[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
OPTIMIZING CARE FOR VETERANS WITH PROSTHETICS: AN UPDATE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
JULY 31, 2012
__________
Serial No. 112-72
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
ANN MARIE BUERKLE, New York, Chairwoman
CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
July 31, 2012
Page
Optimizing Care for Veterans with Prosthetics: An Update......... 1
OPENING STATEMENTS
Chairwoman Ann Marie Buerkle..................................... 1
Prepared statement of Chairwoman Buerkle..................... 18
Hon. Michael H. Michaud, Ranking Democratic Member............... 6
WITNESSES
The Honorable Robert A. Petzel, M.D., Under Secretary for Health
Veterans, Health Administration, U.S. Department of Veterans
Affairs........................................................ 3
Prepared statement of Dr. Petzel............................. 19
Accompanied by:
Mr. Philip Matovsky, Assistant Deputy Under Secretary for
Health, Administrative Operations Veterans Health
Administration, U.S. Department of Veterans Health
Dr. Lucille Beck, Ph.D., Chief Consultant, Rehabilitation
Services Director, Audiology and Speech Pathology
Acting Chief Consultant, Prosthetics and Sensory Aids
Service Veterans Health Administration, U.S. Department
of Veterans Affairs
Mr. C. Ford Heard, Associate Deputy Assistant Secretary for
Procurement Policy, Systems and Oversight, Office of
Acquisitions, Logistics and Construction
MATERIAL SUBMITTED FOR THE RECORD
Questions and Responses from the United States Department of
Veterans Affairs............................................... 21
Summary of Plan to Merge Prosthetic and Sensory Aids Service and
Office of Rehabilitation Services.............................. 22
OPTIMIZING CARE FOR VETERANS WITH PROSTHETICS: AN UPDATE
----------
TUESDAY, JULY 31, 2012
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 4:40 p.m., in
Room 334, Cannon House Office Building, Hon. Ann Marie Buerkle
[Chairwoman of the Subcommittee] presiding.
Present: Representatives Buerkle, Roe, and Michaud.
OPENING STATEMENT OF CHAIRWOMAN ANN MARIE BUERKLE, SUBCOMMITTEE
ON HEALTH
Ms. Buerkle. The Subcommittee will come to order. Good
afternoon and welcome to today's Subcommittee hearing:
Optimizing Care for Veterans With Prosthetics: An Update.
Today's hearing is a continuation of a discussion we began
almost 3 months ago when this Subcommittee heard from veterans
with amputations, members of our VSOs, and officials from the
Department of Veteran Affairs to review the VA's capability of
delivering state-of-the-art prosthetic care to our veterans
with amputations and the impact of the VA's planned prosthetic
procurement reforms. These reforms will, among other things,
take prosthetic purchasing authority away from the prosthetic
specialists and transfer it to contracting officers.
As our veterans so eloquently described in May, prosthetic
care is unlike any other care that VA may provide, and when we
make the mistake of treating it as such, no less than the daily
and ongoing functioning and quality of life of our veterans is
at stake. I was very troubled to hear from our veterans such
strong opposition to the proposed reforms, arguing forcefully
that they would lead to substantial delays in care for veterans
with amputations and clinical judgments regarding veterans'
needs being overridden by individuals with little or no
experience in prosthetic care.
In mid-June, following our hearing, I sent a letter, along
with Ranking Member Michaud, to the Secretary, requesting that
the Department respond to a number of questions and provide
certain materials regarding the strategy, plans, and criteria
used to develop, consider, design and evaluate the proposed
reforms as well as the pilot programs that preceded them.
Our goal was to understand the analysis VA employed to
develop the reforms and what was behind the decision that they
were the best idea for our veterans, especially those who have
experienced loss of limb as a result of service to our Nation.
Sadly, the Department's response, which came a week after
the deadline requested in our letter, did not provide the
information or the level of detail we asked for, and did
nothing to assure me that the plan would be effective or that
our veterans' concerns were unfounded. To the contrary, a close
review of the materials VA provided leads me to believe that
the reforms were developed without careful and thorough
consideration.
It leads me to believe that they were developed without
sufficient input from our veterans themselves, our veteran
service organization advocates, or other stakeholders. It leads
me to believe that they were developed and implemented after
being tested for a very short period of time at a small number
of locations, with very limited feedback. It led me to believe
that they were developed without adequately measuring their
impact on patient care. It led me to believe they were
developed without safeguards in place to ensure that our
veterans' and clinicians' wishes are respected and timeliness
goals are met.
It is concerning that VA would move forward with
instituting such large-scale changes that so directly impact
our veteran patients in this way. If my concerns are
groundless, and I truly hope they are, I want the VA in
explicit detail to explain why.
During our last hearing, our veterans and VSOs spoke very
loud and clearly. Now it is time for the VA to do the same.
[The prepared statement of Ms. Buerkle appears on p. 18.]
Ms. Buerkle. Again, I thank you all for joining us this
afternoon. Our Ranking Member, Mr. Michaud, is on the floor. We
will give him an opportunity to provide remarks when he
returns.
Now I would like to invite our first and only panel to the
witness table.
Joining us from VA is the Honorable Under Secretary for
Health, Dr. Robert Petzel. Dr. Petzel is accompanied by Philip
Matovsky, the Assistant Deputy Under Secretary for Health,
Administration Officers; Dr. Lucille Beck, Chief Consultant of
Rehab Services, Director of Audiology and Speech Pathology, and
the Acting Chief Consultant for Prosthetics and Sensory Aids
Service; and Ford Heard, the Associate Deputy Assistant
Secretary for the Office of Acquisition and Logistics.
Thank you all very much for being here.
Dr. Petzel, thank you for your service to our veterans and
for taking the time out of your schedule to be here this
afternoon to address what we consider an extremely important
issue on behalf of our veterans. I look forward to hearing your
testimony.
You may proceed at this time. Thank you.
STATEMENTS OF HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR
HEALTH, VETERANS HEALTH ADMINISTRATION, UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY PHILIP MATOVSKY,
ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH, ADMINISTRATIVE
OPERATIONS, VETERANS HEALTH ADMINISTRATION, UNITED STATES
DEPARTMENT OF VETERANS HEALTH, LUCILLE BECK, PH.D., CHIEF
CONSULTANT, REHABILITATION SERVICES DIRECTOR, AUDIOLOGY AND
SPEECH PATHOLOGY, ACTING CHIEF CONSULTANT, PROSTHETICS AND
SENSORY AIDS SERVICE, VETERANS HEALTH ADMINISTRATION, UNITED
STATES DEPARTMENT OF VETERANS AFFAIRS, AND FORD HEARD,
ASSOCIATE DEPUTY ASSISTANT SECRETARY, OFFICE OF ACQUISITIONS
AND LOGISTICS, UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. ROBERT A. PETZEL, M.D.
Dr. Petzel. Chairwoman Buerkle, Ranking Member Michaud, and
Members of the Subcommittee, I want to thank you for the
opportunity to speak about the Department of Veterans Affairs
prosthetics procurement reform. Thank you, Madam Chairwoman,
for introducing the people that are accompanying me.
VA testified before this Subcommittee and the Subcommittee
on Oversight and Investigations in May, 2012. We did this
regarding our efforts to maintain the high quality of
prosthetics VA provides to veterans while instituting reforms
to improve compliance with the Federal Acquisition Regulations
and the Competition in Contracting Act, and to improve our
management of government resources.
In follow-up to these hearings, the chairwoman and Ranking
Member submitted a letter to VA on June 21, requesting a
response by July 6 that would offer additional information
about these reforms. On July 12, VA submitted information to
the Subcommittee to begin to address the Subcommittee's
request. I apologize that submission was late and that it was
not sufficient to address your concerns.
Yesterday, at the Subcommittee's request, we formally
submitted additional information to provide a narrative account
of our efforts, and we believe this will better meet your needs
and provide for some further understanding. If you still have
additional questions, we would be happy to respond.
You also have asked for an update on the actions the
Department has taken to reform the prosthetics procurement
process since May 21 in the hearing. On May 23, 2012, VA issued
a memorandum to the field advising them that it is VA's policy
that those engaged in the ordering of biological implants must
comply with the FAR and VA acquisition regulations. That
memorandum states that the VA official performing the
purchasing activity is to comply with a physician's
prescription.
Furthermore, in response to your advice to transition our
warrant program with deliberation and caution, we extended the
date for finalizing this transition from July 1 until September
30, 2012. This transition continues with ongoing communication
and coordination within the VISNs to ensure that procurement
services are not disrupted. We are closely monitoring the
staffing levels for our contracting organizations, the workload
levels, and most importantly, the timeliness of procurement
actions. If we find that we have insufficient resources to
complete this transformation, we will extend the timeline to
allow for a smooth transition.
Finally, you asked me to address the potential impact these
reforms could have on veterans. As we testified in May, we do
not believe that veterans will be adversely impacted in any
way. Indeed, this change should result in no visible effect for
veterans. We believe that our reform efforts are acceptable to
the major service organizations.
Two proposals appear to have raised interest. First of all,
our plans to standardize the purchasing of prosthetics and
other devices; and secondly, our plan to transition procurement
decisions to warranted contracting officers. On the first plan,
many of the products VA purchases are already on contract in
some way, shape, or form. They are either going to become a
part of a veteran or they are going to be a critical part of
their daily lives. We understand the critical value these
devices offer and the independent clinical judgment of our
providers will remain and must remain fully intact.
A contracting officer will not have the capacity to
override a physician's order. This aspect guides a decision-
making process of our leadership and will be preserved in our
policies and in our procedures. Clinicians, in consultation
with veterans, will decide what devices we procure. Our reforms
are designed only to modify how we procure them. When products
are generally available and interchangeable, competitive
procurement may be appropriate. We are hoping that in the long
term we can develop a catalog that will facilitate more cost-
effective purchasing in those instances.
On the second plan concerning the transition of procurement
decisions, I, again, emphasize that this is only changing how
we purchase, not what we purchase. By shifting to contracting
specialists, we can ensure that we secure fair and reasonable
prices for the products while still delivering the personalized
state-of-the-art care that has been earned by these veterans.
In conclusion, VA has been engaging in prudent and
appropriate reform to improve the business processes governing
the procurement of prosthetic devices for veterans. We take
great care to ensure that these changes improve the
accountability of these purchases while maintaining the high
quality of care and clinical decision-making critical to
veterans health care. Clinicians determine the prosthetic needs
of veterans as a part of their clinical care, and VA procures
the devices necessary to achieve personal clinical outcomes.
Our reform efforts will not disturb this arrangement.
We appreciate the opportunity to appear before you today to
discuss this important program. My colleagues and I are
prepared to answer your questions.
[The prepared statement of Dr. Petzel appears on p. 19.]
Ms. Buerkle. Thank you very much, Dr. Petzel.
I will now yield myself 5 minutes for questions. I guess my
first question, as I am listening to your testimony today, as
well as in the last hearing, is could you just briefly explain
to me what prompted this change?
Dr. Petzel. Certainly, Madam Chairwoman. The reform of VA's
procurement processes really began more than 2 years ago, and
they started at the Department level with the procurement of
equipment, with the procurement of pharmaceuticals. This is a
systemwide effort to ensure that we have professional,
certified contracting people doing the procurement. We have
been criticized in the past by organizations such as the IG for
not having a professional procurement force and for not
following in all instances the Federal regulations or VA's
acquisition regulation.
So the effort, in no way, is directed specifically at
prosthetics. This began, as I say, with equipment. It has moved
into pharmaceuticals. Prosthetics is really the last area of
procurement within VA where we have not had certified warranted
procurement officers doing the majority of the procurements
above $3,000.
Ms. Buerkle. Thank you. When I hear words like
``equipment'' and ``pharmaceuticals'' and then ``the
development, possibly, of a catalog,'' what you are talking
about in those instances are so very different from the
testimony we heard in the last hearing regarding the personal
nature of a prosthetic. Amoxicillin is amoxicillin. A
thermometer is a thermometer. But a prosthetic is unique to
that person and to his needs or her needs. That is my concern
with this process, that it will become just like any other
procurement. This is a very different process. I think this is
what concerns the VSOs and concerns the veterans. This is a
uniquely personal service that we have to give to that veteran.
What I am hearing here when you talk about cataloging purchases
concerns me greatly.
Dr. Petzel. Madam Chairwoman, we absolutely agree with you.
This is the most personal of work that the VA does. Crafting
and fitting a prosthetic limb to an individual that has lost an
arm or a leg is a very personal process. The reforms that we
are talking about in terms of procurement will not interfere
with that process. The physician orders the prosthetic. And
that order can be very specific. The prosthetist works with the
patient to determine where the best place is to purchase that.
As you know, we have 600 contracts in the private sector, and
not all, but most of our procurement occurs in the private
sector.
In the process of transitioning and during the pilots, we
audited the orders that the physician had written; we audited
the purchase contract, what was actually purchased; we looked
at the timeliness between when that order was placed and when
it was actually purchased; and we looked at the satisfaction,
particularly of the prosthetist and the physicians, as to
whether or not the needs of that veteran, as they described
them, were met. And in the pilots we found that that was true;
that that worked very well.
The only misjudgment that we made in the pilots is that we
expected a higher level of productivity from the contracting
officers than we actually found, and we had to revise the
number of contracting officers that we felt we needed because
we felt that the four contracts per day that they originally
were going to perform was more than was doable; that 2.5 is a
better example. But, otherwise, the pilots indicated that
things went very well.
Ms. Buerkle. Can you talk to us about the pilots? How many
pilots were done? Over what period of time were the pilots
conducted? Which VISNs were included in the various pilots?
Dr. Petzel. Yes, Madam Chairman, we can, and I would like
to turn to Mr. Matovsky to give you some of the details about
the pilots.
Thank you.
Mr. Matovsky. Thank you, sir. We conducted three pilots,
one of them in VISN 6, which is North Carolina, parts of
Virginia, parts of West Virginia; VISN 11, which is Indiana--I
am going to test my geography here--parts of Michigan as well;
and then VISN 20, which is the Upper Northwest on into Alaska.
We selected them because they were a broad representation, some
of them highly rural, some of they very large and growing. We
also ran them from the period of January through the end of
March, for 3 months. I believe one of them scooted into April.
We tested two different processes. So one process utilized
fully the ECMS, or Electronic Contract Management System, to
place the order and another one in VISN 6 used a slightly
different process. That is the basis for it.
We tested the onboarding of our staff, the training of our
staff, the communication and the collaboration with the
prosthetist, the prosthetics purchasing agent, and then the
contracting management staff. As Dr. Petzel indicated, we did
conduct some audits. For instance, we looked at the technical
appropriateness of the contracting action. But more
importantly, we looked at what percentage of the time did the
contracting officer adhere to the physician's prescription. A
hundred percent of the time, the contracting officer adhered to
the prescription.
Ms. Buerkle. Thank you. With that I will yield to the
Ranking Member, Mr. Michaud, for any opening statement you
might have and 5 minutes for your questions.
Mr. Michaud. Thank you very much, Madam Chair. I apologize
for being late. I was managing the veterans bill on the House
floor. This is the earliest I could get back.
OPENING STATEMENT OF HON. MICHAEL H. MICHAUD, RANKING
DEMOCRATIC MEMBER
I want to thank everyone for attending this very important
hearing. This afternoon is a follow-up. And I also would like
to thank the chairwoman for her persistence in holding the
Department accountable on issues such as prosthetics, not just
for care, but also for procurement, which is so important for
the veterans. Every veterans' needs are unique. VA should get
this right.
We have learned during the last hearing on this issue in
May about VA's proposed changes in the procurement of
prosthetics. At that hearing, there was a high degree of
concern expressed among some of our witnesses as to the
effectiveness of these changes. We are alarmed by the possible
negative impacts on patient care, including substantial delays
in care and clinical judgments regarding veterans' needs being
overridden by individuals with little or no working knowledge
of prosthetic care. And we sent a bipartisan letter to the
Secretary outlining our concerns and soliciting answers to
several of our questions.
This is the third hearing in a handful of months on this
particular issue, and I remain committed to working with the
very dedicated staff at the Department of Veterans Affairs and
the advocacy community to assure that our veterans are getting
the best care that we can deliver in a timely way. In this
joint effort and joint challenges this Subcommittee stands
ready to help.
And I read through your testimony and I just have a few
questions, if I might. In your testimony you said: We believe
that many of our reform efforts are acceptable to all concerned
parties. When you say ``we believe,'' have you worked with the
VSOs and the veterans to find out what their concerns are?
Dr. Petzel. Congressman Michaud, we have. Since the May
hearing, there have been multiple meetings with the service
officer representatives. I have a breakfast monthly with six of
the largest service organizations. We made a presentation and a
discussion at that breakfast earlier in July. And then just a
day ago, on Monday, at a conference call with the service
organizations--the American Legion, VFW, PVA, the DAV, Amvets,
and the Blind Veterans of America--to discuss what we want to
do. And I can say that there was no objection at that meeting
and at that conference to our proposed reforms.
Mr. Michaud. Thank you. My next question actually is two,
but it is a related issue. Is the VA central office instructing
VISNs to restrict access to contract prosthetics or orthotists?
If not, what about the VISNs? Are the VISNs restricting access
to contracts for prosthetics for veterans who rely on those
prosthetics?
Dr. Petzel. Congressman Michaud, our policy that is this is
a veteran's choice. That we have, as I mentioned earlier, 600
contracts. Most of the prosthetics actually are fabricated and
fitted by private vendors. Our policy very clearly states that
there must be available in every one of the medical centers a
list of the contractors, and this must be explained to the
veteran, that they have a choice in doing that.
The practice that I think you may be hearing about from
some of the vendors is that around the country, how this
interaction occurs is variable. In some instances, in rural
areas, where we do not have prosthetists that do fitting, et
cetera, people from the outside, from the private sector, are
invited into the prosthetics clinic and are actually involved
in the discussions with patients because we don't have the
personnel to do that. At our larger medical centers where we
have a large cadre of prosthetists, it would be less likely
that the vendors would be invited in to participate in the
clinic because we have the personnel to do that. But if there
is a connection between a patient and a prosthetist, that
individual is invited in and is welcome to come to the clinic
and welcome to be a part of whatever activities are involved in
our prosthetic clinic.
Mr. Michaud. Thank you. My other question. As you know, we
invest a significant amount of funding into the VA for
fabricating prosthetics. Do you believe it is more cost
effective for the VA to consolidate prosthetics fabrication
internally within the VA, or is it more cost-effective to
continue to rely on contracts?
Dr. Petzel. Congressman Michaud, let me first say that I
think it is essential that the VA retain the capacity to
fabricate and to fit prosthetic limbs. We must be able to do
that. And quite frankly, in years passed, I think that our
capacity to do that had really slipped. And I must say that
over the a last 7 or 8 years, the VA has improved its capacity
to do both fitting and fabrication.
The question about whether or not the VA can do it less
expensively than the private sector I think remains unknown.
The IG had a limited amount of data to look at and made a
statement that it was less costly to do it within the VA than
it was in the private sector. But I think we would all have to
agree that there was not all of the sufficient data to make
that comparison. My personal belief is that it is more cost
effective, but we need to have all the data to say that
definitively.
Mr. Michaud. I see I am running out of time, so thank you
very much, Madam Chair.
Ms. Buerkle. I now yield to the gentleman from Tennessee,
Dr. Roe.
Mr. Roe. Just a couple of very quick questions. The idea,
the reason for doing this was back to what the IG, is that
right, Dr. Petzel, is trying to standardize the procedures, not
only in this but in other areas in contracting that the VA
does? Am I right on that?
Dr. Petzel. To standardize procurement, not procedures per
se, but to professionalize and standardize the way we procure
material. We have been criticized, as I said, in the past by
important groups of people, including some congressional
committees, on our procurement strategies. This systemwide
effort was to try and professionalize that, yes.
Mr. Roe. So I guess what the chairwoman said is correct.
There is obviously a prosthetist sitting right to your left.
That is a very individualized therapy. And I know as a
physician, this has to be tailored per person. I am sure there
is some standardization to it, and this is not going to, in any
way, slow that process down or make that process not as
effective or available to our veterans. Am I correct on that?
Dr. Petzel. Yes, sir, you are correct.
Mr. Roe. And so a patient will be able to come into the
clinic, and that patient won't know the difference. The time
won't make any difference. There is not going to be a
difference in timeliness. The fact that it costs more than
$3,000, that is not going to deflect the time; that that
veteran that comes in that needs a limb or a prosthetic device
is going to get that device?
Dr. Petzel. Yes, sir, that is correct.
Mr. Roe. I think that is extremely important. Secondly,
once you have cataloged this, is there a way to go outside? In
other words, here is what is in our catalog. If the doctor and
the prosthetist look at this patient and say, This is what they
need, it is not right in this little book right here, can they
get that? Because this technology is changing faster than
cardiac stints are changing. It is amazing the technology now
on prosthesis. As that new technology occurs, it is like these
things right here, as soon as you buy it, it is out of date.
And so I see the same thing in prostheses. People are doing
amazing things with this. Once it goes in the Sears and Roebuck
catalog that Sears has, that the VA has, can that person get
something from the new catalog or something brand new that
happens?
Dr. Petzel. Dr. Roe, absolutely. One of the nice things
about the VA and the procurement regulations is 8123, which
basically says that with the proper justifications, we do not
have to do competitive buying; that we can buy specifically
what the doctor has ordered.
So while we may have a catalog of things that are
appropriate in certain kinds of circumstances, the important
part of all of this is the doctor writes an order, and we will
procure for that patient, what the doctor has ordered.
Mr. Roe. So this is not going to negate new technology that
occurs?
Dr. Petzel. Absolutely not.
Mr. Roe. So our veterans can get the cutting edge. They are
not going to get stuck in ``it's not in the book, so you can't
have it.''
Dr. Petzel. Absolutely not, Congressman. Just to give an
example, there are two relatively new knees that were jointly
developed by the VA and the Department of Defense, the X2 and
the Genium. Those are absolutely cutting-edge technology for an
artificial knee. They are available to any veteran who needs
and wants that kind of a prosthesis.
Mr. Roe. So it is one thing to have all the colonoscopes
look exactly like. That was one of the issues when I first got
here. We had that issue that came up. This is a little
different than that. I guess the other question I have, and
then I will have no more is that you said that you don't
believe that the veterans will be negatively impacted. Will
they be positively impacted by this? Will this improve? I know
the VA feels like it will be positively impacted, but will the
veteran be positively impacted by this, or will they even know
the difference?
Dr. Petzel. First of all, Congressman, they should not know
a difference. It should be absolutely transparent to them. But
there are a couple of things that I think will happen that
will, even if they don't notice it, improve prospects, I expect
that once we get this up and running and under our belt that we
are going to cut down on the procurement time, on average. That
is number one.
Number two is that any money that might be saved by getting
a fair price--and that is not our intention, but if that should
happen--is money that can be put back into the system to
provide more care to more veterans.
Mr. Roe. One quick question. When will we know that? When
will you evaluate that and know when it goes in and up and
running, a year from now? Or 2 years from now?
Dr. Petzel. Congressman, I think there are going to be two
different kinds of valuation. One is that in an ongoing fashion
we have to monitor the things that we described before:
Timeliness, was a physician's order actually followed 100
percent of time, was there a level of satisfaction that was
appropriate on the part of the patient, the provider, the
doctor, and the contracting officer, and certain other
technical things about the contract. That is going to be an
ongoing process.
When we have been into this, say, for a year or 6 months,
we will have to look, and we will, look at the overall process
and see what it has accomplished and see if indeed we are doing
overall a better job of purchasing than we were doing before.
So there will be two levels of evaluation.
Mr. Roe. Thank you. I yield back.
Ms. Buerkle. Thank you. I am going to yield myself five
minutes for a second round of questioning, if that is okay.
Just a couple of things. First of all, I am concerned about a
3-month pilot that you mentioned and whether or not that is
going to give us the scope of the situation, and whether or not
this is working. It seems to me that 3 months is a very short
period of time. And I will let you address that question in a
minute.
In your opening testimony, you talked about the potential
if we find insufficient resources to have been allocated after
you implement the changes. What period of time are you talking
about to evaluate that?
Dr. Petzel. Madam Chairwoman, let me answer first the
second part of your question. What I was saying is, if in a
network or at a facility we do not have sufficient, well-
trained contracting personnel to do this, we won't do it until
we have the resources we need in contracting to do this in a
timely, professional fashion. And that will occur as we begin
to extend this into the other networks.
So if there is a network, whatever that might be, where two
or three of the facilities do not have sufficient people, we
won't institute this in those two or three facilities until we
have the appropriate, adequate trained personnel. That is that
I meant to say.
The first part of your question, and I will ask Mr.
Matovsky to comment on this in a minute, is, were the pilots of
sufficient length?
There was a run-up period of preparation in terms of
training, et cetera. So this was 3 months of actual doing the
work. And yes, we think we got a good feel for how this worked,
what the issues might be, and what the potential problems might
be.
Mr. Matovsky, do you want to make any comment about the
length of the pilots?
Mr. Matovsky. We continued running them after the duration.
So the official time period, we wanted 3 months, but we
continued running them. As we have concluded, we then
standardized the process for ordering in VISN 6 so that it
conformed to VISN 11 and VISN 20. And we saw improved
performance by using that new process. And we really saw it
stabilize as well. So our best performing month in terms of
average timeliness was July, across the board.
So it was the official time period for the pilot, and then
as it was there and running, we left it running and observed
how it was running.
Ms. Buerkle. Do you know in that period of time how many
actual transactions there were; how many prosthetic devices
were obtained or tried to be procured?
Mr. Matovsky. I do know that. I am not going to find it in
my notes right now. And we can provide it for the record. But
we do know the specific numbers, yes, ma'am.
Ms. Buerkle. I do want to address a much broader concern,
and that is the question of leadership within the VA with
regard to prosthetics. As I read through the introductions, and
I read Dr. Beck's introduction, the many hats that you wear, I
am concerned that you are acting in multiple capacities, and
there is not one person focused on prosthetic procurement and
the whole prosthetics issue within the VA.
If you could speak to direction of leadership for the VA?
Is this something Dr. Beck will take on herself and then
someone else will relieve her of some of the other duties? It
seems like Dr. Beck is wearing many hats, I am concerned with
regard to the level of leadership.
Dr. Petzel. Thank you, Madam Chairman. You are absolutely
right, she is wearing a lot of hats. Very talented, incredibly
energetic lady, but she has a lot of things that she has to do.
I want to ask Dr. Beck to comment in a minute about
leadership in prosthetics. But I do want to commend the job
that she has done since she has been in that role. There really
has been a palpable change for the better in the way we do our
prosthetics. I think that Lu has done really a fabulous job.
The bench is not as strong as we would like to have it in
prosthetics, so that we can turn most of the operating parts of
prosthetics over to someone else.
I would like you to make a comment about that, Dr. Beck.
Ms. Beck. Thank you, Dr. Petzel, and thank you, Madam
Chairwoman, for your concern. I have had a lot of support from
my leadership, up to Dr. Petzel, as I have taken on this
initiative. We have developed a plan to have a comprehensive
office of rehabilitation and prosthetics. In that office, we
will have a national program director and a large staff devoted
to prosthetics and sensory aid service so that we will be
managing the clinical practices, the procurement and
contracting, their regulatory issues, and the development of
all of the programs. So we have a plan that is just in the
approval stages now that will give us the resident resources
and expertise and leadership roles in the prosthetics office.
One of the important things that we are doing, and I think
one of the veterans service organizations talked about this in
their testimony, is that prosthetics and sensory aids is a very
dynamic service. It is an important clinical support service to
all of the programs in VHA. And so it touches almost every
provider, from our primary care teams to our rehabilitation
teams to many of our specialists. And for that reason we are
linking prosthetics to rehabilitation services so that we can
assure that we have the proper collaboration and coordination
under the direction of Patient Care Services, which is
responsible for all of the clinical activity in VA.
Dr. Petzel. So just to elaborate for a minute, Dr. Beck
would be responsible for rehabilitation services and
prosthetics in the larger sense. There will be specific
leadership in prosthetics and an office and the staff necessary
to administer that program appropriately. And that plan, as I
understand it, is coming shortly to my desk.
Ms. Buerkle. That was going to be my next question; what
would be the expectation for implementation of that plan?
Dr. Petzel. Very soon. I hesitate to give you a specific
date, but I understand the request for people in the
organizational chart is on its way to me. We will review that,
and as soon as it is signed off on, the process of hiring those
people and beginning to do that will begin. So the process will
certainly begin shortly. I can't predict how long it will take
to hire the right person, but we will begin shortly.
Ms. Beck. I would just like to reinforce that. We currently
have many very excellent people in the prosthetics and sensory
aids service who are working everyday with me to accomplish all
of our goals, and also to say that in rehab services, we have
defined leadership and subject matter expertise for each of the
offices. So our physical medicine and rehabilitation office has
a physician leader. So the leadership, as Dr. Petzel says, in
prosthetics and sensory aids service will be devoted to the
clinical support services that we are doing in prosthetics and
sensory aids.
Ms. Buerkle. Thank you very much. Just briefly, and then I
am going to yield to the Ranking Member. You mentioned that
yesterday you had a conference call and that you have been in
touch with the veterans service organizations. As you recall,
at the last hearing there were grave concerns, and in my
opening comments, I expressed the concerns the VSOs have. In
one of the questions you just answered, you talked about this
ongoing process and you talked about timeliness and physicians'
orders and the contracting officers. But, again, there is no
contact, there is no connection, there is no ongoing--there
doesn't seem to be ongoing communication with the veterans
service organizations, with the veterans themselves. It is one
thing to do this operation and to look at it objectively, and
to look at a plan on paper, but the most important ones we need
to hear from are the veterans who are requiring this service,
because that is what is key here.
Dr. Petzel. Thank you, Madam Chairman. Two responses to
that. One is I have ongoing meetings with veteran service
organizations. We do two things: Every month I have a
breakfast, 2-hour meeting with the leaders of the six largest
service organizations. Then every quarter we have a bigger
meeting, again, about 2\1/2\ hours, with a broader range of
service organizations. And we will keep in touch with them
through this. It is important to all of them, but particularly
the Disabled American Veterans, the PVA, and the Blinded
Veterans. Prosthetics is an essence of the service that the
members of those organizations need.
In terms of the veterans, Troy Elam, who was present, by
the way, on the phone call, who had testified earlier, I think
said it at the first hearing, and I had not really heard
anybody articulate it quite as well as she did. And that is,
that we have to have, as part of our ongoing look at this
transition, we have to have a mechanism for asking the veterans
what they experienced, not just with this transition, but with
prosthetics itself.
Perhaps Dr. Beck could just briefly comment on the
instrument that we are going to use.
Ms. Beck. Yes. Thank you, Dr. Petzel. The instrument we are
going to use is called uSPEQ. That is an acronym for the
Stakeholder Participation and Experience Questionnaire. This is
a national benchmarked questionnaire that is used by the
Committee on Accreditation for Rehabilitation Facilities, which
is a national organization that accredits rehabilitation
facilities. We have recently received approval from the Office
of Management and Budget to use that survey to gather
information about satisfaction, and we have arranged a contract
which is now in place with CARF, the acronym for Committee on
Accreditation of Rehab Facilities, and we are beginning the
training of our staffs around the country so that they will be
able to implement the utilization of this questionnaire, not
only for amputation and prosthetics care, but for many elements
of the rehabilitative care that we provide in VA.
One very important aspect of this is that it is a valid
survey. Data are collected from all facilities all over the
country, not just VA facilities, and we are able to benchmark
our care with the care that is provided across the country
related to rehabilitation. So that is important for us. And it
is patient satisfaction. And so it asks the patient what they
think.
Ms. Buerkle. And if I could respectfully suggest, in
addition to the organizations that you are communicating with,
that you would include the newer organizations: The Wounded
Warrior Project, the IAVA. It seems to me they should be
included in this discussion and their feedback should be
obtained as well.
Dr. Petzel. Yes. Thank you.
Ms. Buerkle. I yield now to the Ranking Member.
Mr. Michaud. Thank you very much, Madam Chair. In answering
Mr. Roe's question about procurement time, you said it will cut
down on procurement time. Do you have any idea how much time it
might cut down on the procurement time?
Dr. Petzel. I would, Congressman Michaud, have to ask Mr.
Matovsky if he has any thoughts on that. I don't.
Mr. Matovsky. As we were watching the pilots as they were
running in the most recent month in VISN 20, for instance, our
average timeliness was down inside of 3 days to procure, which
was pretty quick. I think the other thing that we would expect
to find, frankly, and it came out of these pilots, was a
collaboration between logistics and prosthetics so that we
could better tune the inventory management process as well. We
will see how that goes. We will study that.
But what that would allow us to do is it would allow us if
we have better visibility into our inventory avoid a stock-out
situation. A stock-out situation is where we run out of
something. And I think that is where we really have the benefit
of being able to have greater visibility into what we have
available and what kinds of inventory control points would
allow us to have a situation where we are managing at a minimum
inventory level. We are seeing that in VISN 20 in the Upper
Northwest, sir.
Mr. Michaud. Thank you. The OIG in their recommendations
recommend that some VISNs contract out between three and five.
When you look at VISNs that are actually contracting out with
the private sector providers more than the three or five that
was recommended, does that show that there is a greater demand
among the veterans community to go to the private sector, or is
that because veterans pretty much in the rural areas are
accessing those, therefore you have a lot of contracts with
private providers? Or, is the need continuing to increase
dramatically?
Dr. Petzel. Dr. Beck, could you take that?
Ms. Beck. Thank you, yes. The contracts have been
established to provide access, to be sure there was access
close to the patient's home or close to the veteran's home. And
that is the reason for the large number of contracts that we
have had.
Mr. Michaud. Thank you. My last question is in reviewing
your testimony, Dr. Petzel, you stated that VA is instituting
more audits of purchases to ensure that we are getting the best
value for our dollars when we procure prosthetics or other
devices. Can you tell me how many more audits you are doing now
compared to before, who is performing those audits, and who is
analyzing those audits as well as the types of measurements
that you are using for those audits?
Dr. Petzel. Let me, in a general sense, respond,
Congressman, then I would ask Mr. Matovsky to provide some
detail. The things that we are going to be looking at are the
things that I mentioned earlier, was the product that was
ordered and delivered, the product that the physician ordered.
In other words, what is the consonance between what the
physician ordered and what was obtained?
Timeliness will be an ongoing audit. Satisfaction from the
point of view of the patient, the physician provider, the
prosthetist, and the contracting officer will be an ongoing
audit. In the cases where we use 8123 where we don't have to be
competitive, was there an adequate justification for a
noncompetitive acquisition, et cetera. Those are the things
that we in an ongoing way are going to audit. In terms of how
frequent we are going to be doing that, I would turn to Mr.
Matovsky for a comment about that.
Mr. Matovsky. We will be running those every month on a
cycle. We run within VHA two systems of audits that occur every
month and then the Department, under Mr. Heard, has another
audit that comes in and reviews. Ours is probably a little bit
more tactical than the Department's.
We look at primarily two things: First, where there is a
justification for other than full and open under FAR part 6
using 8123, did the contracting officer comply with the
prescription? That is number one. Number two, we are looking at
other elements that are procurement reform-oriented. Is there
an adequate work-up for the justification? Was there a price
negotiation performed? Et cetera. And those are the things that
we are looking at.
Over time, I think where we would see additional
efficiencies, at this point theoretical; again, the most
important thing, did we conform to the 8123 justification? But
over time, looking at things where we are buying many things
repeatedly without a covering contract using 8123, do we have
an opportunity to structure an agreement there. And I think
those are the ones that we would look at over time.
But to your question, every month it cycles through the
VISN level contracting manager, every month it cycles through
the VHA system of national audits. I review every month in
detail one of our VISN's contracting results. This is one of
those results I now review. Mr. Doyle, who is here, also
reviews through his system the audit results.
Mr. Michaud. Thank you. I have no more questions. Thank
you.
Ms. Buerkle. I am going to yield myself another 5 minutes,
and then if Mr. Michaud has other questions, he may ask them.
We keep talking about the contracting officer. What is a
contracting officer?
Dr. Petzel. I would ask Mr. Heard if he would, please,
Madam Chair, to answer that question.
Ms. Buerkle. And if you could speak to their
qualifications, their training, and the agreement they have.
Because initially, I heard there would be a 100 percent
compliance with the physician order for the prescription. Now I
am hearing that is going to be monitored. Does the contracting
officer have any discretion, or why wouldn't he adhere 100
percent of the time the physician's prescriptions for which a
prosthetic device is being prescribed for the veteran?
Mr. Heard. Sure. Madam Chair, we have to look at the
acquisition workforce first to determine what their
qualification skill-sets are. Going back to 2000, the Clinger-
Cohen Act that went into place actually professionalized the
acquisition workforce by putting a positive education
requirement in place. That positive education requirement for a
GS-12 or below is either a degree in any field of study at an
accredited college, or 24 hours of business. At a GS-13 and
above, it requires both an undergraduate degree and 24 hours of
business. The Clinger-Cohen Act also required experience and
also training to be an integral part of that acquisition
professional contract specialist requirement.
The actual warranting of a contracting officer, that is a
delegation. A delegation is based on a need defined by the head
of a contracting activity. In the VA, there are six heads of
contracting activity. For Veterans Health Administration, which
oversees all of the hospital acquisitions, including
prosthetics, that HCA is Norb Doyle, who is here. Norb is
designated by the senior procurement executive for the
Department of Veteran Affairs, Jan Frye. The warranted contract
individuals that are identified based on a need have to show
and demonstrate their experience, their education, and
training.
Training is also a very elaborate criteria requirement that
was identified by OMB back around 2007, called the Federal
Acquisition Certificate in Contracting. Those individuals climb
to a level of FACC level 3. Again, a very rigorous, robust
education training requirement, a curriculum identified by the
Federal Acquisition Institute. Once you are certified, you are
eligible for a warrant at various levels.
Our level 1 warrant holders probably have the lesser amount
of training, but they can be warranted up to $150,000. That is
commensurate with the simplified acquisition threshold. So
these are warranted individuals that are warranted on behalf of
the Federal Government to act as an agent to procure on behalf
of the Federal Government to ensure that contracts are awarded
with a fair and reasonable price, to seek competition, to
comply with the FAR and the VAR.
Prosthetics is a unique requirement. We are really
identifying special needs for our veterans. Those requirements
can be anything, as we talked about today, artificial limbs,
but also products that are also commercial in nature, which
could be walkers, canes, and crutches. Some of those are
available commercially. They are obtained off Federal supply
schedules. But then the others are really very specific to the
surgery that is required for a veteran or other therapeutic
requirements.
Ms. Buerkle. So why wouldn't there be automatically 100
percent compliance with a physician's order? Why is that even a
concern? You are talking about someone with a bachelor of
science degree who maybe has 24 hours of business classes, that
they have discretion to override or to not comply with the
physician's order with regard to the prosthetic?
Dr. Petzel. Madam Chairwoman, I can just take that for a
moment, first, and then we will see if either Mr. Heard or Mr.
Matovsky have anything to add.
The issue there is fair and reasonable price. That is their
only responsibility in that case, would be to ensure that in
purchasing that specific thing that the physician has ordered,
that we are getting a fair and reasonable price. And that might
entail negotiating with that provider--with that prosthetic
provider.
Ms. Buerkle. So I guess I am concerned, because if there is
a prosthetic available that is maybe less money, are we looking
at the quality, are we looking at the prosthetic itself, or are
we just negotiating a price about the same----
Dr. Petzel. We are negotiating, in this case, a price,
Madam Chairwoman, around the specific thing that the physician
has ordered. That is what determines what we buy. The
contracting officer's responsibility is to see that we get a
fair price for it. But when he is not going to be, or she is
not going to be buying something different because it is less
costly. Again, we look at what was the physician's order, and
that is what we buy.
Ms. Buerkle. So you would expect 100 percent compliance
with the physician order?
Dr. Petzel. Absolutely.
Ms. Buerkle. Do you have any further questions?
Mr. Michaud. No. That is a good way to sum it up. I think
it is very important that the physician is the one who decides,
so I do want to thank you, Dr. Petzel, for all that you are
doing to help our veterans, as well as the other three
panelists here today for your efforts in this regard, so thank
you very much.
Ms. Buerkle. I thank the Ranking Member, and I also want to
thank the panel for being here this afternoon. I, again, would
just like to ask, I think it is very important that we get as
many veterans' service organizations involved in this
discussion, as many perspectives as possible. You know, what
you have mentioned, with all due respect, is great, but I think
we have got additional veterans' service organizations that
need to be included in this discussion and to make sure there
is nothing more important than the veterans and making sure
when they come home without a limb because they have served
this Nation, that they have what they need, that they are not
dealing with some contracting officer who has got some
discretion to give him less of a device than he deserves. So
that is all of our concern here--that we get our veterans
exactly what they need.
We heard the last time from veterans who talked about--we
are talking about--the ability of someone to walk his daughter
down the aisle. We are talking about intensely personal
prosthetics and an intensely personal segment of the care that
our veterans need, so there is nothing more important.
And while we are all concerned with regard to costs, that
we make sure our veterans who have served this Nation get
exactly what they need so they can return to their maximum
potential after they have sacrificed so much for this Nation.
With that, I ask unanimous consent that all members have 5
legislative days to revise and extend their remarks and to
include extraneous material. Without objection, so ordered.
Before I close the hearing, I would like to make a request
that you submit to this Health Subcommittee and to the
Veterans' Affairs Committee the plan that you are talking
about. We would like to see that to make sure that the
veterans' best interests are served.
Dr. Petzel. We will do that, Madam Chairwoman.
Ms. Buerkle. Thank you, again, to our witnesses for being
here, to our audience members, and to the Subcommittee members,
to my Ranking Member, for joining in today's conversation.
This hearing is now adjourned.
[Whereupon, at 5:33 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Chairwoman Ann Marie Buerkle
Good morning and welcome to today's Subcommittee on Health Hearing,
``Optimizing Care for Veterans with Prosthetics: An Update.''
Today's hearing is a continuation of a discussion we began almost 3
months ago when this Subcommittee heard from veterans with amputations,
members of our veterans service organizations (VSOs), and officials
from the Department of Veterans Affairs (VA) to review VA's capability
of delivering state-of-the-art prosthetic care to veterans with
amputations and the impact of VA's planned prosthetic procurement
reforms.
These reforms will, among other things, take prosthetic purchasing
authority away from prosthetic specialists and transfer it to
contracting officers.
As our veterans so eloquently described in May, prosthetic care is
unlike any other care that VA provides and, when we make the mistake of
treating it as such, no less than the daily and ongoing functioning and
quality of limb of our veterans is at stake.
I was very troubled to hear our veterans voice such strong
opposition to the proposed procurement reforms, arguing forcefully that
they would lead to substantial delays in care for veterans with
amputations and clinical judgments regarding veterans needs being
overridden by individuals with little to no experience in prosthetic
care.
In mid-June--following our hearing--I sent a letter, along with
Ranking Member Michaud, to the Secretary requesting that the Department
respond to a number of questions and provide certain materials
regarding the strategy, plans, and criteria used to consider, develop,
design, implement, and evaluate the proposed reforms and the pilot
programs that preceded them.
Our goal was to understand the analysis VA employed to develop the
reforms and what was behind the decision that this was the best idea
for our veterans, especially those who have experienced loss of life as
a result of service to our country.
Sadly, the Department's response--which came a week after the
deadline requested in our letter--did not provide the information or
the level of detail we asked for and did nothing to assure me that the
plan would be effective or that our veterans concerns were unfounded.
To the contrary, a close review of the materials VA provided leads
me to believe that the reforms were developed without careful and
thorough consideration. It leads me to believe they were developed
without sufficient input from veterans themselves, veteran service
organization advocates, or other stakeholders.
It leads me to believe that they were developed and implemented,
after being tested for a very short time, at a small number of
locations, with very limited feedback. It leads me to believe they were
developed without adequately measuring their impact on patient care. It
leads me to believe they were developed without safeguards in place to
ensure veterans and clinician's wishes are respected and timeliness
goals are met.
It is concerning that VA would move forward with instituting large-
scale changes that so directly impact veteran patients in this way. If
my concerns are groundless--and I hope that they are--I want VA, in
explicit detail, to explain why.
During our last hearing, our veterans and VSOs spoke loud and
clear. Now it is time for VA to do the same.
Again, I thank you all for joining us this afternoon. I now
recognize our Ranking Member, Mr. Michaud for any remarks he may have.
PREPARED STATEMENT OF HON. ROBERT A. PETZEL, M.D.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee: thank you for the opportunity to speak about the
Department of Veterans Affairs' (VA) prosthetics procurement reforms. I
am accompanied today by Mr. Philip Matkovsky, Assistant Deputy Under
Secretary for Health for Administrative Operations, Veterans Health
Administration (VHA); Dr. Lucille Beck, Chief Consultant,
Rehabilitation Services, Director, Audiology and Speech Pathology, and
Acting Chief Consultant, Prosthetics and Sensory Aids Service, VHA; and
Ford Heard, Associate Deputy Assistant Secretary, Office of Acquisition
and Logistics.
VA testified before this Subcommittee and the Subcommittee on
Oversight and Investigations in May 2012 regarding our efforts to
maintain the high quality of prosthetics VA provides to Veterans while
instituting reforms to improve compliance with the Federal Acquisition
Regulation (FAR), the Competition in Contracting Act, and to improve
our management of government resources. In follow-up to those hearings,
the Chairwoman and Ranking Member submitted a letter to the Department
on June 21, 2012, requesting a response by July 6, 2012, that would
offer additional information about these reforms. On July 12, 2012, VA
submitted information to the Subcommittee on Health to begin to address
the Subcommittee's request. Our interest was in responding as quickly
as possible to your request, and we regret our submission of July 12,
2012, did not sufficiently address your concerns.
You also have asked for an update on the actions the Department has
taken to reform the prosthetics procurement process since the May
hearings. I am pleased to report that on May 23, 2012, VA issued a
Memorandum to the field advising them that it is VA's policy that those
engaged in the ordering of biological implants comply with the FAR and
VA Acquisition Regulation (VAAR). This Memorandum provides further
information and guidance to staff to ensure they understand our
objectives and procedures. That Memorandum states that the VA official
performing the purchasing activity is to comply with a physician's
prescription when it is indicated. Furthermore, in response to your
advice to transition our warrant procurement program with deliberation
and caution, VA extended the date for finalizing this transition from
July 1 until September 30, 2012. This transition continues with ongoing
communication and coordination with the Veterans Integrated Service
Networks to ensure that procurement services are not disrupted. We are
closely monitoring the staffing levels for our contracting
organizations, the workload levels, and most importantly, the
timeliness of the procurement actions.
Finally, you asked me to address the potential impact these
prosthetics procurement reforms could have on Veterans. As we testified
in May, we do not believe that Veterans will be adversely impacted in
any way. We believe that many of our reform efforts are acceptable to
all concerned parties. For example, VA is instituting more audits of
purchases to ensure that we are getting the best value for our dollar
when we procure a prosthetic or other device. We also will begin
tracking our purchasing trends to identify when and where we can enter
into negotiated contracts. Further, we are streamlining and
standardizing elements of the procurement process to reduce variation
and accelerate purchases so Veterans can receive their devices and
equipment faster.
The proposals that have raised interest are our plans to
standardize the purchasing of prosthetics and other devices, and our
plan to transition procurement decisions to warranted contracting
officers. On the first plan, many of the products VA purchases are
either going to become a part of a Veteran or will be a critical part
of their daily lives, helping them walk, work, and interact with their
families. We understand the critical value these devices offer, and the
independent clinical judgment of our providers will remain fully
intact. This aspect guides the decision-making of our leadership and
will be preserved in our policies and procedures. Clinicians, in
consultation with Veterans, will decide what devices we procure. Our
reforms are designed only to modify how we procure them. When products
are generally available and interchangeable, competitive procurements
may be appropriate, and we are hoping that in the long term we can
develop a catalog that will facilitate, more cost effective purchasing
decisions.
On the second plan, concerning the transitioning of procurement
decisions, I again emphasize that this is only changing how we
purchase, not what we purchase. By shifting to contracting specialists,
we can ensure that we secure fair and reasonable prices for products
while still delivering state-of-the-art care.
In conclusion, VA has been engaging in prudent and appropriate
reform to improve the business processes governing the procurement of
prosthetic devices for Veterans. We take great care to ensure that
these changes improve the accountability of these purchases while
maintaining the high quality of care and clinical decision-making
critical to Veterans' health care. Clinicians determine the prosthetic
needs of Veterans as a part of their clinical care, and VA procures the
devices necessary to achieve personal clinical outcomes. Our reform
efforts will not disturb this arrangement, which will remain the
centerpiece of prosthetics care in VA. We appreciate the opportunity to
appear before you today to discuss this important program. My
colleagues and I are prepared to answer your questions.
Deliverables from the United States Department of Veterans Affairs
Date: August 23, 2012
Source: Hearing Deliverables
Inquiry from: HVAC Health
Context of Inquiry: During the HVAC Health prosthetics hearing
three deliverables were noted:
There were three deliverables from yesterday's prosthetics hearing:
1. How many prosthetic devices were procured during the pilot?
2. Please forward the new organizational plan to merge prosthetics
and rehabilitation.
3. Please provide a timeline for how long it will take to complete
the new organization.
Response:
Question: How many prosthetic devices were procured during the
pilot
Response: The table below provides this information.
It is important to recall that only those purchases above $3,000
will transition to a VHA Contracting Officer. There are roughly 90,000
prosthetics transactions executed per year that are greater than
$3,000.
Table: Number of Prosthetics Purchases made by VHA Contracting Officers
VISN 11 VISN 20 VISN 6 Totals
January 57 131 145 333
February 122 149 224 495
March 263 174 299 736
Subtotal 442 454 668 1,564
April 268 166 194 628
May 283 207 358 848
June 226 273 314 813
July (partial 149 150 272 571
month)
TOTAL 1,368 1,250 1,806 4,424
Question: Please forward the new organizational plan to merge
prosthetics and rehabilitation
Response: Veterans Health Administration (VHA) has aligned
Prosthetic and Sensory Aids Service (PSAS) with the Office of
Rehabilitation Services (ORS), to become the Office of Rehabilitation
and Prosthetic Services. The reason for this change is to align both
prosthetic and clinical programs together in order to optimally
coordinate and deliver programmatic services, policies, and guidance
for medical equipment/items and medical rehabilitative services that
promote the health, independence, and activities of daily living for
Veterans and Servicemembers. This realignment of existing VHA resources
will further improve management and oversight of prosthetic purchasing,
inventory control, and clinical coordination in order to better utilize
appropriated resources. The cost of this realignment is budget neutral,
the newly aligned office will remain within VHA Office of Patient Care
Services, and the administrative processes (e.g., budget, HR, planning
and programming, etc) for PSAS and ORS will be completely aligned by
September 30, 2012.
Please see the attached document for a summary of the plan to merge
prosthetics and rehabilitation.
Question: Please provide a timeline for how long it will take to
complete the new organization
Response: The Office will be completely aligned by September 30,
2012.
Summary of Plan to Merge Prosthetic and Sensory Aids Service and Office
of Rehabilitation Services
Health Subcommittee, House Committee on Veterans' Affairs
Deliverable from July 31, 2012 Hearing
Prosthetic and Sensory Aids Service (PSAS) is core to the mission
of VA and affects millions of Veterans and Servicemembers on a short-
term, long-term, and ongoing basis. PSAS should be realigned to most
effectively support clinical services and engineer optimal programmatic
policies, guidance, and regulations to advance the full continuum of
health care practices in VHA. The Office of Patient Care Services will
merge with the Office of Rehabilitation Services (ORS) and become the
Office of Rehabilitation and Prosthetic Services in the Office of
Patient Care Services.
This alignment will improve management and oversight of prosthetic
purchasing, inventory control, and clinical coordination in order to
better utilize appropriated resources. Transition of PSAS under ORS,
with appropriate staffing, will position VHA to most effectively
accomplish that mission. The Prosthetic and Orthotic Program will be
aligned as a separate clinical section under ORS.
The Office of Inspector General (OIG) recently completed reviews,
and Congress has subsequently held hearings regarding concerns about
oversight and management of procurement, inventory management, and
prosthetic services in VHA. Consequently, the pressing need for
improved management, coordination, and alignment of PSAS within
clinical services has become increasingly important.
The transition of PSAS to a national program office under ORS will:
Establish and improve processes for providing prescribed
and clinically appropriate, state-of-the-art prosthetic devices,
sensory aids, and equipment in the most economical and timely manner;
Manage national contracting processes for prosthetic
devices including strategic sourcing;
Maintain a system of information management for
procurement requests; and
Align standards of care and clinical practices and PSAS
purchasing.
PSAS does not currently have the appropriate organizational
structure or staffing to support clinical services aligned with
programmatic policies. If PSAS is realigned with ORS, the resulting
programmatic re-engineering of regulations and policies, contracting
processes, clinical prescription practices, budget accounting,
information technology, and reallignment of key staff will: (1)
leverage pre-existing infrastructure and resources and (2) identify and
mitigate vulnerabilities.
Dr. Lucille Beck, Chief Consultant, will lead this realignment and
the Office of Rehabilitation Services will become the Office of
Rehabilitation and Prosthetic Services (OR&PS). Implementation of this
realignment will commence, with initial organizational restructure
completed within 30 days. Personnel recruitment actions will be
initiated to fill existing personnel vacancies. The existing PSAS
budget will be realigned under OR&PS, with accountability fully
transitioned by the beginning of fiscal year (FY) 2013.
The success of this realignment will be monitored through a number
of strategic outcomes, including: improved timeliness in providing
prescribed items to Veterans; increased numbers of national contracts
and compliance with contracts; compliance and accuracy in recording and
tracking serial numbers of critical items (e.g., surgical implants);
accurate budget execution to ensure appropriate allocation for specific
purpose funds (i.e., prosthetic items, devices, and equipment) and
balance of expenditures to obligations; and implementation of data
accuracy monitors to track and compare issuance codes for consistency
across national averages. Further, programmatic policies, regulations,
and processes for prosthetic services will be aligned with those of
clinical services to improve consistency and continuity of services to
Veterans--from clinical prescription, to procurement, provision, and
verification of receipt of appropriate prosthetic items.