Thursday, May 17, 2012

The sad downward spiral?





"Our nation's commitment to restoring the capabilities of disabled veterans struggling with devasting combat wounds resulting in the loss of limb began with the Civil War," declared US House Rep Ann Marie Buerkle this morning shortly after she brought the House Veterans Affairs Subcommittee on Health to order.  "Restoring these veterans to wholeness was a core impetus behind the creation of the Department of Veteran Affairs and then, now, it continues to play a vital role in the Department's mission."
Buerkle is the Chair of the Subcommittee and this morning's hearing was entitled "Optimizing Care for Veterans With Prosthetics."  Chair Burerkle also noted, "Following WWII, 1945, veterans disatisfied with the quality of VA prosthetic care stormed the Capitol in protest. "  How is the care today?  To answer that question, the Subcommittee heard from four panels.  Gulf War Veteran John Register and Vietnam Veteran Jim Mayer.  Disabled American Veterans' Joy Ilem, American Orthotic & Prosthetic Association's Michael Oros, Paralyzed Veterans of America's Alethea Predeoux and Southeast Wounded Warrior Project's Jonathan Pruden.  The third panel was the VA's Office of Inspector General's Linda Halliday accompanied by Nicholas Dahl, Kent Wrathall and Dr. John D. Daigh Jr. and Dr. Robert Yang.  The fourth panel was the VHA's Dr. Lucille Beck accompanied by Dr. Joe Webster, Dr. Joe Miller and Norbert Doyle.  Some of the issues were outlined in the Ranking Member's opening remarks.
Ranking Member Mike Michaud: I've said it on this Committee before, but what seems to be the case, there is little accountability in management and, once again, procurement procedures and policies were not in place or not followed in managing nearly $2 billion worth of prosthetics and sensor aids.  The VA, in the last year's budget submission, claims $355 million in savings in the Fiscal Year 2012 and 2013 due to aquistions improvements.  But if the VA can't follow its own policies and procedures, how much faith can we have in the claim of acquisition savings?  I hope the VA can help us understand today what accountability we should expect and to make certain that the VA does not continue to overpay for prosthetics in the future, that taxpayers and veterans receive the best value for their devices, and for management to ensure that the prosthetics and sensor aids services is fully meeting veterans needs. Finally, it has come to my attention that VA has proposed changes in the procurement of prosthetics and that there is a high degree of concern among some of our witnesses today as to the effectiveness of these changes. I look forward to hearing from the VA on these changes as well.
A proposed change that's bothering some veterans?  What proposal is Ranking Member Michaud speaking of?  On the second panel, Jonathan Pruden explained the proposal (and here we're using his opening written remarks which differ some what from what he delivered):
Under current practice, VA physicians and prosthetists are able to see a veteran, make a determination regarding the most appropriate type of prosthetic equipment for a veteran, and relay that information to a Prosthetics Service purchasing officer to complete a purchase-order to obtain the needed item.   Those purchasing officers exclusively handle prosthetics' purchases, and are specialists in ordering medical equipment specified by health care providers.  A major change that the Veterans Health Administration intends to institute on July 30th, would require that any prosthetic item whose cost exceeds $3000 -- to include such essential items as limbs, wheelchairs and limb-repair components – must be procured by a contracting officer.  This is not simply a matter of substituting a generalist for a specialist.  Under the proposed change, these contracting officers would use a labor-intensive system (the Electronic Contract Management System (eCMS)) designed to achieve cost savings.  That system, designed for high-dollar bulk-procurement purchases that benefit from using the Government's purchasing power, requires over 300 individual steps to manually process a purchasing order.  While well-suited for buying widgets, the system was neither designed for nor well-suited to procuring highly specific, individualized medical equipment. Ill-suited to prosthetics, this new process would also require increased coordination between clinicians and off-site contracting officers who would be responsible for purchasing everything from light bulbs to now highly specific prosthetic legs.
This is not a small change.  Moreover, it not only increases the margin for error but also the potential for prolonged, delaying "back-and-forth," with the likelihood of clinicians having to justify why a more expensive wheelchair is clinically necessary when a seemingly-similar less- costly model exists.  We see no prospect that this planned change in prosthetics procurement holds any promise for improving service to the warrior.  Instead, it almost certainly threatens greater delay in VA's ability to provide severely wounded warriors needed prosthetic devices.
This would be "the wrong path" Iraq War veteran Jonathan Pruden stated.  He was injured in a July 1, 2003 Baghdad bombing resulting in multiple surgeries including the amputation of his right leg.  This next excerpt is from his oral testimony.
Jonathan Pruden:  Under the change, only a contracting officer could procure a prosthetic item costing more than $3,000.  This policy would effect essential items including most limbs like mine and wheel chairs.  It would require the use of a system designed for bulk procurement purchases that involves manually processing over three hundred -- that's 300 -- individual steps to develop a purchase order.  This system may be great for buying cinder blocks and light bulbs but it is certainly not appropriate for providing timely and appropriate medical care.  Equally troubling, this change offers no promise of improving service to the warrior.  Instead, it would mean greater delays. The change could realize modest savings but at what cost?  A warrior needing a new leg or wheel chair should not have to wait longer than is absolutely necessary.  I know warriors who have stayed home from our events, stay home from school, from work, can't play ball with their kids or live in chronic pain while they wait for a new prosthesis.   I know first hand what it's like to not be able to put my son into the crib while I'm waiting for a new prosthetic, to live in chronic pain and to have my daughter ask my wife once again, "Why can't Daddy come and walk with us?"   With VA moving ahead on changing procurement practices, wounded warriors need this Committee's help.  A prosthetic limb is not a mass produced widget. Prosthetics are specialized, medical equipment that should be prescribed by a clinician and promptly delivered to the veteran.  We urge this Committee to direct VA to stop implementation of this change in prosthetic procurement.
We'll note this exchange from the second panel.
Chair Ann Marie Buerkle: Mr. Pruden, in you testimony, you talked about how VA prosthetic research has lagged in recent years.  Now Mr. Oros talked about outcomes but I think you're talking more generally in terms of the research.  What impact -- and I shouldn't speak for you.  I should let you say what research you were referring to.  And then, if you could, after you tell us that piece, what impact has that had on veterans and the service that they need?
Jonathan Pruden:  VA has-has stepped up in a number of capacties in the past few years.  But, as Mr. Mayer pointed out earlier, DoD has taken the lead on the development of the DEKA Arm [a project DoD and the VA work on together] and all of these advanced techonology things.  In years past, VA has been -- One of its key roles and one of the reasons it exists is to provide specialized medical equipment for our combat wounded, for our veterans.  And VA really needs to have the capacity and the focus on research for durable medical equipment when DoD and Global War on Terror Dollars go away.  And this also ties into the discusssions about the centers of excellence at Walter Reed, Brooke Army Medical Center and so forth.  When these dollars go away, those DoD facilities will certainly scale back their capacity both for rehabilitation and for research.  And what we're calling for is for VA through the amputee system of care and enhancements and research to be prepared to meet the needs as DoD scales back.
Chair Ann Marie Buerkle: Thank you.  Miss Predeoux, I'm extremely concerned with regards to your comments about the filing system being outdated and the backlog that it creates.  Could you comment on that for us?
Alethea Predeoux:  Yes, in my written statement with the filing system, it refers to medical records in one VA medical center.  And if, for instance, one veteran was to relocate -- For example, our director of benefits relocated to this area from San Diego and it took quite a bit of time for the medical records to be delivered from San Diego to DC simply because there's not one central system in which all the medical centers are able to locate and actually view  the medical records of a veteran.  And as the panel before us testified, it's not just a wait time, it's a matter of being able to be comfortable and actually to be mobil.
Noting that Wounded Warrior was favoring a freeze on VA's proposed change, Ranking Member Michaud asked Oros, "Do you think we should ask the VA to freeze the reorganization? Bringing everthing in house?"   Oros responded, "Absolutely. Absolutely." US House Rep Gus Bilirakis wanted to know about the real life effects if VA went through with their change in procurement?
Jonathan Pruden:  Under the current system, there are safeguards in place to ensure that VA is being fiscally responsible. And it can take a month, two months.  Some of this is predicated on the clinical needs of the patient and the availablility of the product in their area  which is appropriate.  Our real concern is that -- is that with the new system, it would be supposition but it may take months and months longer to get purchase orders for needed equipment. And the veterans should not have to wait and the clinician's hands should not be tied.  If they feel that a device is appropriate and going to provide the best care for a warrior, they should be able to prescribe that device.  I have had the opportunity to speak with over a dozen VA clinicians and prosthetists who are currently serving in several former chiefs of prosthetics.  And every single one of them said that they share our concerns about the ability to remain timely and potential delays in veterans receiving needed prosthetic devices under this new system.  Dr. Bechel and she'll say that, 'One of the things that 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? It's going to be somebody in acquisitions , not a physician, not a clinician who has the patient's best interest at heart.  And that -- that's our real concern.
That's one of the main points from the hearing.  Time permitting, we may cover some other issues or go deeper into this one in another snapshot.
From the House to the Senate, Senator Patty Murray is the Chair of the Senate Veterans Affairs Committee and the Committee issued the following today:
Wednesday, May 16, 2012
Contact: Murray Press Office
(202) 224-2834
Senator Murray's Statement on Sweeping Army-Wide Review of Behavioral Health Evaluations and Diagnoses
Investigations Will Review Mental Health Diagnoses Since 2001
(Washington, D.C.) -- Today, U.S. Senator Patty Murray, Chairman of the Senate Veterans Affairs Committee, released the following statement after the Army announced that they will begin a comprehensive, Army-wide review of soldier behavioral health diagnoses and evaluations since 2001.  This major announcement comes after Senator Murray spurred an investigation into inconsistencies in diagnoses at Joint Base Lewis-McChord in her home state of Washington.  The Army has since returned PTSD diagnoses to over 100 servicemembers that sought treatment there.  Murray has repeatedly pushed Army leadership to investigate whether problems similar to those at Madigan were being seen at Army bases across the country.
For more information on the Army's announcement visit:
"The Army clearly realizes they have a nationwide, systematic problem on their hands. I credit them with taking action, but it will be essential that this vast and truly historic review is done the right way.  That means continued engagement from Army leadership at the highest levels, prompt attention to the problems of servicemembers identified during the review, and not only the identification of problems but quick action to implement and enforce solutions.
"This comprehensive review is born out of a review I helped initiate in my home state that has already returned PTSD diagnoses to over 100 servicemembers since the beginning of this year.  That review has been successful because the Army identified and reached out to affected servicemembers and veterans, conducted reevaluations using the appropriate tools and best practices, and was made a priority by top military leaders.  This nationwide review must be given the same attention from leadership in order to succeed.
"But the bottom line is that the Army needs to fix the inconsistencies we have seen in diagnosing the invisible wounds of war.  Out of this review, the Army needs to provide a uniform mental health policy so that service members are given the care they need.
"This is an issue that affects every aspect of the lives of those returning from Iraq and Afghanistan. Without proper mental health treatment we will continue [to] see see servicemembers struggle to readust to family life, contine to self-medicate, and in far too many cases, take their own lives.
"Servicemembers, veterans, and their families should never have to wade through an unending bureaucratic process to get proper access to care. The Army has an extrordinary opportunity to go back, correct the mistakes of the past, and ensure that they are not repeated."
Matt McAlvanah
Communications Director
U.S. Senator Patty Murray
202-224-2834 - press office
202--224-0228 - direct

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