Thursday, August 02, 2012

The Howler Monkeys of the Cult of St. Barack






Chair Ann Marie Buerkle:  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 [of VA] 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 ased for and did nothing to assure me that the plan would be effective or that our veterans concers were unfounded.
When the House Veterans Affairs Subcommittee on Health's Chair Buerkle and Ranking Member Mike Michaud are blown off -- and the Veteran Affairs Dept did blow them off -- it's not just insulting to Congress.  It's also an insult to veterans.  Buerkle and Michaud aren't looking for pen pals.  They're busy and have a great deal to do.  Their staff is very busy.  So when they're asking about something, when they're trying to provide the oversight and ensure that the veterans are being served, they shouldn't be blown off.  The May hearing [May 16th, covered in the May 16th and May 17th snapshots] was rather intense.  That questions would arise from that hearing is not surprising.  It is surprising that the VA would (a) respond late and (b) offer a non-response as a response.
It's insulting.  And it's very sad that at the conclusion of the hearing, Chair Buerkle had to ask for a copy of the plan that the hearing was about, a plan discussed throughout the hearing, to be submitted to the Subcommittee and the House Veterans Affairs Committee.  That should have been supplied some time ago.  As she noted, they needed to see that plan to make sure that "the veterans best interests are" being served.
Yesterday afternoon, the Subcommittee on Health held a hearing on prosthetics.  They heard from one panel which was the VA's Dr. Robert Petzel with Philip Martovsky, Dr. Lucille Beck and C. Ford Heard (all of the VA).  Two terms to know before we go further.  "VSO" refers to Veterans Service Organizations -- like the VFW, the American Legion, etc. "VISN" is the Veterans Integrated Service Network -- medical care facilities.
We're going to emphasize two exchanges early on.  I don't care for Dr. Petzel because I find him to be rude and he tries to run out the clock on his answers.  And he may be wonderful and just come off uncaring.  But as you'll see in the first excerpt, even when he's given the heads up that he's coming off poorly, he doesn't alter his language, he doesn't try to speak in a professional manner that shows care for the veterans.  This is not a new thing with him, this happens every time.
Committee Chair Ann Marie Buerkle: When I hear words like "equipment" and "pharmaceuticals" and then 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.  Amoxicilliin is Amoxicilliin.  A thermometer is a thermometer.  But a prosthetic is unique to that person and to his needs or her needs.  That's my concern with this.  That you -- That this process will become just as any other procurement.  This is a very different process and I think it's what concerns the VSOs and what concerns the veterans.  This is uniquely personal service that we have to give to that veteran and what I'm hearing here when you talk about cataloging purchases concerns me greatly.
Dr. Robert Petzel: Uhm, Madam Chairwoman, we absolutely agree with you.  This -- this is the most personal of work VA does -- crafting and fitting a prosthetic limb to an individual that's lost an arm or a leg is a very personal process.  The reforms that we're talking about in terms of uh procurement will not interfere with that process.  The physician orders the prosthetic and that order can be very specific.  The prosthesist  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 most of our procurement not all but most of our procurement occurs in the private sector. In the process of transitioning during the pilot, we audited the orders that the physician had written, we audited the purchasing contract -- the way the contract --  what was actually purchased. We looked at the timeliness between when that order was actually placed and when that order was purchased.  And we looked at the satisfaction -- particularly at the processes in the physicians as to whether or not the needs of that veteran's 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 was 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 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.
Chair Ann Marie Buerkle:  Can you talk to us about the pilots?  How many pilots were done? How long?  Over what period of time were the pilots conducted?  What areas, which VISINs were included and how you -- What were the various pilots?  How many were there?
Dr. Robert Petzel: Yes, Madam Chairman, we can.  And I'd like to turn to Mr. Matovsky to give you some of the details about the pilots.  Thank you.
Philip Matovsky:  Thank you, sir.  We conducted three pilots.  One of them in VISIN 6 -- I'm sorry, VISIN 6 which is  North Carolina, parts of Virginia, parts of West Virginia.  VISN 11 which is Indiana -- I'm going to test my geography here --  parts of Michigan as well.  VISN 20 which is the upper north west on into Alaska. We selected them because they were a uh-uh broad representation -- some of them highly rural, some of them very large and growing. We also ran them from the period of January through the end of March -- for three months.  I believe one of them scooted into April.  We tested two different processes.  One process utilized fully the ECMS our Electronic Contract Management System to place the order and another one in VISN 6.  a slightly different process.  That's the basis for it.  We tested the onboarding of our staff, the training of our staff, the communication, the collaboration with the prosthesis, the prosthetic purchasing agent and then the contracting management agent staff.  As Dr. Petzel just indicated, we did conduct some audits.  For example, 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?  100% of the time, the contracting officer adhered to the prescription.
Petzel's saying he agrees with the Chair but he makes no attempt to use language that demonstrates he really does agree.  He comes off in hearing after hearing as someone who does not care.  He doesn't want to be informed.  If he's given a chance to correct and impression, he doesn't want to be bothered. 
If I have breakfast with you on a regular basis and your name is Charlie but I keep calling you Carl, that says something.  Especially if it's not a joke between us but it's that I've never cared enough to learn your name.  I bring that up for a reason as we jump into the next excerpt.
Ranking Member Mike Michaud: [. . .] We are alarmed by the possible negative impact on patient care including substantial delays in 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.  And this is the third hearing in an handful of months on this particular issue.  And I remain committed to working with the very dedicated staff at the Dept of Veterans Affairs and the advocacy community to ensure that our veterans are getting the best care that we can deliver in the timely way in this joint-effort and joint-challenges that this Subcommittee stands ready to help. And I read through your testimony and I have a few questions, if I might.  In your testiomny, 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 whether or not they do take in their -- their concerns?
Dr. Robert Petzel: Excuse me, Congressman Michaud, we have.  Since the May hearing, there have been multiple hearings with the -- the service office -- service officers representatives.  I have a breakfast monthly, uhm, with the 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.  I'll just quickly [picks up a list in front of him and reads from it] with American Legion, VFW, PPA, the DAV, AmVet and the Blind Veterans of America to discuss [puts list down] what we want to do.  And I can say, that there was no, uh, objection.
Really?  Not even from the Blind Veterans of America.  Anybody else questioning that?  I've attended a ton of hearings, I write checks to  many organizations helping the wounded.  But I'm pulling a blank on Blind Veterans of America.  Maybe he meant Blinded Amercian Veterans?  Maybe he didn't. Maybe he meant the Blinded Veterans Association?  Maybe he didn't.   But what he said, reading from his list, was "the Blind Veterans of America."  Most of the time, those who get the name wrong mean Blinded Veterans Association.  Usually Dr. Thomas Zampieri is their spokesperson at Congressional hearings and he just nods when their name is stated wrongly and then, in his testimony, he'll note that they are the Blinded Veterans Association.  My guess is that Petzel meant the Blinded Veterans Association.  It's a shame people can't get the organization's name right in a hearing when they're speaking off the top of their heads.  But Petzel wasn't doing that.  He pulled out a list and read from the list.  And that means he most likely has breakfast with Zampieri and others and wrongly calls them the "Blind Veterans of America."
Again, he comes off as someone who just doesn't give a damn.  He meets with this group monthly but he doesn't know their name?  Even when reading off a prepared list, he can't get the name right?  You have to wonder how VA lets stuff that happen.  It's not as if they're image is so sparkling that they can afford to take a few hits from Petzel. 
US House Rep Phil Roe is also Dr. Phil Roe, a medical doctor.  He established a few levels in his questioning.  Before a program goes widespread, the VA always swears it's going to work perfect and this person and that person will benefit and there are never any problems with these program that aren't running yet.  Then they start up and, wow, there are problems.  I think Dr. Roe did a very good job establishing what the goals of this transformation are.  If the new standardization is successful, a year from now we should be able to go through the markers Dr. Roe established.
US House Rep Phil 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, trying to standardize the procedures not only in this but in other areas of contracting that the VA does?  Am I right on that?
Dr. Robert Petzel:  We have to standardize procurement.  Not procedures per se.  But to professionalize and standardize the way we, uh, procure material.  We have been, as I said, criticized in the past by important groups of people including some Congressional Committees on our procurement stratigies. And this system-wide effort was to try and professionalize that, yes.
US House Rep Phil Roe: Okay, so I guess in what the Chairwoman said is correct and there's obviously a prosthesist sitting right to your left.  That's a very individualized therapy and I know as a physician not everything -- I mean, this has to be tailored per person.  I'm sure there's some standardization to it but  it has to be.  And this is not in any way going to slow the process down. Or make that process not as effective or available to our veterans.  Am I correct on that?
Dr. Robert Petzel:  Yes, sir, you are correct.
US House Rep Phil Roe:  And so they'll be able to come -- 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's not going to be a difference in timeliness.  The fact that it costs more than $3000, that's not going to affect the time that that veteran that comes in that needs a limb or needs a prosthetic device is going to get that device?
Dr. Robert Petzel: Yes, sir, that's correct.
US House Rep Phil Roe:  Okay, so I think that's extremely important.  And, secondly, once you've catalogued this, is there a way to go outside?  In other words, here's what's in our catalogue.  If the doctor and the prosthetist look at this patient and say, "This is what they need.  It's not right in this little book right here."  Can they get that?  Because this technology is changing faster than cardiac stents are changing.  I mean, it's amazing now the technology in prosthesis.  So as that new technology occurs, it's like these things right here [holds up a cell phone]. As soon as you buy it, it's out of date. And so I see the same thing in prosthesis.  People are doing things -- amazing things -- with this.  So is it once it goes in the Sears & Roebuck catalogue that Sears has, that VA has, can that person get something from the new catalogue? Or something brand new that happened? 
Dr. Robert Petzel:  Dr. Roe, absolutely.  One of the nice things about the VA and the procurement regulations  is 8123 which basically says that, uh, with the proper justification, we do not have to do competative buying.  That we can buy specifically what  the doctor has ordered.  So while we may have a catalogue of things that are appropriate in certain kinds of circumstances, the important part in all of this is a doctor writes an order and we will procure for that patient what the doctor has ordered.
US House Rep Phil Roe:  So this is not going to negate new technology as it occurs?
Dr. Robert Petzel:  Absolutely not.
US House Rep Phil Roe:  So our veterans can get the cutting edge?  They're not going to get stuck with it's not in the book, you can't have it?
Dr. Robert Petzel:  Absolutely not, Congressman.  Just to give an example, there are two relatively new knees that were jointly developed by the VA and the Dept of Defense.  The 2X or X2  and the Genium.  Is that how you pronounce that? Those are absolutely cutting edge techonology for artifical knee.  They're available to any veteran that needs and wants that kind of a prosthesis.
US House Rep Phil Roe:  So it's not going to be -- I mean, it's one thing to have all the colonoscopes looking exactly alike.  That was one of the issues when I first got here.  We had that issue that came up.
Dr. Robert Petzel:  Yes.
US House Rep Phil Roe:  This is a little different than that.  And I guess the other question that I had -- and then I'll have no more -- is that you said that you don't believe that the veterans will be negatively impacted.  Well will they be postively impacted by this?  Will this improve?  I know the VA feels like it will be postively impacted  but will the veteran be positively impacted by this?
Dr. Robert Petzel:  Well first of all I think --
US House Rep Phil Roe:   Or will they even know the difference? 
Dr. Robert Petzel: I think first they -- First of all, Congressman, they should not know a difference.  This should be absolutely transparent to them.  But there are things -- 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're going to cut down on the procurement time on average.  That's one.  Number two is that any money that might be saved by getting a fair price -- and that's 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.
US House Rep Phil Roe:  One quick question, when will we know that?  When will you evaluate the system and it's up and running?  A year from now or two years from now?
Dr. Robert Petzel: Congressman, I think there's going to be two different kinds of evaluation.  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% of the 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's going to be an ongoing process.  When we have been into this for say a year or six 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're doing overall a better job of purchasing than we were doing before?  So there will be two levels of evaluation.
Let's stay with the Genium X2 prosthetic knee for a moment.  KSTP has a video report here of Iraq War veteran Luke Schmitz after he got the prosthetic knee.  He stated, "As I'm walking, I don't have to think about it and it's doing everything for me." It has a microprocessor in it.   Orange Coast Prosthetics has photos and videos of the Genium/X2 here and explains, "The Genium hydraulic knee joint system functions through the use of simulated physiologic rule sets run by a miscroprocessor, with auto-adaptive swing and stand phase control predicted by multi-modal proprioceptive input.  The system also provides flexed-knee loading to traverse obstacles and ascend stairs, and dynamic stability control for intuititve standing and transitional gait.  After purchasing the Genium Microprocessor Knee, the practitioner manufactures a custom-fabricated prosthesis incorporating the component."  If you click here, you can view a video report by WHIO on Air Force member Chris Trobaugh who got the Genium and explains, "I can run on it.  And I can hike on it.  Play basketball, golf.  Those are all my goals.  All the things I want to do."
Chair Ann Marie Buerkle noted that  she was concerned about the length of the pilot program.  "three months is a very short period of time."  She was concerned that Dr. Lucille Beck had a number of duties already and could not provide sole supervision of this new program.  She made Dr. Petzel go on the record with the fact that a doctor's order would be followed, that a contracting officer (whom she summed up as someone with a Bachelors of Science and a few hours in business courses) would not be allowed to override a doctor's order.  Petzel insisted that was not the case and that the doctor's order would always be followed.  That's something to remember when the first complaints on the program start coming in.  Buerkle was also concerned that the VSOs and veterans were not being properly and/or fully included in the process.  We'll note some of her concluding remarks.
Chair Ann Marie Buerkle:  I think it's very important that we get as many Veterans Services Organizations involved in this discussion, as many perspectives.  You know, what you've mentioned, with all due respect, is great but I think we've got additional Veterans Service Organizations that need to be included in this discussion. And to make sure -- there's nothing more important than the veterans -- and to make sure that when they come home without a limb because they've served this nation, that they have what they need, that they're not dealing with some contracting officer who's got some discretion to give him less of a device than he deserves. So that's all of our concern here that we get our veterans exactly what they need. We heard the last time from veterans.  We're talking about the ability of someone to walk his daughter down the aisle. We're talking about intensely personal prosthetics and intensely personal segment of the care that our veterans need. So there's nothing more important.  And while we are all concerned with regards to cost, that we make sure that our veterans who have served this nation get exactly what they need so that they can return to their maximum potential after they've sacrificed so much for this nation.

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