Amputee Advocates: VA Prosthetics Treatment Not as State-of-Art as DoD

by U.S. Medicine

July 12, 2012

By Sandra Basu

BETHESDA — Marine Corps Cpl. Garrett Carnes lost both legs while serving in Afghanistan earlier this year, but that has not stopped him from walking. Thanks to advances in prosthetics, he recently practiced some of his first steps walking up a ramp in Walter Reed National Military Medical Center’s prosthetics gait lab.

Marine Corps Cpl. Garrett Carnes

“Mentally, it feels great to get back up on my feet,” he told reporters who watched him walk this  spring. “Physically, it is still a little awkward, but it is just going to take some getting used to. I would imagine this is what a baby would feel like when he first gets up on his feet.”

Troops who have lost limbs are not only on the move with new prosthetics, but advances in technology are allowing some to achieve physical feats that once seemed impossible. According to Charles Scoville, chief of amputee services in the orthopedics and rehabilitation department at WRNMMC in Bethesda, MD, more than 1,453 patients have experienced major limb loss since 2001. Of those, more than 300 have returned to active duty, and 53 even went back to Iraq or Afghanistan with prosthetic devices.

Of the 1,453 troops with major limb loss, most have been seen at Walter Reed Army Medical Center and the National Naval Medical Center or the newly combined WRNMMC for at least a portion of their care.

The problem, according to recent testimony to the House Committee on Veterans’ Affairs Subcommittee on Health is when wounded warriors move from care at DoD to the VA.

 “VA lost its long held leadership in prosthetics and was eclipsed by DoD,” John Mayer, a Vietnam veteran amputee and retired VA employee, told the committee recently. “Since 2006, DoD has not just established one but three amputee centers of excellence, which are holistic in care. The warriors there receive world-class care.”

VA needs to up its game with prosthetics care, according to retired Capt. Jonathan Pruden, alumni manager for the Wounded Warrior Project, because, as current conflicts wind down, DoD facilities are likely to scale back services and funding.

“VA must be ready to meet this need, but it’s not yet there. There are pockets of excellence within VA’s prosthetic system, such as the VISN 3 Manhattan prosthetic department, but that level of expertise is not consistently available to veterans across the VA system,” he told the subcommittee in written testimony.

Meanwhile, members of Congress and veteran groups also expressed concern that proposed changes in how VA purchases prosthetics could create unnecessary delays for veterans waiting to receive their devices.

A new policy, set to be implemented this summer, will require prosthetic items that cost more than $3,000 to be purchased by a contracting officer, rather than the prosthetics service purchasing officers who currently handle these purchases. The changes are designed to save money and provide better oversight over purchasing prosthetics, but veteran groups complained that the new process may cause unneeded delays in amputees receiving their prosthetics.

Pruden told the House subcommittee that transferring that responsibility to an off-site contracting officer could create waits on orders for prosthetics and could even mean that a contracting officer’s judgment would override a clinical judgment.

“A prosthetic limb is not a mass-produced widget,” he said. “Prosthetics are specialized medical equipment that should be prescribed by a clinician and promptly delivered to the veteran. We urge this committee to direct VA to suspend implementation of this major change in prosthetics procurement.”

Recent congressional hearings on VA’s prosthetics program come after reports, released in March by the Office of the Inspector General. One VA OIG report examined the VA’s capacity to deliver prosthetic care and asked amputees to describe the prosthetic care they received and their satisfaction levels. While many veterans praised the care they received in open-ended comments, concerns with VA prosthetic services, “centered on the VA approval process for fee-basis or VA contract care on prosthetic services, prosthetic expertise and difficulty with accessing VA services,” according to the report.

Two other reports showed that VAMCs were not only having trouble properly managing their prosthetic needs but that the VA was overpaying manufacturers for its prosthetics. The OIG investigation found that VAMCs spent about $35.5 million more to purchase prosthetic supplies than what was really needed.

“We estimated, during April through October 2011, VHA’s VAMCs maintained inventories of approximately 93,000 specific prosthetic items worth about $70 million. Further, we estimated that VAMC inventories exceeded current needs for almost 43,500 items (47%) and were too low for nearly 10,000 items (11%),” according to a summary of a March 30 OIG report.

In a report earlier that month, OIG audited VA acquisition and management of prosthetic limbs, concluding that “overpayments for prosthetic limbs were a systemic issue at each of the 21 Veterans Integrated Service Networks [VISN].”

“Due to these weaknesses, VHA overpaid about $2.2 million in FY 2010 to procure prosthetic limbs. VHA could continue to overpay for prosthetic limbs by about $8.6 million over the next four years, if it does not strengthen controls,” the authors of the report wrote.

Linda Halliday, assistant inspector general for audits and evaluations in VA’s Office of the Inspector General, explained to the subcommittee that overpayment generally occurred because, “invoices received from vendors lacked adequate review. As a result, the vendor invoices were just processed with charges in excess of the prices agreed to in the vendors’ contracts.”

Amputee Advocates: VA Prosthetics Treatment Not as State-of-Art as DoD

Ordering Prosthetics

VA officials concurred with the reports’ recommendations and said they are working to address the issues of concern.

Norbert Doyle, chief procurement and logistics officer for VHA, told the subcommittee that the new policy that would require prosthetic items costing more than $3,000 to be purchased by a contracting officer, rather than the prosthetics service purchasing officers, is meant to ensure compliance with federal acquisition regulations.

Army Spc. Charles Lemon, previously assigned to C Troop “Maddog”, 3rd Squadron, 3rd Cavalry Regiment, was presented the Purple Heart award by Brig. Gen. Joseph DiSalvo recently for injuries he sustained during a combat mission a year ago. Lemon lost both his legs but was able to stand for the ceremony with the use of prosthetics. Photo by Sgt. Lance Pounds.

Doyle said a pilot project was done the first three months of this year to evaluate the impact of the procurement changes as part of VA’s, “great pains to ensure success of this transfer” of purchasing authority.

“We did learn from those pilots, and we’re implementing changes to ensure that care is not impacted,” he said. “Some of the things that we learned is that our staffing models are incorrect in the number of procurements that we could do in a day in the contracting office. … We have received approval to hire additional people to ensure we can keep up.”

He assured the committee that contracting officers would not interfere with clinical decisions on what devices veterans need.

“I do not want my contracting officers making a decision as to what goes in a veteran’s body or gets appended to it,” he said. “That is clearly a clinician decision.”

Members of Congress, however, expressed their reservations about the proposed procurement changes.

“It is very clear from the VSOs [veterans’ service organizations], some of their statements, that it is not uncommon for clinicians to prescribe something and it be modified by contracting officers primarily because of cost. And that is a big concern that I would have,” Rep. Mike Michaud (D-ME) told VA officials.

Chairwoman Rep. Ann Buerkle (R-NY) said she would be interested in seeing the results of the pilot done earlier this year where the procurement reforms were instituted but said she was “troubled” by the proposed changes.

“My concern is that not enough thought was given to this, not enough consultation was done with the veterans and VSOs,” she said.

Also testifying was Lucille Beck, acting chief consultant for VA’s prosthetics and sensory aids service. She said VA is collaborating with DoD on the establishment of the Extremity Trauma and Amputation Center for Excellence, which will be a virtual center with a focus on clinical care, research and education.

“One of the missions of this joint VA and DoD center of excellence is research coordination,” she said.

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