o.d. and became veterans in the 2005-2006 time frame and we were able to follow those veterans as they transitioned through v.a. and received several years v.a. care. 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 pop leags all the time, 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 amp -- in this population. so whether it's that the blast injury they suffer at the time 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 you would think of. the second feature that stood out from that analysis was the problem of pain management and substance use disorder. in addition to the normal mental health issues that this population would be expected to have, i can't speak out enough on the difficulty that this population has with these disorders and the difficulties the vmplet a. currently has and society has in dealing with these issues. the second population we looked at, we got with the help of dr.

paul pisquina, from walter reed and the doctor in charge of the prosthetic program at t.m.a. they provided us their data set of combat-injured veterans from the recent wars who had major amputations. at the time that we got our data, there were 1rks506 major amputations, 180 were not traumatic, they were related to some other feature. 38 of the individuals were dead. which left us with 1,288 which left us with combat-related amputations. about 450 remained on active dutying some were employed and some it appears to us were severely medically ill and d.o.d. seemed to be keeping them to make sure they were in better condition when discharged from d.o.d. there were about 838 traumatic

major amp cases. if we take that number and provide 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. there is a simple problem of having, you know, 10 or less on average without knowing specifically patients who had these problems across the v.a., just as a point of reference, whereas when you look at the other population the v.a. normally takes care of, it looks to us like they have several thousand amputations a year, the older gentlemen who have diabetes or other vascular disease. there is a kig cant difference there. we also went out and telephone 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. the same people playing softball all the time? or in general are they doning 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 realy maintained that and i don't believe that we'll be -- that what we see on tv is an aberration. i believe in general this population is doing extremely well. there's one caveat to that. the folks at walter reid were -- walter reed were concerned about the 33 veterans at the time, i give you the number 1,500, who had three- and four-limb amputations. that population we were not able 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 really be a different category of disease. i think that we also heard in our interviews, in our discussions with these veterans, essentially the same comments that you've heard from the previous two panels. i won't go through those except to say that people wanted to know why they couldn't take a picture of the -- of their broken extremity and send to them by email 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 doctor beck and their staff, they are aware of the 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 they've been very cooperative, i think, at trying to come up with what the right answer is.

we made three recommendations, one the f.d.a. to consider this data set, which i think has not been available previously and the -- in the detail we published it. and i think they have tried to tailor their care. we believe the upper extremity veterans have, for a variety of reasons, agree -- a great deal more difficulty then than those with lower extremity and we do urge that the appropriate level of effort be made to get the upper extremity prosthetics up to speed and thirdly, we ask v.a. to deal with with the bureaucracy, the fee basis or contract complaints new york a way to lessen the aggravation of veterans who have difficulties in trying to make their way through the system. with that, i'll end my testimony and be tpwhrd to answer any questions you have. thank you. >> i thank the panel. i just have a couple of observations. of course we appreciate you being here and testifying today.

it doesn't look like a huge issue but there, just with simple changes in contracting, i certainly understood what you were saying. this doesn't change the quality of the prosthesis at all. it may be the same one, you just negotiate a lower price for the same -- >> you are definitely correct. what we were concerned was, if we have an existing contract with a vendor and it says that you're going to charge $10 for an item and the invoices start to come in, if they're not reviewed and you realy charged $15 or $20, that's the point we wanned to see the savings. that would be money that could be reprogrammed to prosthetics care. >> and that shouldn't be a big issue. it's not -- money-wise it's a significant amount of money that could be spent because as the captain said a minute ago, there were, i think, $54 million in the v.a. budget,

that's not a lot of money spent on prosthetics. i guess the savings there would be fairly significant and prosthesis, me, as a layperson, in the v.a. terminology, we would think of it as a limb. it could be a hearing aid or wheelchair or a crutch -- am i correct on that? >> it was, but this report we issued looked at the limbs. >> ok, just at the limbs. >> yes. >> and you also agree that this was not an apples to apples, when you were looking at it, not sure what the $2,900 -- >> we absolutely agree with it. it was the only cost information available, we put it in the report and clearly said wasn't apples to apples in our footnote there. the fact was, v.a. did not have good information to make decisions 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. >> dr. day, fascinating data you had that you presented, did i hear right that there were 33 that had three amputations, more than two? >> yes, sir. roughly -- i believe the number we had to report was 33 individuals who had three or four limb amputations who were alive at the time we did the report. >> i think the challenge is, now, just very brief here, but mr. michaud and i went through afghanistan three years ago and i went in october of this past year, and from a physician's viewpoint, the treatment of trauma care has changed dramatically from the time i was in the service. you can see the results. the results are a lot of people are surviving horrific injuries. if you don't die on the battlefield, you have about a

95% chance of surviving that injury, as oppose -- as opposed to when mr. reyes was in vietnam, which was a lot less than that, i can tell you. we 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 the captain said a moment ago, if the v.a. changes its procurement and so forth, this will be detrimental to -- in other words, should we keep doing what we're doing? and then tighten up on what ms. halladay said? inventory, wal-mart can tell you when a tube of toothpaste went out the door. so we should be able to to that in the v.a., it sounds like, by 2015 that should be implemented. do you agree? >> well, sir, i didn't look at the business practices by which these prosthetics are determined, which is appropriate, we simply in this report looked at the population 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. we simply did a population health study. i don't have a comment on that, sir. >> i think the other thing you said, just to make sure that we all understand it, is the cohorts in this study had multiple -- it wasn't just i lost my leg below the knee, that's the only thing wrong with me, am i correct? >> it was impress i to me the total body injury these men and women had sustained which mostly to the outward appearance would be looked at as a missing arm or leg. >> i yield to mr.my should. -- mr. my shaw -- mr. michaud.

>> i have this quote, consider veteran's concerns with fee-base and v.a. contract care, prosthetic service to meet the needs of veterans with amp cases -- amputations, end of quote. could you expand on that in detail? is there a reason you came up with that? were you finding that veterans were being denied care or unduly delayed in receiving care? >> we found in interviews with veterans, complaints similar to what the first panel expressed. these men and women are act i, 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 the car and drive someplace to have an examination done or get the paperwork, you know, accomplished appropriately. we, in our work, did not analyze the business practices of making that happen.

so i was -- i didn't feel i was in position to offer advice as to how to fix that problem but we did have discussions with dr. beck and others to lay out what we thought the problem was. dr. yang and others gave comments and we asked v.h.a. to determine how they're doing their work and if they can improve that 67 i'm not knowledgeable enough at this point in time to give you advice on what i think they should do different. i wish i should but i don't have that information. >> there was been discussion of the cost and savingsing 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 d.o.d. to v.a., is the cost equal, number one, and secondly, talked about the

inventory management, your recommendation consistent with what actually the department of defense is doing? do they have the same problems that v.a. has? in regards to cost and inventory management? >> with respect to the provision of care and the way v.a. and d.o.d. are different, i think that d.o.d. has, i believe, focused the care of patients who are badly injured from war at several discreet centers. and by them 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, san antonio, maybe one or two others, and provide cost effective state of the art care. v.a. is a much more dispersed

organization and veterans live throughout the country, they have been through the acute trauma, they're up and about. it's a different problem. for the second question, we have done no work on the cost of d.o.d. compared to v.a. providing the same level of care. >> when you talk about the wounded warrior utilizing the deform o.d. versus the v.a., the numbers are high for the d.o.d. do you know how many veteran the newer generations -- generation veterans are still utilizing the department of defense versus going to the v.a. because they feel more, they feel they bet get -- they get better service at d.o.d.? and how many veterans are using d.o.d. versus the v.a.? >> we have found in looking at transition to care that there is a flow back and forth between d.o.d. and v.a. for

veterans. some veterans are -- have d.o.d. disability that allows them to go a d.o.d. facility or who are -- or they are retired and therefore able to use d.o.d. facilities. in our report, we show that the veterans transferred with -- the veterans with prosthetic issued transfer to v.a. very quickly and much larger numbers than the average veteran who left d.o.d. did. i was actually, when we started the study, concerned that d.o.d. might hold on to, or that those veterans might reside around the cities where these areas of the d.o.d. areas of expertise have highlighted but i think we found that really, they've not stuck there. they've transitioned quickly to

v.a., which was a surprise to me. i could get back with the specific numbers and specific times but there's a nice chart that shows over four or five years for -- that they're almost all in the v.a. >> thank you very much. >> mr. reyes. >> thank you, mr. chairman. i apologize for being late, we have competing hearings taking place. with regard to the -- we have the -- in fort bliss, we have the wounded warrior transition center and 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 -- what kind of r&d is going on? i know, just seeing the type of

prosthetics being used today from my viewpoint, it's phenomenal. i'm not sure that i understand where that r&d is taking place for prosthetics. >> sir, i apologize. i don't know the answer to that in detail that you need. the next panel may be able to explain what they're fundingened how much, i can't give you a good view of that, sir. >> ok. 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 v.a.? >> to some extent i can offer some comments on that. the v.a. 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, v.a. 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, v.a. 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 v.a. >> so, can you comment on whether or not there's either going to be or is a process of providing feedback? >> i can't comment on that. i think that's a question for v.a. >> ok. thank you. >> thank you. with that, 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 this morning in our fourth panel is dr. lucille beck, the acting chief consultant for the prosthetic and sensory 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 director for the ornotic and prosthetic services and norbert doyle, thank you all very much for being here this morning and -- i guess the afternoon now. dr. beck if you would proceed. -- proceed. thank you. >> good morning. chairman buerkle, ranking membermy should and others, thank you --my head, and others

-- ranking member michaud and others. i am accompanied by the amputation director system of care, our director for ornotic and prosthetic service and our chief procurement logistics officer. v.a.'s prosthetics and sensory aid service is the largest and most comprehensive provided by pross at the -- provider of prosthetic devices. any enrolled veteran may receive any prosthetic when it's determined to promote and preserve the health of an individual and is in accord with the standards of pack tess. i will sum armies the methods under way to promote patient care. staffing and community partnership, accreditation of

v.a. laboratories, approved training for v.a. staff, greater research into amputation and clinical issues and clabreagses with the department of defense. first, v.a.'s prosthetic and sensory aid service has a staff of orthotests and thoss the tists and works with the private sector to provide custom fabrication of ornotic and prosthetic devices. v.a. maintains local contracts with 600 accredited providers to deliver care closer to home. commercial partners help fabricate and fit prosthetics tissue prosthetic limbs for veterans across the country. since its creation in 2009, v.a.'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 v.a. physicians, therapists and pross the tists working together to provide the best devices and state of the art care. second, v.a. promotes the highest standards of professional expertise for its work force of 3,000 orth tists, pross the tists and fitters. each lab is accredited by the american board for prs at thics, ornotics and lo gist exs or both. this ensures quality care and services are provided by trained anding educated practitioners. third to support the continued delivery of high quality care, v.a. 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, v.a. has one of the largest ornotics and prosthetics residency programs in the nation with 18 paid residency physicians at 11 locations across the country. fourth v.a.'s office of research and development is investing hely in prosthetics and amputation health care research. it is issuings with depr applications for studies to investigate a variety of upper limb amputations. v.a. works with the department of defense to support joint research initiative to turn the advocacy and incorporation of new technological advances. finally the partnership between v.a. and d.o.d. extends further to provide a combined collaborative approach to patient care by developing a shared amputation rehabilitation clinical practice guideline for care following lower limb amputation.

v.a. is also supporting the department of defense by collaborating on the establishment of the extremity, trauma and amputation center of excellence. the mission of the center is clinical karin colluding outreach and education and research and is decided to be an elite organization for direction and oversight in each of these areas. the center is currently being implemented and will attain operating capacity by the enof the year. we support ground break regular search into new technologies, training a highly qualified cadre of staff and pursuing accreditation of all eligible prosthetic laboratories in v.a.'s amputation system of care. we are improving our oversight and management, our prosthetic purchasing and inventory management to better utilize resources we have been

appropriated by congress and to serve american'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 its bied on what we heard from the three previous panels, especially the veterans and veterans service organizations. i think they provide a reliable source of informing and they identify needs for us. my first question is, what was the impetus find behind the cheage? you heard concern from the previous panels, what was the impetus behind the change in procurement policy and did you consult with the veterans service organization or veterans? who did you talk to to make the change? >> the impetus for the change

is an impetus from the department to assure compliance with federal accusation regulations. i have with me mr. norbert doyle, our chief procurement logistics officer today, we were anticipating these questions. he's available to provide more information about the change and what is happening. >> just if you would, before you start, does that mean heretofore, the v.a. was not compliant? is that the basis for your change, that compliance is an issue, maybe you could make that clear to us. >> yes, ma'am, thank you, dr. beck. ma'am, yes, the impetus was to bring the v.a. contracting to include v.h.a. and all other v.a. support contracting organizations in line 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 around awarding of contracts and this was also to bring it in house to ensure proper stewardship of the government dollars. in reference to your question, did we talk to veteran service organizations? actually, before -- 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 complaints, 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. to address their concerns that they may have. again, i make that offer that i would 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 veterans service organizations and from the veterans themselves and from those who have gone through this process and who understand intimately as did the first two panelists that it would -- it would seem like very basic, to talk with them and to have them identify needs an concerns. you heard wounded warriors say, we're asking you, congress, to please freeze this change until -- the other point i wanted to bring up, the pilot, you heard paralyzed veterans, their organization mention the pilot. have you done a pilot? if so, what were the findings? did 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 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. only 3% of orders fall in that. 97% of prosthetic orders 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, though those were identified, i think, previously. i want to assure everybody that if a clinician specifies that specific product for a veteran, contracting will get that product for that individual. i do not, as a 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 veterans' body or gets appended to it. that is clearly a clinician

decision. how are we going to get that product that the clinician specified? we're going to do it under the us a pises of the federal acquisition regulations and we're going to cite the authorities of 8123, which is one individual mentioned that the broad latitude given by congress to the veterans administration. we're going to do that by properly preparing justification an approvals for sole source, citing in prar 4 the authorities granted under 8123. there are seven exceptions in part 6 to full and open competition, exception five is the one tagged authorized by statute. that's what we'll 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 transfer and it was a very detailed plan, the plan actually, as we got into it, got more detailed as we went and we identified other issues. we worked with our union partners to ensure they did not have issues and we could proceed successfully. there were pilots as part of the plan, probably the best part, every than bringing field people into the planning process, the pilots was a great aspect. we did pilot in three divisions, six, 11 and 20. the virginia, north carolina -- the 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 we're implementing changes to ensure that care is not impacted. some of the things we learned is that our staffing models were incorrect and the number

of procurements we could do in a day in the contracting office, we are hiring, receive approval to hire additional people to keep up. we are streamlining the process by writing that process so it's more fill in the blank with the clinician's scription. those are the type of prosessdzes. we are implementing in the rest of the veterans health administration, i think four more divisions are starting that process now. and the rest of the divisions will be coming 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 services 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 at division level, remain the eyes and ears so all orders still come through prosthetics, prosthetics is managing them and working with contracting officers to achieve the placement of the order in -- 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 of our -- of 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 pransigs. we're coming into a critical time as we move the transition forward and extend it to other divisions and we have very, very well-developed and exact procedures in place to monitor this as we go. 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. >> 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 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. i will -- i can assure you i will do nothing that hurts the veterans because there but for the grace of god go i, that's the way i look at it. >> thank you, my time is way run over. however, if you will indulge me, i have a couple of follow up questions and i'll allow you as much time as you need.

you said with procurements, it's those over $3,000 and only 3% of the orders are over $3,000. how many requests do you have? >> that's still not an insignificant number, based on our planning estimate, fiscal year 200 on which we plan the trfer over, 3% of the orders rough -- is roughly 97,000 orders. >> i would suggest because we're talking about 1,500 warriors with amputations that probably are in need of amputations that that's going to be a small percentage of what you're doing however all of those will exceed the $3,000 threshold. we heard earlier about a $12,000 limb and if it's $25,000, that doesn't mat because the veterans need prosthetics and they need state of the art prosthetics. that concerns me that piece right there. the other thing that concerns me, 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 veteran who was gone through this. and be more concerned with their thoughts about this being a program that works versus talking to the union partners and lastly the pilot information results, the results of the pilots, if i could respectfully request that you provide us with, i think you said you did three, six, 11, and 20 divisions if you could provide us with the findings from those, thank you and i yield to the ranking member. >> thank you very much, madam chair. i just want to followup, mr. doyle, on your comment you made where you mentioned that contracting officers do not change what the clinician prescribes, but actually in testimony we heard earlier, from p.v.a., that is not the case. that their testimony states that contracting officers, when they do receive the ordersing the requests for the dwiteses

is modified and even even denied in cases because of the cost. so that is a huge concern. there seems to be a disconnect from what you're hearing versus what the v.a. soldiers are hearing. the cost is a factor. it's not the veterans' health care. so do you want to comment on that? >> yes. first of all, are thing officers, all contracting officers do have, as a mandate under federal acquisition regulations to ensure that there's a price reasonableness aspect to what is provided, i don't know if that's a concern or not. i can't really speak to what may have happened before, but i have put out to the contracting community that under 81 3, if a -- if the contracting officer 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. i don't know if it's a concern that, again, i'll take full blame for not bringing the veterans services organizations into the loop in this discussion, we can fix that, but i don't know if that's part of the issue, if that's why that concern was being raised. >> it's clear from the v.s.o.'s, from their statement, that it's not uncommon for clinicians to prescribe something and it to be modified by contracting officers and primarily because of costs. that's a big concern that i would have. my other question is, you talked about older veterans at his practice complaining that there appears to be a new administrative hurdle to prevent their continuing to receive care at -- the v.a.

assured veterans they can choose their own pross the tist yet those who wish to use community-based providers report widespread administrate i hurdles and other pressures to choose in-house v.a. care. how do you explain the perception among veterans and community based providers that there seems to be a disconnect here as well as far as what you have told us versus what is 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 those -- to our slet rans. and tissue to our veterans.

-- to our veterans. in our amputee clinics, when we institute the process for the multidisciplinary compare we provide, we have physicians, pross the decisions and other contracted community partners and vendors from the community 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 we are improving the processes, i think the inspector general pointed out that there's some contract administration initiatives we need to undertake including streamlines the way we do quote reviews so they happen in a more timely fashion and that

they really clarify the scrippingtive elements for fably -- prescriptive elementsers for fabrication of the leg, or the limb, and we are doing that. and the second thing we are doing is making sure 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 tissue to get -- to reinstruct the field and educate them on that. and the third thing we are doning is we are taking a contracted, what we call contracted template where we are developing policy and guidance that can actually go into our contracts so that it is clearly specified for the contracted provider an the v.a. exactly what the rirptes are

and the timeline. so we've taken the report we have from the inspector general about the need to improve contracting administration, to spoth 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 change in -- change that you're providing, gets back to my original question, that thecally fissions -- 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 we have to do, but the bottom lean for me is to make shower that the veterans get the adequate prosthetics that they need. if it costs a little bit more they should be able to get it. if it fits them more appropriately. the concern i have is, yes, you've got to look at ceying

costs but not at the cost of providing what our veterans needs and i do have a concern with contracting officers injecting more cost versus the clinician looking at the veterans' needs. >> yes, sir, i have a concern with that too. i'm a clinician myself working in another area who provides wo in another area who provides rehab technologies to veterans, and it is critically important that what the clinician requests, and that, of course, is done in collaboration and in partnership with the veteran, these are choices and decisions about technologies that our veterans make with our clinicians and we are absolutely rehabilitation is not effective unless we are able to provide the products and services that our veterans need. and our role in pross at the

exs and in rehabilitation is to assure that any tissue that any contract, the way we procure items enhances and -- not only enhances but provides high quality, individualized care. we have done that successfully for a long time and we believe that we are able to do that as we move forward. if mr. doyle has cited the -- we the framework of contracting requirements and the added authority that congress fway us many years ago for 8123, i think, is the other piece of sole source procurement we can do when we need to provide and when we are providing highly individualized products an services. >> thank you, madam chair. >> i now recognize the gentleman from texas, mr.

reyes. >> thank you, madam chair. dr. beck, you mentioned the center of excellence. where is that located? and how much of the work being done there is medical research as it pertains to prosthetics? >> the center of excellence i spoke about is the joint v.a.-d.o.d. center of excellence for extremity care. that will be a virtual center, or it is a virtual center. it will have locations in san antonio, texas, and in washington, d.c. staff will be distburetted across our system so that some of our staff will be in various centers, both v.a. and d.o.d. centers around the country. so that we are collaborating, coordinating our efforts. and i think you mentioned research earlier, sir, and one

of the things that we talked about that we'll be able to do by leveraging the capability with d.o.d. and v.a., we will be able to do clinical trial type of evaluations at a numb of different centers at the same time. that is one of the missions of this joint v.a.-d.o.d. center of excellence is research coordination and studying and reporting on new technologies and developing better outcomes for kear. >> and how will you ensure that the medical research that's going on is somehow tied back with the feedback give -- being given back by the veterans? you know, their experiences with the different types of prosthetics, the challenges that they have and also pain

management? is that all part of that? >> it is. i will comment and i will ask dr. webster to comment. the participants in these studies will be veterans and active duty service members. they'll be able to report firsthand what their experiences are. so that's how we will tie in the feedback. we also listen carefully to our veterans in our -- as we look at our outcomes of care and their successful use of prosthetic limbs and technologies. to gain information about where the research needs are. i'm going to ask dr. webster to comment just for a minute on what we're doing with pain management. >> thank you. i really appreciate the opportunity to be here today and provide this testimony.

i agree that it is extremely important that we get feedback and information from the veterans an servicemens with amputations on what is important in research. we can do research looking at various things but if it's not important to the veteran or service member it's not going to do us much good. that is critically important. that is done on a routine basis. the captain provided testimony earlier that an expert panel put together looking at amputation care as well as prosthetic care that will continue to occur as we move forward with our research efforts. again, with the center of excellence, some of the physicians, our administrative headquarters will be in san antonio and the national capital region but many of the research staff are locate witness stand our treatment facilities so within walter reed or within the center for the intrepid. they're completely integrated

with the clinical staff and with the soldiers and veteran whors being treated in those facileties. >> and how -- i'm curious how the process works. is there like a caseworker that will have a case load of the particular veterans? to make sure that feedback is coming to the caseworker and that feed back -- feedback goes into the r&d component? how does the process work? >> i think it can occur both directly from the service member or veteran to the researchers, again, they're going to be co-located in the clinical areas. that feedback can come directly but there's also opportunities for the feedback to the people who are doing the research to come from the case managers, to come from other providers,

whether it be a physical therapist or physician. any of those providers who are providing care for people with amputations -- amputations can provide input into what is important for research and research initiatives. >> when would this process be implemented? is it already going on? if so, are there examples or an example of how that's working to make sure that the feedback of the veteran is taken into account? >> well, the center that we spoke about is standing up now. we expect it to be operatal by -- operatal by the end of -- operational by the end of this year. i want to talk about a couple of research projects that are good examples of the work we are doing. i think that one of them is what's known as the dar p -- darpa arm, probably the most advanced research activity

that's going on and that's the defense agency project for the development of a prosthetic, upper extremity, an arm. the way that is working, that has been funded by the defense department. >> that's the one that medal of honor winner petri has, right? >> yes. >> the one the hand -- >> does he have that arm? we're going to find out that for you. we're not exactly sure. >> i think that's right because i visited with him in my office and he actually took the hand off and put it back on and i -- i'm not 100% sure but i think either he or somebody referred to it as the car pa arm. >> we'll -- as the darpa arm. >> we'll check on that for you. one of the things, a good

example of veteran feedback is in the first study that was done to evaluate the arm, our veterans participated in that study and came to v.a. facilities. and participated in the study. we anticipate the second part of the study, which will now be a take-home study, where veterans will be able to take the arm home and use it in their everyday activities and a they will be providing feedback on the arm and what is required next. and we do that frequently with technologies. and the knee technology that v.a. and d.o.d. have worked on together and had our veterans

and active-duty service members participate in those evaluations. >> each veteran is a case on to him or herself and the responsibility will be with the equivalent of a v.a. case worker to make sure that all of these things take place? >> the v.a. has in place a type of case manager for amputees or amputation care and that person is known as an amputation rehabilitation coordinator. and at all of our major amputation care sites that we talked about, seven regional centers, additional 15 network sites spread throughout the country, we have in place this special kind of case manager who is case managing our amputees

and providing those services and seeing that their needs are met. so it is a case management kind of function similar to the other types of case manager, but it is specialized to address the needs of our amputees. and many of those case managers are they are pivots. these are physical they are pivots or occupational therapists. >> this may be an area where we can follow up on. >> would you like a second round of questioning? with that, i think we'll start a second round of questioning if you have the time and indulge us for a few more questions this afternoon. in the panel with mr. pruden, captain pruden, he talked about this new system that you are

going to go to, the electronic contract management system, and talk to us about the fact that it requires 300 steps to the request in. can you comment on that. >> i'm going to ask mr. doyle, who is our expert in this area to comment on that electronic contract management system. >> it's new in that we will be putting in place as part of this system, the module, which is the part where the requiring people in this case, prosthetics can put in their requirements and that's how it is transferred over to the contracting office. we have had the electric tronic contract management system in v.a. for several years and that's what our contract writing tool in effect. and that's what we will use to write the contracts for the prosthetics that come across to us. as for the 300 steps, i will say

i know it's probably not the easiest system to use and can be labor intensive and i have to sit with the individual that came up with the 300 steps. that is a new figure on me. >> i guess when we are talking about light bulbs or tissues our any items we need to purchase and contract out within the v.a., that's one thing. we are talking about in the whole scheme of things, a very small quantity, a very specialized product. and this morning in the testimony i heard the word intimate. it becomes a part of the veteran's body. it's not like some isolated product that we use. it is specific to that person. and to take that request or contract and dump it into a system like this, it seems to me that the opportunity for a lack

of timeliness, lack of personalization, you name it, this thing is arrive with the pockets -- rife with the possibilities, means i can't walk my daughter down the aisle, those are intimately personal that we, the v.a. or whatever the system, we may run the risk of not allowing our veterans to do that. and every day without a wheelchair or prosthetic, shame on us, shame on this country. if he we are ever on our game, we ought to be providing for our military. my concern is that as soon as you take away the personal piece of this, we run the risk of the government buyer buyer and making sure that veteran has exactly what they need as soon as they need it, and it is state of the art and so that they can

get back to the life they had as best a as they can and maximize them. that's my concern. our concern is to maximize the quality of life for these veterans. and when i hear this,, you all know what it's like to deal with government and how impersonal, even in a small settings, with prescriptions and everything else, but this goes to the veteran's quality of life and my concern is that this was an arbitrary and i will be anxious to see the thoughts of the pilot studies and not enough consultation was had and not enough work was done before this change was made. and we aren't talking about 25,000 to 30,000 prosthetics, but a much smaller group and we need to make sure we are doing

it right for these veterans and i will yield to the ranking member if he has additional questions. >> just two additional questions. my first is, does the v.a. have an objective measure to evaluate the pros thet particular outcome -- prosthetic outcome? >> we took the number of orders that were expected to come over to acquisition and work load factor model and we anticipated or assumed a number of people that would be required. our staffing model was wrong and we were hiring additional people. people we are hiring are pittsburgh agents who are coming across and will now be working with procurement which is good for them which is good

opportunity as an 1102 as versus a purchasing agent 1105. we are staffing to the level of two to three complete orders per day. that's the metric and we will be tracking those metrics to make sure we don't fall behind. if we do start falling behind, if the unexpected does happen, bus we are approaching the fourth quarter as well which is the busiest time of the year, we have the legacy system that we can fall back upon.

>> people are working together to make sure we meet the needs of the veteran. but the prosthetics people are the upfront face to the veteran and identifying what they need and we will get under 8123, if it is a specific product, we will get that product and the product will come back to the prosthetics people for the follow-up aspect for the veteran and if there are delays that the prosthetics folks will let us know and make sure there is an issue. >> delays in getting -- my question is, the veteran themselves, have you done an evaluation?

>> we have looked at using our what our amputees used at that time. the inspector general in the most recent report also provides us with veterans' satisfaction

data. we realize we need to do more in that area and are now looking at a couple of options that we have . one is with the standardized survey that related to patient satisfaction that the committee on accredit dation of rehab facilities uses. we intend to use that and for our amputation system of care we will use that veteran satisfaction survey in all of our amputation care clinics and we are also looking at other ways to assess veteran satisfaction. >> can you provide the committee with your latest survey for the veterans and their satisfaction. my last question is do you find it difficult -- this is a special field, to find and hire

qualified clinical personnel? >> we have done a lot of hiring in the field of rehabilitation. and for the clinicians over the last several years and i think we have added a lot of new providers, providers who are highly experienced and very capable for this profession, as we have with physical therapy and occupational therapy and some of the rehab professions, the jobs are extremely competitive. we have done a couple of things in our system. one is that our clinicians are title 38, so we are able to recognize them for their clinical capabilities and advance them based on that performance and pay scale.

and while it is a challenge, we have been able to attract high quality providers and fill our positions. i'm going to ask dr. miller to give you some comments. >> thank you very much. i am an iraqi vet and had the honor of serving both at walter reed army medical center and chief in prosthetics. with regards to our work force, the v.a. is very competitive in that we are able to attract and retain quite a few of the few of the private sector clinicians. when we give them the ability to treat and care for veterans, that's a mission they enjoy and wanting to do. we offer training and education. we offer the accessibility to the technology that the veterans

receives and that technology is available only within the v.a. and d.o.d. and that is attractive to those who want to practice and do clinical care. >> mr. reyes, any additional questions? >> just a couple of brief points. of the 600 vendors that you mentioned, the contact with our veterans, are they independent of the v.a. or through the v.a. does it sometimes happen that a patient will be contacted outside the v.a. and something they ought to try. how do those vendors have contact with our wounded warriors?

>> the 600 contracted vendors are community partners and so they are active within our v.a. facilities and attend clinics and help in the prescription rationale of that item for that veteran. and so they are involved extensively with us in the care. >> they would not have independent contact with the veterans themselves? >> they would. if the vendor was selected to provide that limb, the veteran would go to their private facility and have that designed for them independent of what's going on at the v.a. medical center. >> and do those vendors, are they just doing these prosthetics based to v.a. specs or do they do them independent? >> whenever a prescription is written for that, it's done to

what we refer to as industry standards. we contact those providers that have. >> for a specific product? >> that's correct. >> on the surveys, part of what i think doesn't reflect the sentiments of the veteran base and i say this from experience as we have had there in el paso, the veterans that are not getting either access to health care or upset about something, they are very good about taking these surveys and sending them back in. it's been my experience and i say this because i had even some of the members of my family that have gotten those surveys and because they are satisfied, they don't return them. they just chuck them. is there a way or a process that

you factor into that? in other words, if you send out 20,000 surveys and you only get back 1,000 -- how -- is there some way to factor in those veterans that don't send it in because they are satisfied? these surveys are multiple pages and don't want to take the time or can't take the time to answer all those questions. and i think that really skews the results for the v.a. facility. is there some way that can be done or is that being done? is that taken into consideration? >> that's a very challenging question and going to answer that a couple of ways. i think when any of us use surveys or publish surveys or read about surveys, you will very often see a statement about the response rate because if the

response rate is very low, if you send out 20,000 questionnaires and only 1,000 people respond, then your questionnaire doesn't have a lot of validity because the number of people you are sampling and that's a challenge and every way we do surveys. that would be the first thing that we do. i think our surveys -- try to design surveys that will be easy so that people return them. and i think, you know, we need to do better with that. as we are developing outcome measures and satisfaction measures we are focused on making them short and easy for the clinicians and for the veterans to fill out. and i think that is what we are trying to do as we address patient satisfaction, veteran satisfaction and even outcome measures. >> because if you include a

postcard that basically says i'm satisfied. i can't or don't want to go through the whole survey, count me as satisfied, because i believe that -- the results are being skewed because veterans don't want to go through those multiple pages. whoever is designing those to be short is sailing. i have gotten them myself and let me tell you, 16 pages is not short. >> i don't want to fill those out either. thank you. >> before we adjourn this afternoon's hearing, i would respectfully request thaw provide us -- earlier, dr. beck, you mentioned, there are shared clinical practice guidelines. so much of the testimony we heard is that d.o.d. is taking the lead in prosthetics and you are assuring there is some collaboration between d.o.d. and v.a.

if you could provide for the subcommittee all of the initiatives that are going to ensure that the v.a. is working with in trying to emulate and catch up to d.o.d.'s prosthetic programs, that would be helpful for us. >> thank you, yes. we will do that. >> if there are no further questions. i want to thank the sports panel for your endurance. this was a long hearing and for your willingness to be here. thank you and both of you for being here. and before we adjourn the meeting, this is always a good opportunity for this subcommittee to say thank you to all of the veterans, to the veteran service organizations for your service and for your sacrifice to this country. the united states is the greatest country in the history of the world and because of the history of the sacrifice for the men and women who have served this country. with that, i ask unanimous consent that all members have five legislative days to revise

and extend their remarks and include any extraneous materials. without objection. thank you to all our participants for joining in today's conversation. the hearing is now adjourned. >> this hearing held by a house veteran subcommittee took place almost two weeks ago. tomorrow, we'll have more about health care for veterans with pros thet particulars and how the veterans affairs department purchases prosthetics for vets and some of the purchasing responsibility to contractors. see that hearing live tomorrow afternoon at 4:00 eastern on c-span3. starting at 10:45 a.m. eastern, american enterprise institute hosts an event with ashton carter and will speak about u.s. defense department priorities and automatic budget cuts in

january. his remarks live here on c-span. a look back at the 2008 financial crisis and what led to it. witnesses include a former chief economists and witnesses who wrote about the collapse hosted by the american enterprise institute live noon eastern also here on c-span. >> distinction between success and greatness and too many folks are chasing success and lost sight of what it means to go after griteness. you can be successful without being great. but you will never be great without being successful. if your whole goal is to have, have, have, to get, get, get, more, more, more, if that's all it's about, then you are chasing success. and in truth, you aren't chasing significance but it can't be about the chase for success. we must also be skeshedr

concerned about what it means to be great and greatness is he who is greatest among you will be your servant. >> watch commencement speeches from the past three decades online at the c-span video library. spend the weekend in kansas with book tv and american history tv saturday at noon eastern, literary life with book tv on c-span2. american presidents from "business on black and white" and "the barn stormer and the lady." browse a rare book collection. and sunday at 5:00 p.m. eastern on american history tv, experience early plane life at the old museum, the early days of flight. two participants from the kansas civil rights movement. in 1958 they sat down for service at a local drug story.

c-span's local content vehicle explores cities across america. this weekend from wichita, kansas on c-span 2 and 3. >> writing is a transactional process. writing assumes reading and goes back to that question about, you know, a tree falling in the forest if there is no one there to hear it. if you have written a wonderful novel, one of the parts of the process is that you want readers to be enlarged and enriched by it. and you have to pull on everything at your disposal. >> anna quinn lan will talk about writing and life and her guide to social policy and "lots of candles plenty of cake" and will be available for tweets and emails on c-span2.

>> president obama hosted the presidential medal of freedom ceremony earlier today at the white house. former secretary of state madeleine albright and john glenn and bob dylan and john paul stevens. it is the highest award created in 1963 as an executive order by president kennedy. this is 35 minutes.

president obama and first lady michelle obama presenting the presidential medal of freedom to 13 recipients. [applause] [applause] >> ladies and gentlemen, the president of the united states. [applause] >> everybody, please have a seat, and welcome to the white house. it is extraordinary to be here with all of you to present this year's medal of freedom. and i have to say, just looking around the room, this is a packed house. which is a testament to how cool this group is. everybody wanted to check them out. this is the highest civilian honor this country can bestow. which is ironic because nobody sets out to win it. no one ever picks up a guitar or fights a disease or starts a movement thinking, you know what, if i keep this up in 2012, i could get a medal in the white house from a guy named barack obama.

that wasn't in the plan. but that's exactly what make this is award so special. every one of today's honorees is blessed with an extraordinary amount of talent. all of them are driven. but, you know, we could fill this room many times over with people who are talented and driven. what sets these men and women apart is the incredible impact they have had on so many people. not in short, blinding bursts, but settled over the course of a lifetime. together, the honorees on this stage and the ones who couldn't be here have moved us with their words, have inspired us with their actions. they've enriched our lives and changed our lives for the better. some of them are household names, others have labored quietly out of the public eye.

most of them may never fully appreciate the difference they've made or the influence they've had, but that's where our job comes in. it's our job to help let them know how extraordinary their impact has been on our lives. so today, we present this amazing group with one more accolade for a life well led. that's the presidential medal of freedom. so i'm going to take an opportunity, i hope you guys don't mind, to brag about each of you. starting with madeleine albright. usually madeleine does the talking. once in a while she lets her jewelry do the talking. when saddam hussein called her a snake, she wore a serpent on her lapel the next time she visited baghdad. when slobodan milosevic referred to her as a goat, a new pin

appeared in her collection. as the first woman to serve as america's top diplomat, her courage and toughness helped bring peace to the balkans and paved the way for progress in some of the most unstable quarters of the world. as an immigrant herself, granddaughter of holocaust victims who fled her native czechoslovakia as a child, madeleine brought a ewe meek perspective. once at a naturalization ceremony, an ethiopian said, only in america can a refugee meet the secretary of state. she replied, only in america can a refugee become the secretary of state. we are extraordinarily honored to have madeleine here. i think it's fair to say i speak for one of your successors who is so appreciative of the work you did and the path you

laid. it was a scorching hot day in 1963 and mississippi was on the verge of a massacre. the funeral procession for medgar evers had disbanded and a group of people were slowing stones at police officers. a man in shirt sleeves walked toward the protesters, hands raised, and convinced the protesters to go home peacefully. he was the face of justice in the south and proof that the federal government was listening. over the years, john doar escorted james meredith to the university of mississippi. he walked alongside the selma to montgomery march he laid the groundwork for the civil rights act of 1964 and the voting rights act of 1965. in the words of john lewis, he

gave civil rights workers a reason not to give up on those in power. and he did it by never giving up on them. and i think it's fair to say i might not be here had it not been for his work. bob dylan started out singing other people's songs, but as he said, there came a point where i had to write what i wanted to say because what i wanted to say, nobody else was writing. born in minnesota a town, he says, where you couldn't be a rebel, it was too cold. bob moved to new york at age 19. by the time he was 23, bob's voice, with its weight, its unique, gravelly power was redefining not just what music sounded like but the message it carried and the way it made people feel. today, everybody from bruce springsteen to u2 owes him a debt of gratitude. there's not a bigger giant in

the history of american music. all these years later, he's still chasing that sound, still searching for a little bit of truth and i have to say that i am a really big fan. in the 1960's, more than two million people died from smallpox every year. just over a decade later, that number was zero. two million to zero. thanks in farther tissue part to dr. bill foege. as a young medical missionary in nigeria, he helped develop a vaccination strategy used to eliminate smallpox from the face of the earth. when that war was won, he moved on to other diseases, always trying to figure out what works. in one remote nigerian village, after vaccinating 2,000 people in a single day, he asked the chief how did he get so many people to show up? he said, i told them to come see

the tallest man in the world. today, that really tall -- the world owes that really tall man a great debt of gratitude. on the morning that john glenn blasted off into space, america stood still. for half an hour, the phones stopped ringing in chicago police headquarters. new york subway drivers offered a play-by-play account other the loud speakers. president kennedy interrupted a breakfast with congressional leaders and joined 100 million tv viewers to hear the famous words, god speed, john glenn. the first american to orbit the earth. john glenn became a hero in every sense of the word. but he didn't stop there serving his country. as a senator, he found new ways to make a difference. on his second trip into space at

age 77, he defied the odds once again. he reminds everybody, don't tell people he lived a historic life, don't put it in the past tense. he's still got a lot going on. judge hirabayashi, as a student at the university washington, gordon was one of only three japanese americans to defy the executive order that forced thousands of families to leave their homes, their jobs, and their civil rights behind and move to interment camps in world war ii he took his case to the supreme court and he lost. it would be another 40 years before that decision was reversed, giving asian americans everywhere a small measure of justice. in gordon's words, it takes a

crisis to tell us that unless citizens are willing to stand up for the constitution, it's not worth the paper it's written on. this country is better off because of citizens like him who are willing to stand up. similarly, when cesar chavez sat dolores huerta down at his kitchen table and told her they should start a union, she thought he was joking. she was a single mother of seven children, so she didn't have a lot of time. but she remembered seeing children come to school hungry and without shoes so in the end she agreed and workers everywhere are glad she did. without any negotiating experience, she helped lead a worldwide grape boycott that forced growers to agree to some of the country's first farmworker contracts. ever since, she's fought to give more people a seat at the

table. don't wait to be invited, she says. step in there. and on a personal note, dolores was very gracious, when i told her i had stolen her slogan, yes, we can, knowing her, i'm pleased she let me off easy because dolores does not play. for young, jan karski's students knew he was a great professor but didn't know she was a hero. he served as a courier for the polish resistance in the darkest days of world war ii. before one strip across enemy lines, resistance fighters told him jews were being murdered on a massive scale and smuggled him into the warsaw ghetto and a polish death camp to see for himself.

he took that information to president franklin roosevelt, giving one of the first accounts of the holocaust, and imploring the world to take action. it was decades before jan was ready to tell his story. by then, he said, i don't need courage anymore so i teach compassion. growing up in georgia, in late 1800's, juliette gordon low was not exactly typical. she flew airplanes. she went swimming. she experimenting with electricity for fun. and she recognized early on that in order to keep up with the changing times, women would have to be prepared. so at age 52, after meeting the founder of the boy scouts in england, she came home and called her cousin and said, i've got something for the girls of is a va na and all the world -- of savanna and all the world and we're going to start it tonight. 60 years later, millions of

girls have gained confidence through the organization she founded. including astronauts and my own secretary of state. from the very begin, they included all races and abilities, just the way juliette would have wanted it. toni morrison, as a -- an employee at a publishing company by day, she would write at night. with her kids pulling her hair and jewelry. once a baby spit up on her tablet and she wrote around it. toni morrison's prose brings us that kind of moral and emotional intensity that few writers ever attempt.

"song of solomon," to "beloved" she reaches us deeply using a ten that's lyrical, precise, distinct and inclusive. she believes that language arcs toward the place where meaning might lie. the rest of us are lucky to be following along for the ride. during oral argument justice john paul stevens would often begin with a polite, may i interrupt? or may i ask a question? you imagine the lawyers would say ok. after which he would just as politely force the lawyers to quit dancing around and focus on the major part os they have case. he is the third longest serving justice on the supreme court. justice stevens supplied throughout his career his clear and graceful manner to the defense of individual rights and

the rule of law, favoring a pragmatic solution other an ideological one. ever humble, he would happily comply when unsuspecting tourists asked him to take their picture in front of the court and at his vacation home in florida, he was john from arlington, better known for his world class bridge game than his world-changing judicial opinions. even in his final days on the bench, he insisted he was still learning on the job. but in the end, we are the ones who have learned from him. when a doctor first told pat summitt she suffered dementia, she almost punched him. when a second doctor advised her to retire, she responded, do you know who you're dealing with here? obviously they did not. as pat says, i can fix a tractor, mow hay, plow a field, chop tobacco, and call the cows but what i'm really known for is winning.

as pat said, i can fix a tractor, plow a field, chop tobacco, fire a barn and call the cows but what i'm really known for is winning. in 38 years at tennessee she racked up eight national championships, more than 1,000 wins, understand, this is more than any college coach, male or female, in the history of the ncaa. and more importantly, every player that went through her program has either graduated or is on her way to a degree. that's why anybody who feels sorry for pat will find themselves on the receiving end of that famous glare or she might punch you. [laughter] she's still getting up every day and doing what she does best which is teaching. the players, she says, are my best medicine.

our final honoree is not here. shimon peres is the president of israel who has done more for the cause of peace in the middle east than just about anybody alive. i'll be posting president peres for a dinner here at the white house next month and will be presenting him with his medal and honoring hi his incredible contribution to the state of israel and the world at that time. so i'm looking forward to welcoming him and if it's already with you, i will say my best lines about him for that occasion. so these are the recipients of the 2012 medals of freedom. and just on a personal note, i had a chance to see everybody in the back. what's wonderful about these events for me is so many of these people are my heroes individually. you know, i know how they impacted my life. i remember reading "song of solomon" when i was a kid and not just trying to figure out how to write but also how to be and how to think. and i remember in college

listening to bob dylan and my world opening up because he captured something about this country that was so vital. and i think about dolores huerta, reading about her when i was starting off as an organizer. everybody on this stage has marked my life in profound ways and i was telling somebody like pat summitt, when i think about my two daughters, who are tall and gifted, and knowing that because of folks like coach summitt, they're standing up straight and diving after loose balls and feeling confident and strong. then i understand the impact these people have had extends beyond me. it will continue for generations to come. what an extraordinary honor to be able to say thank you to all

of them for the great work that they have done on behalf of this country and on behalf of the world. so, it is now my great honor to present them with a small token of our appreciation. [applause] >> presidential medal of freedom citations. madeleine albright. madeleine albright broke barriers and left be a indelible mark on the world as the first female secretary of state in the united states history. through her consummate diplomacy and steadfast democratic ideals, secretary albright advanced peace in the middle east, nuclear arms control, justice in the balkans and human rights around the world. with unwavering leadership and continued engagement with the

global community, she continues her noble pursuit of freedom and dignity for all people. [applause] >> john doar, as african-americans strove for justice, john doar led federal efforts to defend quality and enforce civil rights. risking his life to confront injustices around him, he prevented a violent riot, obtained convictions for the killing of civil rights activists and stood by the first african-american student at the university of mississippi during his first day of class.

during pivotal moments and in the troubled times of the watergate scandal, john doar fought to protect the core values of liberty, equality and democracy that have made america a leader among nations. [applause] >> bill foege. >> he is pretty tall. [laughter]

>> a distinguished physician, bill helped lead a campaign to eradicate smallpox that stands among medicine's greatest success stories. at the centers for disease control and prevention, the carter center and the bill and melinda gates foundation, he has taken on humanity's most intractable public health challenges from infectious diseases to child survival and development. william foege has driven decades of progress to safeguard the well-being of all and has inspired a generation of leaders in the fight for a healthier world. [applause]

>> john glenn. john glenn has set an example through his service to our nation. as a marine corps pilot in the first american to orbit the earth, he sparked our passions for ingenuity and adventure and lifted humanity's ambitions into the expanses of space. in the united states senate, he worked tirelessly to ensure all americans had the opportunity to reach for a limitless dream. whether by advancing legislation to limit the spread of nuclear weapons, or by becoming the oldest person ever to visit space, john glenn's example has moved us all to look to new horizons with drive and optimism. [applause]

>> susan carnahan, accepting on behalf of her husband, gordon hirabayashi. in his open defines of discrimination against japanese americans during world war ii, gordon hirabayashi demanded our nation live up to its founding principles. in prison for ignoring curfew and refusing to register for internment camp it's, he took his case to the supreme court which ruled against him in 1943. refusing to abandon his belief in an american, he pursued justice until his conviction was overturned in 1987. his legacy reminds us that patriotism is rooted not in ethnicity but in our shared ideals and his example will forever call on us to defend the liberty of all our citizens. [applause]

>> dolores huerta. one of america's great labor and civil rights icons, dolores huerta has devoted her life to advocating for marginalized communities. alongside cesar chavez, she co-founded the united farmer workers of america and fought to secure basic rights for migrant workers and their families. helping safe thousands from neglect and abuse. dolores huerta has never lost faith in the power of community organizing and through the dolores huerta foundation, she continues to train and mentor new activists to walk the streets into history. [applause]

>> adam daniel roadfeld, foreign polish-born minister accepting on behalf of jan karski. as a young officer in the polish underground, jan karski was among the first to relate accounts of the holocaust to the world. a witness to atrocity in the warsaw ghetto, he repeatedly crossed enemy lines to document the face of genocide and courageously voiced tragic truths all the way to president roosevelt. he illuminated one of the darkest chapters of history in and his intervention on behalf

of the innocent will never be forgotten. [applause] >> richard flats accepting on behalf of he's great aunt, juliette gordon low. an artist, athlete and trail blazer for america's daughters, juliette gordon low founded an organization to teach young women self-reliance and resourcefulness. a century later during the year of the girl, the girl scouts more than three million members are leaders in their communities and translating new skills into successful careers. americans of all backgrounds continue to draw inspiration from juliette gordon low's remarkable vision and we celebrate her dedication to

empowering girls everywhere. [applause] >> toni morrison. the first african-american woman to win a nobel prize, toni morrison is one of our nation's most distinguished story tellers. she has captivated readers through lyrical pros that depicts the complexities of a people and challenges our concepts of race and gender. her works are hallmarks of the american literary tradition and the united states proudly honors her for strengthening the character of our union. [applause]

>> john paul stevens. from the navy to the bench, john paul stevens has devoted himself to service to our nation. after earning a bronze star in world war ii, stevens returned home to pursue a career in law. as an attorney he became a leading practitioner of antitrust law and as a supreme court justice he dedicated his long and distinguished tenure to

applying our constitution with fidelity and independence. his integrity, humility and steadfast commitment to the rule of law have fortified the noble vision of our nation's founders. [applause] >> pat summitt. pat summitt is an unparalleled figure in collegiate sports. over 38 seasons, she proudly led the university of tennessee lady volunteers to 32 s.e.c. tournament and regular season championships and eight national

titles. becoming the all-time winningest coach in ncaa basketball history. on the court, coach summitt inspired young women across our country to shoot even higher in pursuit of their dreams. off the court she has inspired us all by turning her personal struggle into a public campaign to combat alzheimer's disease. pat pat summitt's strength and character exemplify all that is best about athletics in america. [applause] >> bob dylan. >> come on, bob.

>> a modern day troubadour, bob dylan established himself as one of the most influential musicians of the 20th century. the rich poetry of his lyrics opened up new possibilities for popular song and inspired generations. his melodies have brought ancient traditions into the modern age. more than 50 years after his career began, bob dylan remains an eminent voice in our national conversation and around the world. [applause] >> could everybody please stand and give a rousing applause to our medal of freedom winners. [cheers and applause]

you don't have to stand. >> well, we could not be prouder of all of them. we could not be more grateful to all of them. you have had an impact on all of us. and i know that you will continue to have an impact on all of us.

so, thank you for being here, thank you for putting yourself through white house ceremonies which are always full of all kinds of protocol call. fortunately we also have a reception afterwards. i hear the food around here is pretty good. so, i look forward to all of you having a chance to stay and mingle and, again, thank you again to all of you. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2012]