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SUBCOMMITTEE HEARING ON ENSURING 

CONTINUITY OF CARE FOR VETERAN 

AMPUTEES: THE ROLE OF SMALL 

PROSTHETIC PRACTICES 

COMMITTEE ON SMALL BUSINESS 

SUBCOMMITTEE ON CONTRACTING AND 

TECHNOLOGY 

UNITED STATES HOUSE OF 

REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

JULY 16, 2008 

Serial Number 110-105 

Printed for the use of the Committee on Small Business 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/house 

HOUSE COMMITTEE ON SMALL BUSINESS 

NYDIA M. VELA ́ ZQUEZ, New York, Chairwoman 

HEATH SHULER, North Carolina 

CHARLES GONZALEZ, Texas 

RICK LARSEN, Washington 

RAUL GRIJALVA, Arizona 

MICHAEL MICHAUD, Maine 

MELISSA BEAN, Illinois 

HENRY CUELLAR, Texas 

DAN LIPINSKI, Illinois 

GWEN MOORE, Wisconsin 

JASON ALTMIRE, Pennsylvania 

BRUCE BRALEY, Iowa 

YVETTE CLARKE, New York 

BRAD ELLSWORTH, Indiana 

HANK JOHNSON, Georgia 

JOE SESTAK, Pennsylvania 

BRIAN HIGGINS, New York 

MAZIE HIRONO, Hawaii 

STEVE CHABOT, Ohio, Ranking Member 

ROSCOE BARTLETT, Maryland 

SAM GRAVES, Missouri 

TODD AKIN, Missouri 

BILL SHUSTER, Pennsylvania 

MARILYN MUSGRAVE, Colorado 

STEVE KING, Iowa 

JEFF FORTENBERRY, Nebraska 

LYNN WESTMORELAND, Georgia 

LOUIE GOHMERT, Texas 

DAVID DAVIS, Tennessee 

MARY FALLIN, Oklahoma 

VERN BUCHANAN, Florida 

MICHAEL DAY, Majority Staff Director 

ADAM MINEHARDT, Deputy Staff Director 

TIM SLATTERY, Chief Counsel 

KEVIN FITZPATRICK, Minority Staff Director 

Subcommittee on Contracting and Technology 

BRUCE BRALEY, IOWA, Chairman 

HENRY CUELLAR, Texas 

GWEN MOORE, Wisconsin 

YVETTE CLARKE, New York 

JOE SESTAK, Pennsylvania 

DAVID DAVIS, Tennessee, Ranking 

ROSCOE BARTLETT, Maryland 

SAM GRAVES, Missouri 

TODD AKIN, Missouri 

MARY FALLIN, Oklahoma 

(II) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Braley, Hon. Bruce .................................................................................................. 1 

Davis, Hon. David .................................................................................................... 3 

WITNESSES 

Downs, Mr. Frederick , Jr., Chief Prosthetics and Clinical Logistics Officer, 

Department of Veterans Affairs .......................................................................... 5 

Bacik, Captain Mathew,USA Ret.,Montgomery Alabama .................................... 20 

Clark, Mr. Dennis, CPO, Clark and Associates Prosthetics and Orthotics, 

Waterloo, IA .......................................................................................................... 22 

Rogers, Mr. James, CPO, FAAOP, President, American Academy of Orthotists 

& Prosthetists ....................................................................................................... 24 

Guth, Mr. Thomas, CP, President, National Association for the Advancement 

of Orthotics & Prosthetics OH ............................................................................ 26 

Smith, Mr. Christian T.Z., CPO, BOCOP, President, Victory Orthotics and 

Prosthetics, Inc., Johnson City, TN .................................................................... 28 

APPENDIX 

Prepared Statements: 

Braley, Hon. Bruce .................................................................................................. 42 

Downs, Mr. Frederick , Jr., Chief Prosthetics and Clinical Logistics Officer, 

Department of Veterans Affairs .......................................................................... 44 

Bacik, Captain Mathew,USA Ret.,Montgomery Alabama .................................... 50 

Clark, Mr. Dennis, CPO, Clark and Associates Prosthetics and Orthotics, 

Waterloo, IA .......................................................................................................... 56 

Rogers, Mr. James, CPO, FAAOP, President, American Academy of Orthotists 

& Prosthetists ....................................................................................................... 62 

Guth, Mr. Thomas, CP, President, National Association for the Advancement 

of Orthotics & Prosthetics OH ............................................................................ 77 

Smith, Mr. Christian T.Z., CPO, BOCOP, President, Victory Orthotics and 

Prosthetics, Inc., Johnson City, TN .................................................................... 83 

(III) 

(1) 

SUBCOMMITTEE HEARING ON ENSURING 

CONTINUITY OF CARE FOR VETERAN 

AMPUTEES: THE ROLE OF SMALL 

PROSTHETIC PRACTICES 

Wednesday, July 16, 2008 

U.S. HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON CONTRACTING

AND TECHNOLOGY, 

COMMITTEE ON SMALL BUSINESS, 

Washington, DC. 

The Subcommittee met, pursuant to call, at 10:00 a.m., in Room 

1539, Longworth House Office Building, Hon. Bruce Braley [chairman of the Subcommittee] presiding. 

Present: Representatives Braley, Cuellar, Clarke, Sestak, Akin, 

and Davis. 

OPENING STATEMENT OF CHAIRMAN BRALEY 

Chairman BRALEY. This hearing on VA contracting with small 

prosthetic practices is now called to order. 

The human cost of the Iraq conflict has been nothing short of 

devastating. In 5 years of war, our troops have suffered 4,000 

deaths and another 29,000 injuries. As our wounded soldiers return 

from overseas, the Nation now faces a moral and financial challenge of providing for their medical care. 

Why should we care about the prosthetic needs of our Nation’s 

veterans? In the aftermath of the devastating revelations about the 

conditions at Building 18 in Walter Reed Army Medical Center, an 

Independent Review Group headed by the Honorable Togo West 

was assembled to report on rehabilitative care and administrative 

processes at both Walter Reed and the National Naval Medical 

Center at Bethesda. The Independent Review Group identified 

traumatic amputations as one of the four signature injuries associated with the current conflicts in Afghanistan and Iraq. 

It is important to note that today’s Veterans Administration 

serves not only the wounded returning from current conflicts, but 

also the additional 70 million Americans otherwise eligible for VA 

benefits. My brother, Brian Braley, knows this very well. He treats 

these patients as a kinesiotherapist at the VA hospital in Knoxville, Iowa. And I am very proud of him for making a difference in 

the lives of the patients he works with. A great number of these 

men and women will require prosthetic and sensory aid resources. 

In 2007 alone, more than 1.3 soldiers sought these services. As amVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
2 

putees continue to return from the war, the number of patients 

who require prosthetic services will continue to rise. 

In order to meet this increased demand, the VA’s budget for 

prosthetic and sensory aid services, PSAS, has risen dramatically. 

Increased funding for this service has been a bipartisan effort. 

Democrats and Republicans alike are dedicated to providing the 

best possible care to our wounded veterans. But while the VA has 

made great strides in offering treatment, many amputees continue 

to face obstacles. 

In addressing these challenges, we should first look to small 

health care providers who comprise the bulk of the prosthetics industry. Small firms make up 80 percent of this vital medical sector. 

In fact, the administration currently holds 600 agreements with 

small prosthetic practices. But despite the VA’s efforts to ensure 

quality care to amputees, many vendors have raised concerns. 

The system, while enormously helpful to the vast majority of veterans, is not perfect. A series of issues regarding procurement have 

made this sector increasingly difficult to navigate. As a result, the 

well-being of our wounded soldiers could be improved. 

In order for small health care providers to successfully serve 

these men and women, several barriers must be addressed and 

overcome. One of the greatest challenges facing prosthetic businesses is the VA’s obsolete contract procedure. The documents for 

this process can be outdated and hard to follow. In some cases, it 

would seem that neither the practice nor the paperwork has kept 

pace with industry development. Similarly, the bidding procedure 

for the administration’s proposals can be disorganized and inconsistent. Consequently, many small businesses find themselves shut 

out of the system. These logistical roadblocks have deterred many 

entrepreneurs from participating altogether. This means more than 

just decreased revenues for small firms. It means fewer choices for 

wounded veterans. 

Further compounding the choice issue are restrictive contracting 

practices. Prosthetic providers around the country have noted instances in which VA hospitals have narrowed patient selections. 

This can be devastating to amputees who need specific devices 

made by a limited number of providers. 

In outsourcing to small prosthetic businesses, the VA allows veterans to seek more personalized care. We must ensure that amputees continue to have this option. It is important to note that these 

suggestions are not intended to undermine the vital work of the 

VA. 

On the contrary, this Committee recognizes the administration’s 

considerable efforts in providing quality care to veterans. As we 

will hear today, its services have been a literal lifeline to countless 

veterans across the country. What is more, the VA has been and 

continues to be an important partner for the small business community. With this in mind, we must ensure that the administration 

and small business providers have the opportunity to build an even 

stronger partnership. In doing so, we will not only bolster our small 

businesses, we will also support the heroic men and women who 

have answered our Nation’s call. 

These noble warriors have spilled their blood for us and served 

their country with courage. They have earned and deserve our supVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
3 

port. Their well being is our moral obligation, and we should not 

shirk our financial responsibility to care for them as a fundamental 

and patriotic duty. If we fail to live up to that responsibility and 

give them the best chance to reach their full potential, we will pay 

a heavy price over their lifetimes in added medical expenses due 

to chronic disease processes that are aggravated by inactivity, such 

as morbid obesity, diabetes and vascular diseases that lead to heart 

attacks and strokes. To paraphrase the old Fram oil filter commercial, we can pay for them now or we can pay for them later. 

In this morning’s hearing, we identify future needs of amputees 

who face care decisions in the DOD and VA medical systems and 

examine ways in which the VA and small businesses can work together to address those critical needs. 

I want to thank all of our witnesses in advance for taking time 

from their busy lives to travel here and share their testimony. I 

look forward to a lively, frank and informative exchange. 

And at this time, I have the privilege of recognizing the ranking 

member, my friend, David Davis from Tennessee, and ask him to 

share his opening statement. 

Mr. DAVIS. Good morning and thank you, Chairman Braley, for 

holding this hearing on the important topic of veterans and prosthetic practices. I would like to thank each of our witnesses who 

have taken the time to provide a witness to this Subcommittee 

with their testimony. I would like to extend a special welcome to 

my fellow Tennesseean, Christian Zach Smith, a board certified 

prosthetist and orthotist, and I will introduce you later. 

The Department of Veterans Affairs operates the Nation’s largest 

integrated health care system, and like most other Federal health 

care programs, the system is a direct service provider rather than 

a health insurer or payer for health care. VA health care services 

are generally available to all honorably discharged veterans to the 

United States Armed Forces who are enrolled in the VA’s health 

care system. Under the VA prosthetic service policy, a lack of funds 

will never cause a prescription or prosthetic from being filled or delayed. This policy has enabled the VA to provide the highest quality prosthetic services and care of any government or civilian medical system in the world. 

A proper prescription by a VA clinician can make any prosthetic 

device in the marketplace available to the veteran. This means the 

VA’s prosthetic service is required to stay abreast of all new technology, both in research and development stages and when the 

product is available for use after it is approved by the FDA. Because of this attention, the VA is often among the first to prescribe 

new prosthetic devices that come to the market, especially if they 

are high tech and high cost. 

All the 61 VA prosthetic and orthotic labs have earned certification by either the American Board of Certification in orthotics, 

prosthetics or pedorthics, the ABC, or the Board of Orthotist/Prosthetist Certification, the BOC, which are the two national accredited organizations. Almost all VA prosthetics and orthotists are 

board certified. Additionally, eight of these accredited labs have 

also earned certification from the National Commission on Orthotic 

and Prosthetic Education, which enables the labs to participate in 

residency programs from the nine prosthetic and orthotic programs 

4 

in universities and colleges in the United States. This same standard is applied to all contractors to help ensure consistent quality. 

Under title 38, section 1823 of the United States Code, the VA 

is authorized to procure orthopedic and prosthetic appliances and 

related services, including research, without regard to any other 

provision of law. The VA only uses its expanded acquisition authority on a case-by-case basis to ensure veterans the highest quality 

of care. 

The VA has an active prosthetics small practice outreach program. For example, the VA’s Office of Small Business and Disadvantaged Business Utilization has several initiatives that train 

small orthopedic and prosthetic practices to do business with the 

VA. 

Also, VA works very closely with prosthetic contractors in 

hosting conferences around the country where there is a mix of VA 

attendees and prosthetic small practices. These seminars are typically organized on a local and regional basis as a mechanism of 

outreach with independent practices and an opportunity for mutually beneficial collaboration between the VA and small practices. 

This effort has resulted in approximately 80 percent of contracts 

for these services by number of purchase orders and by a total cost 

being awarded to small practices. 

Chairman Braley, I look forward to working with you on this important issue. And again, I would like to thank each of you for 

being here with us today. And with that, I yield back my time. 

Chairman BRALEY. Thank you, Mr. Davis. Before we introduce 

our first witness, let me explain the 5-minute rule for all of the witnesses who are here present to testify. We will move on to the testimony of witnesses, all witnesses will be allowed 5 minutes to deliver their prepared statement and there will be a timing device 

right in front of you. The way the lights work is when 1 minute 

remains, the yellow light will come on and when your time is up, 

the red light will come on, and your entire written statement will 

be included as part of the record. 

Let me introduce our first witness. We are honored to have Mr. 

Frederick Downs as our first witness. He is currently the Chief 

Prosthetics and Clinical Logistics Officer for the Veterans Health 

Administration, Department of Veterans Affairs, headquartered 

here in Washington, D.C. Mr. Downs manages a nationwide $1.3 

billion dollar prosthetics and sensory aids program that furnishes 

assistive aid and services to nearly 2 million veterans with disabilities. 

Mr. Downs served in Vietnam where he was severely injured, losing his left arm above the elbow. He has four purple hearts and 

was inducted into the Officer Candidate School Hall of Fame at 

Fort Benning Infantry School. We are honored to have you here. 

Thank you for your service to our country, and we look forward to 

your testimony. 

5 

STATEMENT OF FREDERICK DOWNS, JR., CHIEF PROSTHETICS 

AND CLINICAL LOGISTICS OFFICER, OFFICE OF PROSTHETICS AND CLINICAL LOGISTICS, DEPARTMENT OF VETERANS AFFAIRS 

Mr. DOWNS. Thank you, sir. Good morning, Mr. Chairman and 

members of the Subcommittee. Thank you for the invitation to discuss the Department of Veteran Affairs’ relationship with independent prosthetic contractors in our efforts to ensure continuing 

care for our veteran amputees returning from combat. I would ask 

that my written statement be entered into the record. 

VA furnishes prosthetic services to enrolled veterans as part of 

the Department’s medical benefits package. This includes sensory 

aids for those who meet VA’s eligibility criteria. Our prosthetic devices include an array of items from appliances, parts or accessories that are necessary to replace or substitute for a deformed, 

weakened or missing anatomical portion of the body. 

Our Office of Prosthetics has a long tradition of using an extensive network of VA laboratories and contract prosthetic labs to provide prosthetic and orthotic devices. We operate 61 prosthetic labs 

and each one of them is accredited by one of the two national accrediting bodies, which was mentioned. And we also hold our contract lab—our contract prosthetist that we do the contracts with, 

it was over 600, to the same standards. In fact, we held them to 

those standards before we adopted them. So it has always been a 

tradition that we required certification from our contract 

prosthetists for them and their labs. 

We contract with over 600 independent labs, as we said, and that 

provides, by the way, about 97 percent of the total limbs. And there 

is a misperception that VA fabricates most of the limbs, and that 

is not true at all. We only fabricate at the most 3 percent of the 

limbs that are provided to America’s veterans. 

Now, to keep our people up to speed in prosthetics, we hold our 

conferences concurrent with and endorsed by the American Academy of Orthotists and Prosthetists during their annual meeting in 

their scientific symposium. This annual meeting is attended by approximately 2,000 prosthetists. Many of these are small business 

owners and VA contractors. Our goal is to improve communications 

and interaction with all members of the independent prosthetic 

community. Many small business owners in the field of prosthetics 

are members and supporters of this annual conference. This forum 

presents a unique opportunity to enhance the relationship between 

the private sector and VA. Small businesses, including the VA contractors, are invited to present their products and attend these scientific presentations. Businesses are provided exhibit tables or 

space that enables them to meet and interact directly with VA physicians, administrators, therapists, orthotists and prosthetists. We 

believe it is a model of professional and business interaction with 

government. 

Our network of providers reaches the most rural areas throughout the country to bring quality care to the veteran. Currently, 

those 600 contractors we have across the country provide access to 

necessary care close to their home, whether in a rural or urban 

area. 

6 

In fiscal year 2007, as was mentioned before, we provided prosthetic services to 1.6 million unique veteran patients. And I would 

like to add that once we accept one of our wounded veterans or soldiers into our system, we have them for the rest of their lives. In 

my case, that has been 40 years and we will take care of those veterans until they die, with the prospects and as they grow older 

they need more prosthetics as their body function begin to deteriorate. 

From the beginning of the war, through current—to the end of 

the year 2007, 300,000 of the Iraqi-Afghani vets have returned and 

sought care from VA. For the nearly 800 veterans who were treated 

for major amputations within the Department of Defense, the prosthetics has provided services to over 200 of these major amputees 

last year and our data shows that we are going to double in this 

fiscal year as they are discharged from DOD care and come into VA 

care. 

We have implemented several initiatives to assist the OEF/OIF 

service members as a transition into VA care. Our VA prosthetic 

staff, case managers and social workers have regular contact with 

the program officials responsible for the various benefits a veteran 

may be eligible to receive. 

I am running out of time here. I would like to add one important 

thing. We have just recently signed a contract with the Amputee 

Coalition of America to furnish amputee peer visitation programs 

at all of our 21 VISN integrated service networks. This program is 

designed to assist individuals and their families coping with a variety of injuries. It will allow enhanced networking among our patients with amputations to include sharing of information regarding access to prosthetic care in the VA. 

In addition, we work in concert with DOD to provide specialized 

items such as hand cycles, personal digital assistance and vehicle 

modifications which DOD is not able to provide. So even though 

these soldiers are still active duty, we work with Walter Reed and 

with Brooke Army to make sure that these active duty soldiers as 

they are recuperating are able to get the wheelchairs, hand bikes 

and whatever they need in order to facilitate their recuperation. 

And if they go home and convalesce and leave, even though they 

are still active duty, the local VA will provide all the prosthetic 

care they need. We will continue to do that. We are always looking 

forward to the new technologies as they are coming on the marketplace. We want to be first in line to make sure that our vets have 

that available to them. 

Mr. Chairman, that concludes my statement. I am pleased to respond to any questions you or the Committee members may have. 

[The prepared statement of Mr. Downs is included in the appendix] 

Chairman BRALEY. Thank you, Mr. Downs. Despite the VA’s best 

efforts to provide veteran amputees with the best care, some veterans have raised concerns about their ability to secure certain 

types of health care in the VA system. Some have mentioned that 

in certain VA facilities, veterans are told they are not permitted to 

receive care from practitioners outside the VA setting. To your 

7 

knowledge, does the VA prohibit veteran amputees from seeking 

care from outside practitioners? 

Mr. DOWNS. What they are talking about outside practitioners— 

I assume they are talking about—we have contractors within the 

VA catchment area of the facility. And so we ask the veteran—we 

give the list of the contract prosthetists—and these are the small 

companies around the facility. And here is a list of these contractors. So you can go to any one of these that you choose. Now, those 

prosthetists who do not have a contract, the veteran is allowed to 

go there if they wish because it has a lot to do with the chemistry 

between you as the amputee and the prosthetist. So they are allowed to go there if they want, but we, of course, have this contract 

process and we encourage them to use the contractors. 

Chairman BRALEY. Now, we know that in some parts of our 

country, particularly the more rural areas, access to those services 

can be a challenge. Are you able to tell us today what might be the 

greatest type of mileage range that a veteran returning home 

would face in locating a certified O&P provider that would be able 

to meet their needs in certain parts of the country? 

Mr. DOWNS. Oh, out in the West, sometimes a couple hundred 

miles, they have to—one of our—it has to be a certified prosthetist. 

That is how we ensure quality. But if that veteran—whatever the 

prosthetist closest to that veteran—we are very flexible in how we 

work with the veteran in trying to achieve their needs. So we have 

a system set up. That is how we control this complex, multi-faceted 

operation. Taking care of 1.5 million disabled vets and trying to 

make sure that all of them are pleased with their care is a challenge. So what we will do if one of those veterans who is 200 miles 

away, if there is a prosthetist close to them that is certified, who 

is not on the contract and he wants to go to that prosthetist, then 

we will work on an arrangement with the prosthetist. We will ask 

that prosthetist to accept the contract price in that geographical 

area, and invariably all of them do. It is a fair price. And then the 

arrangements are made. 

We are a large organization, sir. And certainly we have bumps 

along the road. We have new employees who don’t understand the 

rules, the policies. There are always issues that we have to deal 

with. So we try to keep on top of them. And one of the things we 

do is make sure we are available. We have a system set up so that 

the veteran—if the veteran is not getting satisfaction at that facility, there is any number of places they can go to. First of all, of 

course to their Congressman. Also they can contact their veteran 

service organization. They can call us. We have a Web site. We developed that after having a forum meeting with the Iraqi/Afghani 

vets. A number of them were complaining about the very things 

you are talking about. And we are saying we have an actual policy 

to cover all of this, why isn’t the word getting out there. It is a constant frustration communicating and getting the word to everyone. 

So we had this forum and these folks came together. And they said 

what you need is an Internet site so that we can start talking to 

you. So we developed an Internet site—and I have got the numbers 

here some place. We are up close to 300,000 hits on it, so that people can now contact us directly that way. Our numbers are published, my phone number, along with my staff. Our phone numbers 

8 

are published. We have VISN prosthetic reps. Their numbers are 

published. So we attempt everything we can to get communication 

out to people. And it is a constant battle, I have to tell you. 

Chairman BRALEY. One of the problems that was identified when 

we had multiple hearings in oversight and reform on the independent review group’s report and the Wounded Warriors bill that 

we passed out of the House was that there seemed to be a great 

number of case managers in the VA system who were advocating 

through the system itself on behalf of patient, but there seemed to 

be a lack of patient advocates whose sole responsibility was to help 

patients navigate sometimes the maze of regulations and requirements and be there as a source to patients. 

Are you aware of anything going on with O&P patients to address that problem? 

Mr. DOWNS. Well, they are like any other patients. They have access to those case managers at the medical centers. Let us say they 

went down to the prosthetic service, they went to the amputee clinic team and they didn’t think they got the right service. They can 

go to the director of the medical center for one. They can go to the 

patient advocate and voice their concern. So there is a prosthetist 

in place there for that individual to voice his concerns. 

Chairman BRALEY. I am sure that you are aware that Congressman Filner, who is the Chair of the Committee on Veterans’ Affairs, recently introduced the Injured and Amputee Veterans Bill of 

Rights. And this legislation would require displays in VA amputee 

clinics, documents informing veterans of their right to quality O&P 

care. It would also express the rights of veterans to see the practitioner of their choice. 

Do you see that this proposal would be useful to veteran amputees who are confused about their rights in the system? 

Mr. DOWNS. That would help. It certainly would. Anything. VA 

has a Patient Bill of Rights that is posted in all our VA facilities. 

That covers all aspects of their medical care. But if it is felt that 

an extra posting in our labs would help, then fine. Because we have 

a passion to make sure that these men and women coming back get 

the best of care and that the VA is open to them, and so we keep 

putting the word out constantly. We have monthly conference calls 

with our orthotists and prosthetists. We have an e-mail group with 

our prosthetists and orthotists. And as I said, they attend the academy meetings once a year. We do everything we can to make sure 

that they are aware of what is our policy from Washington. They 

need to hear that all the time and we tell them that all the time. 

We tell them—and we tell the clerks, we tell everyone that we can 

in the prosthetic area. These individuals coming in here are dealing 

with lots of issues, losing an arm, spinal cord injury, you are blind, 

your life is ended you think, you have got to get yourself back together. So what they need is a friend. So when they come to prosthetics, certainly we preach to them you don’t just say no if you 

have to say no, we don’t want you to say no, figure out how to say 

yes. And for a combat injured, there is no doubt it is a yes. And 

then you make sure that you take care of this person. And that 

means—and we have tried to institute this, too. If you have got to 

take that person by the hand—and we have a number of people 

that do that. Take him by the hand, he doesn’t need anything in 

9 

prosthetics, nobody has taken care of that, take him down the hall 

yourself to rehab or wherever he needs to go. It is that constant 

word all the time from Washington that they know what the message is, and we try to make sure that that message is clear to 

them. 

But again, it is always a challenge. We are dealing with 200,000 

employees in VHA and about over 1,000 of them work in prosthetics and you have everyone in range from GS-5s up to the GS14s, the whole range of issues they are dealing with because we are 

taking care of—with 1,000 employees, we are providing appliances 

to 1.5 million disabled veterans and wheelchairs and legs and aids 

for the blind. And each one of those specific disability areas takes 

expertise. And you have to be flexible, too, because—for instance, 

this TBI, traumatic brain injury, that we are dealing a lot with 

now with these young troopers coming back, we are discovering 

new prosthetics that we need to provide to them. Because a prosthetic really at the VA is anything that goes to support a bodily 

function. So what they determined when we had some meetings is 

that with a traumatic brain injury patient, if you take a personal 

device, a personal digital device like a BlackBerry, only don’t call 

them that, and put a different program into it so that it will read 

software. And so for a blind or little-vision person, it will give an 

individual instructions of how to navigate. So even though we 

didn’t use PDAs before, we now have the prosthetic device now. So 

we provide those. 

We have to be alert to all kinds of new technologies that can be 

used in different ways to serve the disabled that we really hadn’t 

thought about before, and we have disabled people on our staff nationwide in wheelchairs, low vision. And so my own people out 

there keep us informed of new technology. It is a dynamic process. 

Chairman BRALEY. If you were listening during my opening 

statement, I brought up the interrelationship between providing 

optimal care for O&P patients to deal with their long-term health 

care needs, and I wonder if you are aware of any longitudinal studies of the O&P patients in the VA system and how they respond 

over their lifetime to getting the maximum return on their O&P investment and what other types of health care implications it has 

for them? 

Mr. DOWNS. Well, they have—there is not any longitudinal studies now, but there are—recently there was a meeting out in Seattle 

with our VA folks and researchers to put together a system—how 

can we do a longitudinal study. There has never been really a good 

way up to this point of saying which limb is better, is a computer 

leg better or of the different types of ankle, which one is the best, 

which type is the best knee. And it really comes down—which socket is the best socket. It comes down to basically how does it feel. 

If it feels good and comfortable, then it is a good prosthetic device. 

And we have often—we have not had the data systems yet, sir, to 

track that. And now we are getting to the place we have data systems to track it. Then we have to have the researchers develop programs to look at those longitudinal studies. Is the body powered 

arm superior to the myoelectric arm? Do you need a myoelectric 

arm for social occasions and use the body powered arm for doing 

your day-to-day work? And of course we provide as many different 

10 

arms and legs to the individuals as they want. They want a running leg, they want a walking leg, they want a swimming leg. All 

of these are available to them. And that is a misperception that the 

VA doesn’t do this. We actually provide all of this. In fact, we have 

always been in the vanguard of it. 

As a medical health care system, a national medical health care 

system, where we do have problems, it is—people point it out very 

quickly. And that is good because we are responsive and we need 

to be able to go out and find out what exactly is that problem out 

there, what is occurring. So we do have this feedback system to 

keep us up on the technology, make sure we know what is going 

on out there. 

And one of the things that frustrates my staff and I all the time 

is we deal with the problems every day. All the vast majority of the 

disabled veterans out there who are happy with the service, we 

never hear from them and that is great. But we hear the problems 

day after day. So we certainly try to stay on top of those, sir. 

Chairman BRALEY. Thank you, Mr. Davis. 

Mr. DAVIS. Thank you, Mr. Chairman. Thank you, Mr. Downs, 

for your service. God bless you. You are a true American hero, and 

I appreciate that. Last year I lost my cousin Fred who was in a 

wheelchair from Vietnam. And thank you for the service you gave 

to Fred and those things will never be forgotten. I do appreciate 

your service. 

You mentioned in your response to the chairman that a veteran 

can go outside the contract and choose a provider. Is there any negative consequences to the veteran if they do that? 

Mr. DOWNS. No. No. And where the problem comes from, sir, is 

that at the local level, people get into routines and say, here is our 

list of contractors and perhaps they don’t explain fully to the person, if you are not happy with any of those contractors, if there is 

a prosthetist you would rather go to—maybe that conversation 

doesn’t take place as often as it should. So that is where the confusion comes in sometimes, too. But one of the keys to our success 

in our prosthetic program is that—and it was developed in World 

War II because of—the amputees coming back were just getting 

low bid limbs and that was it. They were very angry, they went to 

Congress, laws were passed and the Prosthetic Service in the VA 

was formed. And the idea was to increase the quality of the limbs, 

make sure we are on top of things. So that tradition remains true 

today. And one of the reasons I was appointed 28 years ago to the 

position of prosthetics—I have been around a long time, but I love 

this job—as a Vietnam vet I was bound and determined that future 

veterans would not go through what I went through and my peers 

went through and your cousin went through. So we are in the system now and we are bound and determined we are going to make 

it as good as it can be. 

Mr. DAVIS. So there is no negative financial consequences if they 

go outside? 

Mr. DOWNS. No. 

Mr. DAVIS. The only requirement you have is the provider is actually certified to provide the product? 

Mr. DOWNS. Yes. There is no negative. And if a prosthetist says 

to the individual, well, you have got to pay extra money, you have 

11 

to co-pay, that is absolutely wrong. And if we find out about it, you 

can’t get any contracts from the VA because we pay for everything. 

These soldiers coming out of DOD, when they—they are used to the 

Walter Reed and the Brooke environment, so they want to stay 

with the military. But when they find out that TRICARE requires 

a co-pay and this and that and even for the combat veterans, well, 

then they start shifting to the VA because we provide a holistic picture of—because we take care of everything for you. And they learn 

that. And that is the reason they are shifting to the VA in the 

numbers that they are, because of our philosophy and how we deal 

with the disability. 

Mr. DAVIS. You mentioned in your testimony working with Walter Reed and other active duty military. Can you tell me how you 

work together? 

Mr. DOWNS. Yes, we have—for instance, after this hearing I will 

be going out to Walter Reed for a town hall meeting they are having so I can speak to the amputees and the other disabled about 

what we have in prosthetics and the VA. I myself have been going 

to Walter Reed for years before the war and certainly now during 

the war just to avail myself on a personal level, pure—I am an amputee and I am succeeding, and therefore you can do the same 

thing. And that is very important psychologically, because when 

you see someone who is doing something and you are laying in the 

bed—I remember my first example of that, I was in bed at Qui 

Nhon and I had been wounded about 5 days, my arm was gone and 

I thought my world had ended. And this major, she brought by a 

picture of a double arm amputee and he was fly fishing and he was 

driving. And it clicks in your mind, well, if he can do that, I can 

do that. Well, it is the same kind of philosophy of me and other 

peer visitors. Lots of peer visitors go out there to do that. So, yes, 

we go to Walter Reed on that level. 

On the VA level, I work out there with the clinicians so they 

know we are here. We work our way through problems. That is 

how we begin to realize that they weren’t able to buy the high-tech 

wheelchairs and sports wheelchairs. So we worked out a deal 

where we just provide those. And even though appropriated funds 

for us weren’t supposed to depend on active duty and vice versa, 

we went to the Secretary of the VA, at that time Mr. Principi, and 

he said sure, go ahead, we will take care of that. So we worked out 

those arrangements. 

Now, we officially—we also have a—we are rotating our 

prosthetists, orthos and therapists through Brooke and Walter 

Reed so they can spend a week there to see what it is like with 

the active duty. So when they go back to the VA, they have got a 

better sense for it. We have, of course, case managers and social 

workers at each one of those facilities. And those case managers at 

the VA level are to be—they get the hand-off from the Brooke and 

Army—or from Brooke and Walter Reed and I think now San Diego 

is in this, Balboa. So we have a lot of activity going on. 

My deputy, Jane Randolph, will be going down to the military 

treatment facility at Brooke in a week or two. And that is where 

they bring their clinical folks together. And we will have some VA 

people there so that we will receive training on what is going on 

and what is current right now. 

12 

So, yes, there is a lot of activity. You know what happened to us 

at the beginning of the war is we are in our routines. And so these 

young soldiers were coming into the medical center and we thought 

if we had everything—into the Walter Reed, for instance. What 

happened was that they then go home on convalescent leave and 

they go to the VA medical center and they would say no, you are 

not a veteran yet so you can’t come to the VA system. Well, of 

course, that was a political relations nightmare for us because the 

soldiers said I can’t get treated in the VA, they won’t treat me. 

That was one of the problems we had. Because you can’t explain 

to a young soldier the difference between DOD appropriations and 

VA appropriations. They don’t understand that. But that is how we 

operated, because that is the way the law was. So that caused us 

problems. 

The other problem was for some reason the perception was the 

VA did not provide high quality, high tech prosthesis. And in this 

day and age, these kids out there, they would type in bad stuff into 

the Internet at the speed of light all around the world and all of 

a sudden we weren’t doing this. And it took us—it has taken us 

years to—you know, we are trying to prove our point that yes, we 

do. So we learned a lot of lessons. And we have made a lot of corrections since then in the forum meetings with the folks who were 

criticizing us so they could see what we are really doing, the Internet site that we have set up, and pushed emphasis on making sure 

that we reach out to these amputees. 

So what our folks are supposed to do now is that when a soldier 

goes—is discharged, the VASecretary sent out 500 and some thousand letters to those individuals to make them aware the VA is 

there, we provide services to you. Our prosthetics people are supposed to contact each one of the amputees or individually who uses 

prosthetic devices to let them know that we are here for you, when 

you need us come here. So we have a lot of those lessons learned 

that we are implementing now, too. 

Mr. DAVIS. How does the VA ensure a timely transfer of medical 

records between active duty military and the VA? 

Mr. DOWNS. That is a question I am not really knowledgeable 

enough to answer. They are working hard on it, I can tell you that. 

Because the problem is that the DOD medical records are different 

than the VA and they don’t transfer electronically. That is an issue. 

And I think the report probably pointed that out. So I know we 

have teams working on that very hard and diligent with DOD. But 

I am not knowledgeable in that area. 

Mr. DAVIS. Let’s take it from the next level then, from the VA 

to the prosthetist, to the provider. What type of communication do 

you have between the local hometown community provider of a 

product? 

Mr. DOWNS. Well, there are a couple of things that go on. First 

is the local prosthetic rep, prosthetic chief is supposed to have contact with the prosthetic services shops in his area or her area and 

they have had for years and years. And they in the contract—so 

when they get ready to do a new contract, they send out a request 

for proposal to the folks who are already on contract but it is also 

published in FedBizOPPS and other publications. So that those 

prosthetists can compete for the contract in that VA area. And that 

13 

relationship, the prosthetist is often a part of the amputee clinic 

team. So that relationship goes back and forth, whether they meet 

on a weekly, basis, biweekly, whatever their workload is. So that 

is the relationship that exists at that level. 

At our level is that we meet with the academy and the AOPA 

leadership on a regular basis. Often they will contact me if there 

is a problem someplace. So our relationship there I think is very 

good, very solid. I hope they confirm that so that—we are open to 

whatever they have to say to us, because that relationship is key. 

One of the things that I had to build back up when I took over is 

all those relationships had gone bad. And to me, we are not successful unless—in the VA unless we have a relationship with the 

people who provide these goods and appliances. And so we need to 

have that communication flow. You can’t do this in a vacuum. And 

to me I have never considered civilian industry as the enemy, so 

to speak. It is our partner. And I really believe that because another philosophy of mine is you buy American and you buy small 

business. And that is something that I admitted in prosthetics in 

the beginning, and when I took over the logistics 3 years ago that 

was the philosophy. And we established small business liaisons at 

each of the VISN levels. And we are supposed to have them at the 

facility level. 

We are building on that relationship. We just attended the big 

small business meeting out in Las Vegas and gave a presentation 

out there last week or the week before last. So it is a continual 

process of keeping people informed, communicating. And whenever—we think we are trying to cover all the bases. We are trying 

to come up with new ideas all the time. But again, being available 

to the national representatives of the associations, the prosthetic— 

we make presentations at AOPA so that we are there, they can 

come and ask us questions. And, of course, all of our information 

is published so that they can call us and send us letters, which 

they do. And we answer a tremendous amount of volume of mail 

and telephone calls. I meet with—I meet or my staff meet with 

vendors, not only in the prosthetic world, but vendors of all types 

because as the Chief Officer of Prosthetics and Clinical Logistics, 

that covers the whole gamut of everything we do in the health industry, med surg equipment, the nonexpendable equipment. 

So we have found that if we allow people to come in and talk to 

us instead of trying to brush them off, then we have a much better 

relationship because they need information, we need to give it to 

them. The government is a very complex organization. The contracting to me—you know, contracting to me is like in the government. We have all these rules and regulations, 200 pages of FAR. 

And it makes it dad gum hard to get a contract with anybody. If 

you are in private industry, you look at the government and think 

how the heck do they do business. Well, it is difficult but we follow 

all the rules and regulations to try to get there. 

Mr. DAVIS. I will yield back. 

Chairman BRALEY. The gentleman from Pennsylvania is recognized for 5 minutes. 

Mr. SESTAK. Thank you, Mr. Chairman. Thanks for your service, 

sir. Two things I think are most important, I would gather, and 

you mentioned at least one of them and even the second. The first 

14 

one is how to get information to all the veterans, not just in your 

area, but everywhere else. The second one is the standard of care, 

that it is consistent in the quality that everyone gets. And so it is 

a bit disconcerting to hear the Tammy Duckworth testimony on the 

Senate side where she made it very clear that the care being provided in Walter Reed and other places was of a higher quality than 

the VA to her exposure not just as an amputee, but for the organization she heads in her State. 

My question from—the first of my questions are, you have several standards of quality. I mean, we have over 600 good contractors out there. But how do we ensure this standard? I do mentioned several of them, the ABC and the BOC. But the ABC is felt 

to be a higher and more quality of care. Why do we have two 

standards then? Then you have another standard called the—as I 

remember, the National Commission on Prosthetic and Orthotic 

Education. If you want to work with universities and you are starting to go out that way yourself with this agreement you have just 

had and then you have your own guidelines. 

Do you think we need to step back here and have one standard 

quality of care unique to the veteran that we can all kind of accept? 

Mr. DOWNS. Well, sir, let me answer that for you. The American 

Board of Certification is the oldest certified body that I know of in 

America. And so— 

Mr. SESTAK. Just because the chairman will cut me off shortly 

because I am a freshman. 

Mr. DOWNS. Sorry. 

Mr. SESTAK. Should we have one standard is really my question. 

There is four right now you are kind of using. 

Mr. DOWNS. No, not really. There are only two certification bodies for prosthetists and orthotists, and that is ABC and BOC. And 

BOC is the newest one. I think it came in—we accepted them as 

a certifying body. And I forget when it was, the late 1980s or early 

1990s. And in the world of accreditation, they meet those requirements to be an accrediting body. 

So our general counsel tells us that we have to accept them because ABC or BOC, they are both verified by accrediting bodies. 

And those are the two— 

Mr. SESTAK. If I could, sir—I understand that. But why don’t you 

use some system like your VA/DOD clinical practice guideline for 

rehabilitation for lower limb amputation? I have gone through it 

and it is fairly vague in some areas. But why not—I know somebody is telling us we have to use it. But is it the best when we have 

two different sets of criteria out there? 

Mr. DOWNS. ABC is the best. 

Mr. SESTAK. Should everybody be required to go ABC, then, because it is the best. 

Mr. DOWNS. I have to say this. ABC and BOC are the best. In 

fact they are the only certifying bodies for us in the area of 

prosthetists and orthotists. They have education programs, requirements and continuing education programs. So those are the best. 

There is no problem there. Going back to Tammy and her disillusion with the VA— 

Mr. SESTAK. If you don’t mind. I could come back in the second 

round. 

15 

Mr. DOWNS. Go ahead. 

Mr. SESTAK. I was just struck by her testimony, and then diving 

into the different accreditations if I could, how do we ensure that 

all these small companies ensure that our—what is the standard 

we go by to ensure every small company will give the same type 

of access to all the technologies that prevail out there? And you 

mentioned a number of them. You know, one you mentioned early 

on was the microprocessor controlled knee. How do we ensure that 

every one of those has access to the technology? Do we and how 

do we do it? 

Mr. DOWNS. Well, this is part of the certification prosthetist. So, 

for instance, a company may be certified by ABC or BOC. So that 

means they have met certain education requirements and length of 

time and training and experience. If a new technology comes out 

like the C-Leg. So that manufacturer says here is the criteria that 

you must be trained on as a prosthetist before you are going to be 

allowed to fit this. Because the company doesn’t want the— 

Mr. SESTAK. Why do you waive companies from being accredited 

and give contracts to them? You have under your Veterans Administration Solicitation 260-AA, you actually say, hey, we will accept 

proposals from those offers who have not been able to complete 

their accreditation in the ABC and BOC. I am happy to give you 

a copy of it. So my question is, why are we actually solicited—my 

concern keeps going back to what is the standard for consistency, 

particularly when we are offering contracts out there without the 

accreditation being done by these companies? 

Mr. DOWNS. Sir, the guarantee of quality is a certification process. I am not familiar with that instrument you are reading there. 

Mr. SESTAK. I should end. I am over my time. My background in 

the military has always made me concerned when there is two sets 

of standards or more. And my concern really comes—I am seeing 

now there is a little leakage here where we are letting some of 

these companies maybe be accredited before they are. But I want 

to make sure the care for the veteran is number one and consistent 

across the Nation. 

Thank you. 

Mr. DOWNS. The only reference I can make to that without seeing a document is that the—by the time the contract is signed, they 

must be certified. They must meet certification of ABC or BOC because it is our policy that you must be certified. 

Mr. SESTAK. It says in the contract award that 6 months after 

the award they could become certified. 

Mr. DOWNS. Okay. Well, maybe somebody has changed the contract without us knowing it at a particular facility. Because I can 

guarantee you that is not something we would accept. And in the 

medical area, there are often more than one certification—more 

than one certifying body on the accreditation process. It would be 

easier for me if everything was simple like that, I guarantee you. 

I will say that. It would be easier for all of us in the government 

if there was just one set of criteria on something like that. 

Mr. SESTAK. I can’t agree more. I didn’t understand all these— 

Chairman BRALEY. The gentlewoman from New York is recognized for 5 minutes. 

16 

Ms. CLARKE. Thank you very much, Chairman Braley and Ranking Member Davis, for holding this important hearing today. Mr. 

Chairman, let me just briefly state that I felt compelled to attend 

this hearing today, and I am glad I did. I want to feel assured that 

quality health care is provided to our injured soldiers who fought 

in Afghanistan and Iraq. 

Many of these veterans are young Americans, who are at the advent of their adult life and they have lower incomes and whose injuries necessitate special health care, attention and response. I am 

concerned that these very valued individuals have complete and 

full access to the prosthetics they need to fulfill their God given potential. We must ensure that the VA’s health care system is operating at such a level that if a veteran is seeking assistance, they 

will in fact get the best available care. 

Having said that, I am honored and actually I honor you, Mr. 

Downs, for your ongoing service today and your presence at today’s 

hearing. I would like to know if you can tell us the percentage of 

prosthetic care that is provided by VA personnel versus the percentage provided by contracted service providers. 

Mr. DOWNS. Do you want me to answer that now, ma’am? 

Ms. CLARKE. Yes. 

Mr. DOWNS. Artificial limbs, about 97 percent of those are provided by our contractors. About 3 to 1 percent of the limbs are— 

less than 3 percent are fabricated by our VA labs of lower extremities and 1 percent of the upper extremities are fabricated by our 

VA labs, and all the rest of the business goes to private industry. 

Ms. CLARKE. Let me ask. What kind of outreach, including initiatives, and conferences does the VA Office of Small Disadvantaged 

Business Utilization use to build and maintain relationships with 

independent prosthetic contractors? Since most of the business is 

really outside of your purview. For instance, are you using the 

Internet and computer technology to establish quality control and 

information sharing regarding the latest in prosthetic technology? 

Mr. DOWNS. Well, the OSDBU, which is the Office of Small and 

Disadvantaged Businesses, we work very closely with them to 

make sure that we are included in any programs they put out 

across the Nation and what their responsibility is, not only in prosthetics but across the board, that the VA’s attention is on doing 

business with small business. So we work closely with them and 

they, of course, attend many conferences with small businesses and 

are always promoting that. 

Ms. CLARKE. Just put a pin in that statement. Does the VA provide oversight? Is there a liaison so that you are clear on them 

meeting their goals in terms of that and what type of quality they 

are supporting in terms of businesses that are out there? 

Mr. DOWNS. Yes, ma’am. OSDBU’s job actually is to oversee 

what we do. The office of OSDBU, they answer directly to the Secretary. And so Scott Denison, who is in charge of that, why his job 

is to make sure we are doing our job. So he does performance 

measures on us which are presented to the Secretary every month, 

how are we doing in VHA, how is VBA doing, how is the cemetery 

service doing. And all those socioeconomic goals are broken down 

and they were raised for all of this year. And as you know, a law 

was just passed. 

17 

So our first place that we have to go to in VHA is to the small 

disabled veteran owned businesses. They are our first avenue that 

we have to look at in any business that we do now. 

Ms. CLARKE. Do you feel assured that there is a quality control, 

there is enough communication vehicles to make sure that the 

standard of care, and I am just sort of referring back to something 

that Congressman Sestak said, the quality of care is available and 

equally distributed to all veterans who seek it? 

Mr. DOWNS. Yes, ma’am. In the area of prosthetics, the reason 

that the ABC or BOC certification is so crucial is because that is 

the standard of care. Those are the—that is how we guarantee 

quality. Being certified, of course, doesn’t mean that you are naturally the best. Certified means you have met the criteria that you 

should be at a certain level and so that is the only measurement 

we have actually, is that certification—and that is the same way 

that we do with our other medical areas too—is that whether you 

are a cardiologist or a physical therapist you have got to be accredited in your field before you can work for the VA and provide that 

care. And that is one of the ways that we determine quality. And 

there are other areas of quality, too, which are not so easily measured in the area of prosthetic/orthotics. Certification is one process, 

but then again is the individual receiving training in that device 

that they are wearing, that they are being provided. 

So that is another aspect of it, that each of the amputee clinic 

teams is supposed to make sure—part of their criteria, has that 

person been trained on how to use that new limb, that new type 

of limb, are they being introduced to the new technology. So those 

are all constant signals that we send out to people. But the certification is something that guarantees us at least equal access of the 

quality—the potential for quality. 

Ms. CLARKE. Thank you very much, sir. My time has run out. 

Thank you, Mr. Chairman. 

Chairman BRALEY. Mr. Downs, because of the importance of your 

testimony, we are going to open up to a brief second round limited 

to 2 minutes per person. So I would ask you to keep your remarks 

focused so that we can move quickly through this. 

But one of the concerns that has bee raised by independent O&P 

providers is that the terminology and the processes used by the VA 

have sometimes not kept up with current thinking in the O&P 

community. Specifically there has been criticisms that some of the 

RFPs that are used are error laden and contain outdated terminology. 

Can you tell us what the VA is doing to address those concerns 

and make sure that the internal departmental framework matches 

up to what is going on in the industry? 

Mr. DOWNS. RFP. 

Chairman BRALEY. Requests for proposals. 

Mr. DOWNS. I didn’t realize that that was a problem, and I will 

immediately address it. 

Chairman BRALEY. And maybe some of our other panelists can 

address that in their remarks and follow up with you. 

The other question I had for you is we know when someone loses 

a limb outside the VA system and they are either being cared for 

by Medicare or sometimes by private pay, one of the things that 

18 

is often critical in helping plan for the long-term care needs of 

those patients is either a prosthetic needs analysis or that may be 

incorporated into a broader life care plan. This gets back to my concern I raised earlier about the total impact of a prosthetic device 

and the need for that type of long-term care. 

Many of the young men and women who are coming back from 

Iraq and Afghanistan are in that 20-year age range. They are going 

to have a 55-year life expectancy. So is the VA doing anything to 

do metric planning for the long-term care needs so that we in Congress can be better equipped to talk about what it is going to cost 

over the life expectancy of these returning veterans as we are doing 

our long-term financial planning here in Congress? 

Mr. DOWNS. Our metric in that area is our budget planning and 

the numbers of disabled that we serve. And in that respect, yes, we 

project out in the coming years, the age of the veterans, the type 

of devices and the increase in the cost and the potential of new 

technology. We factor it into our budget. So that is how we forecast 

the metric to take care of that. 

Chairman BRALEY. Thank you. 

Mr. Davis. 

Mr. DAVIS. How does the VA ensure that veterans are receiving 

consistent care across the country from prosthetic providers? 

Mr. DOWNS. Well, we have our feedback mechanism on that, of 

course, is from the veterans themselves. But the amputee clinic 

teams, they are the ones who evaluate the limb after it is fabricated, the individual—the patient is supposed to come back into 

the amputee clinic team and show the amputee clinic team his limb 

or her limb and the team asks him a number of questions, are you 

satisfied with it, does it fit, et cetera, et cetera, and only then will 

the VA pay for it. That is the process. So that is the quality assurance there. 

Mr. DAVIS. One last question. How does the acquisition process 

differ from the national contracts versus local contracts? Is there 

a difference? 

Mr. DOWNS. No. Well, yes and no. National contracts, we establish the contract and the pricing structure. And then that is how— 

that is what every one of the individual facilities then must pay to 

use that contract. At the local facility when they do a contract, it 

is negotiated locally so they are in charge of what that structure 

would be, the pricing structure, and it is different at each place. 

We don’t have a national contract for artificial limbs or orthotics. 

Mr. DAVIS. Thank you. I yield back. 

Chairman BRALEY. The gentlewoman from New York, do you 

have any further questions? 

Ms. CLARKE. Thank you, Mr. Chairman. Mr. Downs, how does 

the VA analyze or track prosthetic devices utilization and how does 

it schedule repair and replacement of prosthetic components and 

technologies? 

Mr. DOWNS. That is a difficult thing for us to do. We know how 

many new devices and what type and we have our repair costs. So 

we know what we pay for repairs each year. But we haven’t—we 

track through our compliance with the contract, the types of limbs 

that are provided, and so what we look for there are trends. Do we 

19 

see an increase in the number of C-Legs, for instance, and—but we 

don’t really have a way of analyzing it beyond that. 

The uniqueness about an artificial limb is that the patient has 

got to be happy with it. And one of the questions we always have 

is, well, we issue it to them, do they wear it or do they stack it 

away. So one of the ways we check on that is do they come back. 

Because if they are coming back, they are regular users. If we provide it to them once and they don’t come back— 

Ms. CLARKE. Do you think it would be valuable to sort of set up 

a separate sort of database that is dedicated specifically to this 

data and then having that available to distill and really, you know, 

follow up on it? 

Mr. DOWNS. Absolutely. 

Ms. CLARKE. And if a veteran has the option of using a VA laboratory or a contractor, what are the advantages and disadvantages with each choice? 

Mr. DOWNS. There is none really. It has to do with the personal 

preference. Sometimes if you like the prosthetist—it depends on 

how you are treated. Did the people in the VA lab treat you nice, 

did they fabricate a quality limb and you are comfortable with it, 

you are going to go back. If you are not comfortable with it, you 

are not going to go back. That is clear cut. You can’t make an individual go to a prosthetist that is not doing a good job for them. And 

the strange thing about it is, is that I may think this prosthetist 

is good, but another amputee thinks that prosthetist is terrible. So 

that chemistry stuff comes in there, too. But there are no negative 

consequences there. 

Ms. CLARKE. Thank you very much. Thank you, Mr. Chair. I 

yield back. 

Chairman BRALEY. Mr. Downs, thank you for taking time from 

your very busy schedule and joining us today. We really appreciate 

your testimony and look forward to continuing to work with you on 

these very important issues that affect our Nation’s veterans. 

At this time, I would like to call our second panel up and ask 

them to be seated so that we can begin with their statements. Before we begin with the second panel, I want to apologize to you for 

the constricted environment you find yourself in at the table. This 

is not our normal hearing room for the committee and it is currently under renovation over at Rayburn. So we would not have 

these columns here if we could create the ideal hearing room. But 

thank you for your indulgence. 

I will introduce each individual witness and allow them to give 

their statement before moving on to the next one. And, Mr. Davis, 

you will be introducing Mr. Smith; is that correct? 

Mr. DAVIS. Thank you. 

Chairman BRALEY. Our first witness on Panel II is Captain Matthew Bacik, who is a 2002 graduate of the United States Military 

Academy. He served two tours in Iraq and one in Afghanistan. 

Captain Bacik has served in the 82nd Airborne Division, and I 

have to tell you that my colleague and friend from Pennsylvania, 

Patrick Murphy, will be delighted to hear that you joined us here 

today. And the elite Special Operations Third Ranger Battalion. He 

received three Purple Hearts and a Bronze Star over the course of 

14 total months deployed. He medically retired from the Army in 

20 

2006 after losing his right leg below the knee, the result of an IED 

attack near Baghdad. 

Captain Bacik currently coordinates the Wounded Warrior 

Project—thank you for that—where he performs outreach services 

for OIF/OEF soldiers and veterans in Alabama. 

Welcome. 

STATEMENT OF CAPTAIN MATTHEW BACIK, RETIRED ARMY 

Captain BACIK. Mr. Chairman, Congressmen, thank you for giving me the opportunity to be here today. It is an honor. I would 

like to share with you just my experience in transitioning from the 

battlefield to the civilian world. 

I was deployed three different times, Iraq in 2003 with the 82nd 

Airborne Division, Third Ranger Battalion in Afghanistan and Iraq 

in 2005, and received a total of three Purple Hearts, all from improvised explosive devices. My third injury destroyed most of my 

right foot, and I underwent a total of 13 reconstructive surgeries 

before my leg was amputated on the right side below the knee. 

Shortly after the amputation, I chose to pursue a medical retirement. My experience is somewhat unique. I did not have an amputation at Walter Reed and have always relied on private providers 

for my prosthetic care. The VA system has been very beneficial to 

me for three specific reasons: One, the VA has paid for and approved the absolute best equipment that I could ask for; two, communication between myself and Mr. Fred Downs’ office through 

their open forums; and, three, I have established a very strong relationship with a provider who is a member of my local community. 

I would like to focus on the relationship that I have established 

with Glenn Crumpton of Alabama Artificial Limb and Orthopedic 

services in Montgomery, Alabama. Glenn is a certified provider; 

however, he does not hold a contract with the VA. His family has 

been providing prosthetic arms and legs for veterans from every 

conflict since World War II until the present. And just as important, before the wars in Iraq and Afghanistan, Glenn had experience making legs for all different types of amputees, both active 

and not so active folks. 

Glenn’s patients wanted to run, bike, swim, skydive and ski in 

the best available equipment and Glenn’s shop has a wealth of 

trade knowledge in crafting these custom fit prosthetics that enable 

folks to do those very challenging physical activities. He has an unparalleled conviction to learn and grow with his patients and carries the heavy burden. If the leg he manufactures isn’t right, the 

patient’s life isn’t right. 

Last month, I met Glenn twice at 6:30 a.m. before work to work 

on my new running leg. Just last week, I broke my every day—my 

main foot. Glenn and I checked our respective schedules and by 

chance we were both in Birmingham, Alabama on separate business. Glenn had a foot shipped to the hotel that he was staying at 

and when our respective engagements were completed, I met Glenn 

in his hotel and I had a new foot put on and I was 100 miles from 

my home and 100 miles from Glenn’s shop. 

Most of our work together has been on weekends, evenings and 

in early mornings, and he provides that same level of care to all 

his patients. The interesting thing, how did I find Glenn? It was 

21 

just good luck. He doesn’t hold a contract with the VA and had I 

not been resourceful enough and, you know, capable enough after 

returning from the war and retiring from the Army to go out and 

seek this gentleman, I might not have ever linked up with him. 

And if you consider the stresses of such a traumatic life changing 

injury, I was very fortunate to be able to research on my own and 

vet the different providers that were available to me and come up 

with who I thought would be the best fit. The VA in my area uses 

a national company and—not a national contract holding company, 

a company that is very large, having offices across the Nation. And 

they hold the contract for the prosthetic care out of the Montgomery facility. A lot of times with such a large private provider, 

there is a lot of lateral transfers and there is a lot of up and down 

transfers of personnel and you are not able to establish that same 

relationship with a gentleman or a lady who is going to live in your 

community and be, you know, by your side for that next 55 some 

years of your life expectancy. 

The benefits of the relationship Glenn and I have established can 

easily be transferred to other veterans if they know he is there and 

know his capability. In the VA clinics, Glenn has been allowed to 

attend with his current patients, but if a new patient comes into 

the clinic, the firm holding the contract automatically receives the 

work unless the veteran has somehow linked up with Glenn prior 

to the clinic, at which point Glenn can bring him to the clinic as 

his patient, his representative. 

For me, VA at the national level has been very instrumental in 

helping me learn about what my options were, what was available 

to me and how to navigate the prosthetic system as a disabled vet. 

Mr. Downs’ forums have been an invaluable part of keeping good 

communication flow between not myself but many other different 

veterans. Many of the civilian nonprofit organizations that try to 

supplement and point vets in the right direction also attend those 

forums. 

And on a final note I would just like to say again that the VA 

has paid for any type of equipment that I have asked for and that 

I have needed, and they have done an excellent job of following up 

on and checking on my progress to make sure that I am using the 

equipment that I have been provided. And I would just like to close 

with that. 

[The prepared statement of Captain Bacik is included in the appendix.] 

Chairman BRALEY. Thank you, Captain, and thank you for your 

service to our country. 

Our next witness is somebody that I know very well. He is not 

just a friend, he is a neighbor of mine in Waterloo, Iowa. Dennis 

Clark serves at the President of Clark & Associates Prosthetics and 

Orthotics, headquartered in Waterloo. The company was originally 

started in Waterloo by Mr. Clark’s father Dale. Dennis purchased 

the company in 1987. There are now four locations in Waterloo, 

Marshalltown, Dubuque and Mason City. 

Mr. Clark has served as past President of the American Orthotic 

and Prosthetic Association and the American Board for Certification in Orthotics and Prosthetics. And if I may be allowed to inVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
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dulge just a second, my father went ashore on Iwo Jima the day 

both flags were raised and he had a very high standard for heroes. 

There are many people in this room today who meet that standard. 

But I just want to say that Dennis in my mind is one of the people 

who deserves our honor and respect. When he saw the need for returning veterans coming back with prosthetic needs, he made the 

trip to Walter Reed for 20 months on his own dime, staying here 

in Washington, D.C. On his own dime to provide the care that our 

Nation’s veterans deserve. 

And I have a picture of him here holding a heater out at Walter 

Reed working on a socket. And, Dennis, you are the type of inspiration that we wish we could clone and send across the country of 

Americans who saw a need and responded and at great personal 

sacrifice. I am very proud to have you here today, very proud to 

call you my friend, and we look forward to your testimony. 

STATEMENT OF DENNIS CLARK, CPO, PRESIDENT, CLARK & 

ASSOCIATES PROSTHETICS AND ORTHOTICS 

Mr. CLARK. I thank you very much. Chairman Braley and Ranking Member Davis, I would like to thank you and the members of 

the subcommittee for creating this forum and for your participation 

in discussing this very significant issue, ensuring continuity of care 

for veteran amputees: The role of small prosthetic practices. And 

I am honored to be here to testify. 

My name is Dennis Clark. I am a certified orthotist-prosthetist 

and owner and president of Clark & Associates Prosthetics and 

Orthotics, Inc., a small business located in Iowa with offices in Waterloo, Dubuque, Marshalltown and Mason City. My family’s involvement in caring for wounded veterans began during World War 

II. My father, Dale Clark, also a certified prosthetist, worked for 

a company named Ray Trautman & Son in Minneapolis, Minnesota. He worked for the company for over 20 years, eventually 

buying out the Waterloo, Iowa location and incorporating Dale 

Clark Prosthetics in Waterloo in 1968. It is no small coincidence 

that I began working for my father in the summer of 1968, eventually purchasing the company from him in 1987. 

As Chairman Braley indicated, in September of 2003, I was contacted by a representative from Walter Reed Army Medical Center 

and asked if my clinical staff and I would be willing to spend the 

remaining months of 2003 helping provide lower extremity prosthetic care to soldiers returning to Walter Reed from Iraq and Afghanistan. We proudly accepted this opportunity to serve and in 

fact continued providing care at both Walter Reed and occasionally 

at Bethesda Naval until the end of May, 2005. During that time 

we were honored to provide prosthetic care for over 300 soldiers. 

Since our departure from Walter Reed, Clark & Associates has 

continued to provide prosthetic care for a small number of service 

connected veterans from the current conflict as well as a number 

of other nonservice connected veterans and as well as service connected veterans from other military actions. 

My primary concern here today is making sure that these soldiers continue to have access for quality care and current technology. To this end, it is important that the VA maintain its position on qualifying practitioners by requiring American Board for 

23 

Certification in orthotics and prosthetics, ABC certification, as a 

minimum requirement for persons providing care to our Nation’s 

veterans, as well as requiring facility accreditation also by ABC, 

being part of the standard for companies providing orthotic and 

prosthetic care to veterans. 

Since this is the first war fought in what I would call the Information Age, more media coverage and public focus has been placed 

on prostheses and prosthetic rehabilitation than at any time in the 

history of prosthetics. This fact, coupled with the reality that advances in prosthetic industry are arguably bolstered by the effects 

of war, suggests we will see more new technology in the next decade than in all of the previous decades. 

Technology for technology’s sake was not part of our thought 

process or protocols at Walter Reed. We steadfastly attempted to 

match technology with the associated function and use of the prostheses in order to meet the patient and the care team’s goals and 

objectives. 

In the past, new technology in terms of techniques, materials and 

components mostly came from within the profession. However, 

today scientists and researchers from various digital and microprocessor oriented backgrounds are making significant new contributions in advancing prosthetic outcomes. This trend will continue into the future. That is why it is so important that training 

and comprehensive training and knowledge is required to use these 

new technologies within a patient’s prosthetic management will 

further highlight the need to qualify and measure the performance 

of not only the prostheses, but prosthetic providers. 

In addition to my role at Clark & Associates, I am also President 

of POINT Health Centers of America. POINT is the only United 

States prosthetic and orthotic network consisting of 100 percent 

ABC accredited facilities. Each of these 146 member companies are 

independently owned small businesses. These companies are acutely affected by any VA prosthetics and orthotic procurement decisions. Accordingly, effective communication relative to VA contractor regulations and other administrative requirements is vital 

to these small businesses. 

In closing, it is critical that we remember the discussion we are 

having here today will affect this current group of wounded warriors for the next 40 to 50 years as most of them are in their early 

to mid-20s. The groundwork for the investment we make in their 

care today should be as important as the sacrifices they made for 

our freedom. We have not yet seen the depth and breadth of the 

contributions of this differently abled group of Americans has 

made. But having worked with hundreds of them, I firmly believe 

in time this group of volunteer soldiers will one day be known as 

the next greatest generation. 

Thank you. 

[The prepared statement of Mr. Clark is included in the appendix.] 

Chairman BRALEY. Thank you. Our next witness is Mr. James 

Rogers, who currently serves as the President of the American 

academy of Orthotists & Prosthetists. In 1994, Mr. Rogers founded 

Orthotic and Prosthetic Associates in Chattanooga, Tennessee. It is 

24 

the largest provider of O&P services in the tri-state area with eight 

offices in multiple clinical specialties. The American Academy of 

Orthotists & Prosthetists was founded in November of 1970 to further the scientific and educational attainment of professional practitioners in the disciplines of orthotics and prosthetics. 

Welcome, Mr. Rogers. 

STATEMENT OF JAMES ROGERS, CPO, FAAOP, PRESIDENT, 

AMERICAN ACADEMY OF ORTHOTISTS & PROSTHETISTS 

Mr. ROGERS. Thank you, Chairman Braley, Ranking Member 

Davis. I would like to thank the members of the subcommittee for 

allowing us to testify today. The American Academy of Orthotists 

& Prosthetists, the Academy, is the national membership organization that represents the interest of the orthotic and prosthetic professionals. 

It is a privilege to be a part of a profession whose work helps 

people who need orthotic and prosthetic services resume full and 

productive lives and to be able to continue to support themselves 

and their families. We have a proud history in our profession of 

working to serve veterans and working with the VA. We do this 

both through contracts between small businesses and the VA and 

also by having many of our members actually work within the VA 

system. 

Over 60 percent of our membership actually own a small business or work for one. They work in all sorts of settings, including 

large cities, suburban communities and the most rural areas of our 

Nation. 

The services we provide for veterans and the Veterans Administration is some of the most important work that we do as professionals and as Americans. One way to thank veterans for their 

service is to ensure that the VA and the many small businesses 

who are contracted by the VA provide the needed orthotic and prosthetic services and that they will be available to meet the needs of 

the veterans for the rest of their lives. 

We need to remember that the VA not only serves veterans who 

return—a veteran who returns from war with a service related injury, but they will also serve the needs of patients in the future 

through the normal aging process and the possibility of acquiring 

a disability or an injury later on as they develop. With modern 

technology, we can return a veteran who has an amputation or another severe orthopedic injury to full functionality and give them 

the ability to continue to support themselves and their families and 

to participate as fully in society as they wish to. 

But why is the involvement of small business so crucial to the 

success of our rehabilitation efforts with veterans? To answer this 

question, you have to understand the history of our profession. Before the First World War, prosthetic and orthotic businesses were 

not allied health professionals. They were by and large craftsman 

from a variety of different professions who were introduced to the 

disabled community through personal contact and circumstance. 

After the conclusion of World War II, the large influx of amputees 

and young men without careers created an enormous need for these 

services and an opportunity to advance the technology. 

25 

With funding from the Federal Government and specifically the 

VA, prosthetic and orthotic education and training programs were 

begun at a number of select universities. Many of those trained 

were veterans themselves. The majority of the current 3,500 O&P 

facilities in the United States remain small businesses and many 

are even family owned. It is not unusual at the Academy’s annual 

meeting in scientific symposium to see more than one generation 

take continuing education courses together. 

An example of this cooperation between the VA and small prosthetic businesses is a veteran I will call Jack. He is a young man 

from rural America where family, farming, hunting and fishing define one’s existence. He lost his dominant right arm in an RPG attack while serving as a gunner on a Bradley in Iraq. He was stabilized in country and arrived at Walter Reed within days of his 

injury. While as Walter Reed, Jack was there for 3 months alone 

without his wife and his three young children. When I met Jack, 

after his transition from the DOD to the VA system, he had already received four prostheses, three at Walter Reed, one through 

the VA contracted provider set up. None of these prostheses were 

suitable for the activities he would resume back home. He was 

frustrated, he was angry, and he was referred to me as a problem 

case. 

He recognized that the care and service he received was quick 

and of the highest technological value, but that wasn’t what he 

wanted nor what he needed. He needed a prosthetist that would 

allow him to work as a conservation officer in a variety of weather 

conditions and make a prosthesis after listening to his needs that 

would suit those needs. He needed a prosthesis that would allow 

him to shoot a bow, hold and fire a shotgun or a rifle, enable him 

to fish with his children and take a creel study in a local lake. 

What he received was the very best technology we have available 

in myoelectric and cosmetic prostheses. What he lacked was a local 

prosthetist who understood his day-to-day existence and appreciated what was important to him and how that translated into a 

specific design. After I made the rugged weatherproofed prosthesis 

that he required, he has invited me back several times to Kansas 

to hunt and fish and spend time with his family, and it remains 

one of the most rewarding experiences I have and it is an example 

that highlights the relationship of the VA and small businesses and 

the necessity for that. 

We need to continue this contracting process and the intimate relationships that it fosters. We, the Academy and our professionals, 

appreciate the good working relationship we have with the VA and 

Fred Downs and his staff, and it is our goal to continue to work 

to develop a closer relationship in the area of research and particularly to look at best practices in the O&P field. 

I would like to again thank the committee for holding this hearing and allowing me to speak. 

[The statement of Mr. Rogers is attached in the appendix.] 

Chairman BRALEY. Thank you. Our next witness is Mr. Tom 

Guth, who is the President of the National Association for the Advancement of Orthotics and Prosthetics. Mr. Guth is also the owner 

of RGP Prosthetic Research Center, the largest prosthetic manufacturer on the West Coast. Founded in 1987, the National AssociaVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
26 

tion for the Advancement of Orthotics and Prosthetics is a nonprofit trade association dedicated to educating the public and promoting public policy in the interest of O&P patients. 

Welcome. 

STATEMENT OF THOMAS GUTH, CP, PRESIDENT, NATIONAL 

ASSOCIATION FOR THE ADVANCEMENT OF OTHOTICS AND 

PROSTHETICS 

Mr. GUTH. Thank you. Thank you, Chairman Braley, Ranking 

Member Davis and members of the subcommittee. Thank you for 

this opportunity to testify on the role of small prosthetic businesses 

and their important work with veteran amputees who rely on quality prosthetic care or artificial limbs to return to full function. 

I am Tom Guth, and I am a certified prosthetist for RGP Prosthetic Research Center. I am here as a small business owner. RGP 

Prosthetic Research Center in San Diego was started by my father 

in 1947, and today RGP is one of the premier prosthetic clinics in 

the country. I have dedicated my career to developing new ways to 

increase the quality of life and comfort of amputees who use artificial limbs, many whom are injured and amputee veterans who wish 

to continue an active lifestyle. 

I am here today representing the National Association for The 

Advancement of Orthotics and Prosthetics. NAAOP is a nonprofit 

trade association dedicated to educating the public and promoting 

public policy that is in the interest of orthotics and prosthetic patients and providers who serve them. I am testifying today to bring 

forth the view of small business professionals serving O&P patients, particularly those who work with our Nation’s veterans 

through the VA. 

RGP has served veteran amputees as a component of our prosthetic practice for over 6 decades and we are proud of our service 

to the VA. However, the current system is not always without challenges to both the veteran in gaining access to appropriate prosthetic care and the private practitioner in serving that patient. 

Take, for example, my patient of nearly 40 years, who I will refer 

to as Tom to protect his confidentiality. I first designed and fabricated a prosthetic limb for Tom after his return from Vietnam 

where a land mine had taken off one of his legs above the knee. 

For nearly 40 years, I have worked with the local VA prosthetic 

chief and Tom to provide high quality prosthetic care. Recently 

after 8 years of walking on the same prosthetic limb, Tom came to 

my office with a VA prescription for a new prosthesis with the 

same design as his existing limb. But technology had changed dramatically over the past 8 years, and I recommended that Tom receive a microprocess prosthetic knee unit that would allow him to 

walk more consistently and safely. Tom wanted to try the new 

knee, but the local VA staff denied Tom access to the microprocess 

unit, stating that he did not need the more recent technology and 

generally giving him the run around. Tom then became ill and is 

fighting to return to his health. His request for the microprocess 

knee has not been approved to this day, although he could have 

benefited from it for months now. 

So it is important to realize that the positive pronouncements 

and the favorable signals from the national VA office that the proVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
27 

gram covers whatever the amputee veteran needs are sometimes 

lost in translation at the regional and local levels. 

As service members return from Iraq and Afghanistan with amputations and neuromuscular skeletal injuries, many will need 

prostheses and orthoses. The VA contracts with the utilized private 

business to provide prosthetic care to approximately 97 percent of 

the O&P patients. However, as it stands, anecdotal evidence suggests that there are significant inconsistencies and access to quality O&P care throughout the country. It also appears that in some 

areas of the country, such as San Diego, the VA is actively working 

to increase the amount of O&P care provided in house by a VA 

hired O&P staff and decrease veterans access to the private O&P 

practices and professionals who have served the VA patients well 

for decades. 

Overall, with the collaboration of small business, the VA has provided quality orthotic and prosthetic care to the veterans over the 

years, whether or not their underlying impairment was service connected. But there are many areas where inconsistencies across the 

country are apparent and require improvement. 

The adoption of the VA several years ago over regional decision 

making through the VISNs, the regional service network, has highlighted these inconsistencies. It is imperative that the VA establish 

standards that all veterans understand and can rely on with regards to their prosthetic and orthotic needs. 

This is why NAAOP supports H.R. 5730, the Injured and Amputee Bill of Rights. H.R. 5730 proposes the establishment of a bill 

of rights for the recipients of VA health care who require orthotic 

and prosthetic services. This bill of rights will help ensure that all 

veterans across the country have consistent access to the highest 

quality of care, timely service, and the most effective and technology advanced treatment available. NAAOP believes that the 

adoption of a bill of rights will establish a consistent set of standards that will form the basis of expectations of all veterans who require orthotic and prosthetic care. 

The bill proposes that every VA facility throughout the country 

be required to promptly display the bill of rights. In this manner, 

the veteran across the country will be able to read and understand 

what they can expect from the VA health care system. And if a veteran is not having their orthotic and prosthetic needs met, they 

will be able to avail themselves of their rights. 

To improve the current bill, we propose that a copy of the bill of 

rights be required to be provided in paper form to every veteran 

attending the amputee or rehabilitation clinic and that each patient sign off on the clinical file to indicate that they have received 

and read the document. 

In addition, we propose that Congress direct the VA to establish 

a toll free dedicated telephone number to report instances of noncompliance with these rights as an ombudsman could help resolve 

this agreement. 

NAAOP thanks this committee for examining how small prosthetic businesses work with the Department of Veterans Affairs to 

provide for the needs of veterans with injuries and disabilities requiring orthotic and prosthetic care. I thank you for this opportunity to testify before the committee. 

28 

[The prepared statement of Mr. Guth is included in the appendix.] 

Chairman BRALEY. I thank you. Mr. Davis. 

Mr. DAVIS. Thank you, Mr. Chairman. I would like to introduce 

a fellow Tennesseean, Christian T.Z. Zach Smith. Zach, welcome. 

Zach is President and Co-Owner of Victory Orthotics & Prosthetics, 

Incorporated. Victory has three offices and 19 full-time employees. 

Zach graduated from the former Median School for Allied Health 

located in Pittsburgh, Pennsylvania. He is board certified in both 

orthotist and prosthetics and licensed to practice in the State of 

Tennessee. 

Zach was inspired to enter the orthotic and prosthetic field by his 

dad. His father incurred a below the knee amputation in 1991 and 

has enjoyed a full and active life since. He enjoys working in his 

profession because it allows him daily to experience the reward of 

helping amputees to live a fulfilling life by enabling them to walk, 

run, work and contribute to society. 

Zach, welcome. 

STATEMENT OF CHRISTIAN T.Z. ZACH SMITH, COP, BOCOP, 

PRESIDENT AND CO-OWNER, VICTORY ORTHOTICS & PROSTHETICS, INC. 

Mr. SMITH. Thank you. Thank you, Congressman Davis and 

Chairman and the committee, for your time and dedication to our 

deserving veterans. 

As Congressman Davis stated, I have experienced the VA process 

personally with my father’s amputation and professionally as a 

contracted provider, and my father’s positive prosthetic experience 

is the reason I am in this profession. 

As a prosthetist, I am involved in several clinics. The clinical 

model I participate in at Mountain Home in Johnson City is the 

most efficient and patient oriented clinic that I have the privilege 

of participating in. The primary reason for the success of this clinic 

is the team approach to care. In attendance is a physician of rehab, 

physical therapist, a kinesiologist, the VA’s prosthetic rep, and the 

contracted orthotist and prosthetist. The role of each member is as 

follows. 

The physician is present to explore the full medical history and 

current medical condition of the veteran. In addition, she determines if the veteran’s current health condition can sustain the use 

of the proposed prosthesis or orthosis. 

The physical therapist and kinesiologist are present to review 

and present the physical therapy history and current treatment 

modalities. They also discuss future therapy needs of the prescribed orthosis or prosthesis. 

The contracted orthotist and prosthetist discuss as a team the 

most appropriate prosthesis or orthosis to best treat the patient. 

The prosthetic rep is present to facilitate the paperwork and coordinate all aspects of his or her care, including the prosthesis, 

physical therapy and possibly an additional assisted device. Once 

the veteran has chosen a contract provider and the provider delivers the prosthesis, the veteran returns to the VA clinic for final delivery. 

29 

This process is very efficient from the initial evaluation to the delivery, and the VA is also involved in following the patient to confirm the efficacy of the prescribed orthosis and follow-up treatment. 

Despite the strength of this model, I believe we can improve in the 

following ways. 

I recommend the following: A preamputation consultation. This 

benefits not only the patient but the family involved by informing 

them of post-op pain management, post-op fall precautions, post-op 

care and follow-up and explore the options of an immediate postop prosthesis. In addition, the amputation consultation may involve 

the surgeon to discuss the amputation level and possible procedures. This ensures efficacy of the future prosthesis and may involve the patients on his or her prosthetic options. Immediate postop prosthesis is great for early ambulation, optimal healing position, residual protection, edema control and a physiological benefit 

for the patient and the family. 

Improved communication between the DOD and the facilities is 

necessary. I have been informed of difficulty in obtaining prior 

medical history when the veteran is transferred from the DOD facility to the VA system. 

In addition, I would recommend improved provider selection accommodations. Selection of a vendor based on geographical location 

is unfair. He or she should be allowed to review the education, the 

certifications and the experience of the prospective facility and 

prosthetist. In keeping with this, facilities should provide assurance of this information. I believe we need to develop a standard 

of care and a method of sharing technology. 

I have explained this process because from my knowledge, not 

every VA clinic is set up in this particular configuration. As an example, I would like to read a short story of a veteran I had the 

privilege of taking care of. An example of my positive experience 

as a VA contractor and small businessman is apparent in my experiences caring for a veteran with an above knee prosthesis in 2007. 

For the sake of privacy, I will refer to him as John. 

John had been an amputee since 1971. He incurred a traumatic 

amputation which left him with a very short above knee residual 

limb, 4 inches in fact. The trauma of losing a limb and the difficulty he experienced with ill-fitting prostheses over the years had 

him contemplating suicide in several instances. 

However, he came to grips with his situation and has used the 

prosthesis ever since. When we first evaluated him, his residual 

limb was bloody, extremely painful and he had severe low back 

pain. He commonly had to refrain from activities that required a 

lot of physical exertion. However, given the fact that he owned a 

farm required him to participate in strenuous activities, the days 

following those activities forced him to remove the limb for several 

days until his residual limb had healed. He repeated this painful 

cycle over and over again for the last 37 years. 

Our desire to provide the highest technology and best possible 

care led us to attend an educational event that taught a method 

of socket design that far exceeds anything we had previously used, 

the negative pressure system. In short, we fabricated and fit John 

with the NPS style socket that has forever changed his life. He 

wears the limb each and every day. His residual limb is now 

30 

healthy and pain free. And most importantly, he has returned to 

work on his farm, providing for his family and improved his sense 

of self-worth tremendously. 

Competition driven patient care. Independent contract providers 

exist in a very competitive market outside the VA system. We are 

required by our credentialing organizations to maintain continuing 

education levels. This market is not based on price, but on service 

and clinical competence. When price is a determining factor, the 

low bidder wins and service is no longer a consideration in patient 

care and commitments to continuing education sometimes falter. In 

fact, service may be cut to make the process profitable for the provider. 

In the private sector, fees are relatively fixed and clinicians are 

forced to stay current with technology and technique. The level of 

service provided determines the success, failure of the provider. 

This type of competition exists in the clinic that I attend and ensures a high level of service and guarantees that veterans will receive quality care with the highest appropriate technology. 

In summation, I am proud be to a contract provider in the VA 

system. This is a great system and in my region it works very well. 

However, the vets we treat have risked their lives and sacrificed 

their limbs. They deserve the highest level of care and expertise we 

can offer. 

Battlefield medical advancements have saved many lives that 

would have been lost in previous conflicts. The results are more severely wounded soldiers and more complex amputees to care for. 

These wounded soldiers deserve every advantage to restore them to 

productive sons, daughters, fathers, mothers and whatever else 

they desire to be. We owe it to them to create and maintain a system of contracting that serves them all. 

Thank you. 

[The prepared statement of Mr. Smith is included in the appendix.] 

Chairman BRALEY. Thank you, Mr. Smith. 

Mr. Guth, I want to start with you and the story you were telling 

about the patient you were caring for about the micro-process knee. 

Do you remember that? 

You know, I have had the opportunity over in the Rayburn 

Building to see some amazing advancements in upper extremity 

technology with neuro motor driven prosthetic devices. And this 

gets back to one of the points I made in my opening statement. You 

seem to be not very satisfied with the overall relationship that the 

VA has with small businesses and expressed concerns about the inconsistencies and how they are treated by their local VA. 

How would this Injured and Amputee Veterans Bill of Rights address some of that different treatment and help veterans get the 

type of care selection that you feel they deserve? 

Mr. GUTH. Well, what happens is that the Bill of Rights is actually the rights that the VA already has in place for these amputees 

and orthotic patients. The problem is that the VA is not going out 

of its way to educate its patients on exactly their rights. They tend 

to just not let them know that they have the right to go outside 

the contract, to go to any provider they want to go to. They don’t 

31 

tell them that they have the right to have a micro-processed knee 

or the latest technology. They don’t tell them that they have a right 

to have a leg for the shower or the swim, you know. 

So I think what is happening is between the national office saying the guy can have five legs and they can all be micro-process 

if they want to. And down to the VISNs, it doesn’t communicate 

that way. I think the VISNs are being more controlled by the bean 

counters than the policy at the VA. 

So they are fearful to give these kind of products that cost a lot 

of money to these veterans, and also some of the new contracts that 

they put out—now, my company was contracted for the last 60 

years with the VA. We just lost the contract. And some of the new 

contractors have never worked with VA patients, have never had 

a VA contract, do not have some of the qualifications required to 

put on micro-process knees or propiol feet or the new i-Hand that 

you are talking about. 

So they are limited. The VA is not going to order those parts if 

the contractor that they are dealing with doesn’t even have the license to do it. But some of them do. You know, it is not all of them. 

But it is just that I think that the VISNs are just not giving the 

patient their rights. If the patient knows his rights, he will be able 

to, you know, get done what he needs done. 

Chairman BRALEY. Thank you. Captain, I first had contact with 

Mr. Clark’s business when one of my clients, a young man about 

your age, had a below the knee amputation in an unguarded auger 

accident. And he was very concerned as a young man about his future and what types of mobility he would have as he progressed if 

his life. I was just hoping you might be able to share with us what 

a typical, young veteran with a below the knee amputation or an 

above the knee amputation goes through as you are trying to deal 

with planning for the rest of your life, coping with the rehabilitation process and how vital the VA benefits are as you are going 

about that. 

Captain BACIK. Yes, there is a couple of different phases that the 

soldier, you know—that the veteran would go through. And the 

first is when you are transitioning from DOD to VA and a lot of 

that depends on where you are transitioning to, what vision that 

you are heading to. Once you are in the VA system and you start 

to figure out, okay, what am I going to do with my life and that 

leg, getting that leg straight, getting that leg right is definitely 

your first priority. And I think that, you know, the nonprofits have 

a role to play and maybe we should have thought about maybe representing that role a little bit, too, at this table. But a lot of these 

problems that happen in certain parts of the country have already 

happened where I am at and we have already addressed them, and 

the way we are sharing lessons across the table is through these 

nonprofit organizations that are kind of there to, you know, just 

share lessons back and forth, meet with folks like this, talk to 

other veterans and I think that is where we could maybe make it 

better for people in different parts of the country. 

And as you move out, I think they—Mr. Downs said maybe 800 

amputees. So maybe we should expect to see about 40 amputees 

per State and if there is three main clinics, it is like 15 or 13 amputees in each State. Some of them are still going to be on active 

32 

duty, some are still at Walter Reed, some of them are not at the 

point in their health care yet where they are going in to see a prosthetist. So when you break it down to the community level, you 

may only have, you know, two or three amputees that have walked 

through a clinic that sees 2,000 OIF/OEF veterans. And without— 

it is important to educate the patients, but we also need to be educating the folks that we are entrusting to kind of guide the patients 

through their care. And if you are going to see 2,000 vets, you 

know, if I was a case manager, I would be worried first about 

PTSD because you are going to have a larger portion of that pile, 

have issues with that than you are going to have amputees. And 

getting the information to these folks about what programs are 

available for amputees is where I think the—you know, maybe the 

issue is. 

As far as the capabilities—as you go up your leg, as long as you 

have your knee, you are fine, you can do anything, the sky is the 

limit. As you start to go up a little bit higher, life gets more challenging. 

Chairman BRALEY. One of the concerns that was raised in the 

Independent Review Group study was that—it was something that 

you talked about earlier in your opening remarks, and that is the 

impact of travel on someone who is in need of orthotic and prosthetic services. And they talked in the report about those veterans 

who are on TRICARE Prime who had a reimbursement allowance 

for mileage as part of that. But patients who were under TRICARE 

Standard had no similar reimbursement. 

Is that something you hear veterans talking about as it relates 

to getting not only high quality care but also access to care, especially in a time of high gas prices? 

Captain BACIK. Definitely, you know, people are concerned about 

that. And from the veterans standpoint, our time as a member of 

the civilian workforce is valuable to us. And you know there is a 

cost associated with spending 8 hours at the VA trying to accomplish something and, you know, making the correct phone calls, 

sending the correct e-mails while you are trying to manage a professional career and also, you know, be a father or a mother and, 

you know, have some kind of—have something to do on the side of 

that, just go play a game of golf or something. You know, that is 

all—our time is very valuable to us. And I think that having—you 

know, for me, having my private provider, he interfaces with the 

VA and does most of that war gaming on behalf of me because he 

has established that relationship at the local level. Very beneficial. 

He knows—you know, he is motivated because if he doesn’t—if he 

doesn’t get a leg made for me, he doesn’t bring food home to his 

family. So he is motivated to make it happen, knows who to talk 

to, knows how to navigate the system. 

As far as the traveling requirements, you know, my prosthetist 

lives about a half hour away from me and he has a satellite office 

in the same town I actually live in. So I will see him there or he 

will travel to see me, whatever he needs to do. 

Chairman BRALEY. Thank you. Mr. Clark, as a leader in the 

O&P community, you have had the opportunity to talk with a lot 

of practitioners about the VA procurement process and its challenges. From your background and experience, can you share with 

33 

us what issue raises the most concern with O&P professionals 

about their interaction with the VA system? 

Mr. CLARK. Yes. The concern that comes up most often is the 

technology issue and the contracting, the other two. It is technology, access to technology for patients where that technology is 

appropriate, not unlike the case that Mr. Guth talked about. That 

technology seems to make good sense is appropriate for that patient and there are occasionally constraints put in there. I believe 

that is getting better. But constraints can be put in there and hurdles can be made that are sometimes usurious to get beyond. 

The other thing is just the contracting process. It is getting more 

complex, even how you are informed that there is the RFP out 

there. Getting that information is tougher to find. You almost have 

to be a watchdog or hire a watchdog to find that out for you in 

some of the VISNs. So those are the two big issues that are out 

there. I would like to say, you know, that seeing Ms. Russell as 

part of—a deputy for Fred Downs is great. She comes from Walter 

Reed. We worked with her at Walter Reed. She, like all the other 

people within the VA system, has such an incredible passion to 

make sure these things get taken care of. 

So I think things are hopefully going in the right direction. This 

study obviously highlights many things. 

Chairman BRALEY. What recommendations are you familiar with 

maybe coming from either professional associations, a certification 

board on how to deal with that communication problem within the 

VISN so that there is—you should be able to get 24-hour a day, 

one-stop shopping, check in, find out what is available, be involved 

in the procurement process, why isn’t that happening? 

Mr. CLARK. I think the Web site that has been created is going 

to be a great help and I think that kind of 24/7 access to information is going to be a great help. It takes time to disseminate that 

information. The VA is the largest health care system I think in 

the world. So it takes time to disseminate all of this information 

out to everyone. And everyone has their own little fiefdoms possibly 

within the business and the way they like to do things. Once we 

determine and are able to stabilize everyone with the same core 

values and the same core beliefs and the same core strategies, then 

we can go out and they can tactically do what they need to do within their VISNs. 

It is going to be education both to the patient and to the people 

managing the VA centers and continued education like these town 

hall meetings, like the information that is on the Web site, like the 

information that gets sent out to those people that are managing 

this care. 

Chairman BRALEY. Thank you.Mr. Davis. 

Mr. DAVIS. Thank you again. You have provided some wonderful 

testimony and I appreciate each one of you. Captain Bacik, if you 

would, tell me a little bit about why you think Glenn chose not to 

contract with the VA. 

Captain BACIK. Well, Glenn certainly tried to contract with the 

VA. And in the past he was a contractor on their books. And Dennis might know more details to the story. But at a certain point, 

I think when they transitioned to an electronic bid system for renewing the contract Glenn was not privy to the new system for esVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00037 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
34 

tablishing or renewing that contracting relationship. So he was 

taken off their contracting rule. 

Mr. DAVIS. So he provides good health care, you the patient appreciates the care you are receiving and because of a computer 

glitch he was not able to contract? Is that what I hear? 

Captain BACIK. Yes, sir. And of course that situation as I understand, and it might be more than a computer glitch, but basically 

it is a paperwork issue where his contract was not renewed. And 

he is very active in the State. It is not like—you know, he sits on— 

he was the immediate past President of the State Certification 

Board. So he is a well-known provider locally. 

Mr. DAVIS. Mr. Clark, you look like you want to add to that, and 

I would love for you to. 

Mr. CLARK. Again, I don’t know—as Mr. Bacik said, I don’t have 

100 percent of the input. But I believe what happens is a similar 

story, and again I am relating it secondhand, as to what happened 

in Houston. The RFP was placed out there on a government Web 

site and I received an e-mail from someone one day telling me that 

no one in Houston replied. I find that a little bit hard to believe. 

No one in Houston replied because nobody knew it was out there. 

You had to reach out to that government Web site. 

My guess is that Glenn didn’t go to the Web site at the right 

time to find out that he needed to submit the RFP by a certain 

date in the way that it needed to be submitted. And because of 

that, he was eliminated as a contract provider by not responding 

the way he needed to in a timely fashion, even though he was not 

made aware of that fact. 

I am speculating that that is the issue because the story, as Mr. 

Bacik relays it, is so familiar to what I heard from some folks in 

Houston. We actually hired someone in our company to watch 

those e-mails and let us know when that—when the RFP would 

come out so that we wouldn’t miss that deadline. 

Mr. DAVIS. And the smaller the business, the harder it is to have 

someone monitoring government Web sites? 

Mr. CLARK. Without question. 

Mr. DAVIS. Especially when you are in front of a small business 

committee. Has someone relayed these problems to Mr. Downs? Because this morning he sounds like he really wants to work with the 

provider community. Has anyone related this problem? 

Captain BACIK. Glenn has been in contact with our VISN director. We are VISN 7 in Atlanta. It is headquartered there. And I 

know he has spoken with him often about it. 

Mr. DAVIS. Sounds like this is something Chairman Braley and 

I may be able to work together on and try to find a solution. 

Moving on down the line, Mr. Rogers, you spoke of a Jack. You 

said he had had four prostheses. Why did he have so many? 

Mr. ROGERS. Well, I think what happened was that—according 

to Jack—is thatthere was such an emphasis paid on providing him 

quick care and high technology in a very busy environment at Walter Reed that it was very difficult for him to make the adjustments 

as an amputee that he needed to make. And he didn’t have a lot 

of help doing it. And the next thing he knew he was being shipped 

back to Kansas and had prostheses that he was asked to sign for 

that really didn’t relate to anything that he was hoping to do when 

35 

he got back. And he made a fairly quick transition through the VA 

system, at least from what I understand is normally the case, and 

had a single provider available to him who really didn’t serve his 

needs well. 

I think by everybody’s estimation he wasn’t cared for well by that 

particular provider in the VA system. Because he was referred to 

me through the Wounded Warriors at Fort Reilly and he had already transitioned into the VA system. The way he was able to do 

that is that he maintained his employment on the base. So they 

asked me as a noncontracting VA provider in the area if I would 

see him. And I think the emphasis—the lesson to be learned from 

this example is that the care of a local prosthetic and orthotic professional where an amputee knows that they are not going to see 

somebody for a brief period of time and then there is going to be 

a huge distance between them where that relationship is going to 

end, the local relationship fosters development in communication 

and there is an interest taken on the part of the prosthetist in that 

individual. And the individual knows that. And that is the model 

that has existed for a 100 years in the United States and provides 

the civilian population with excellent prosthetic care, and that 

model needs to be promulgated throughout the VA system. 

Mr. DAVIS. I hear you saying Jack didn’t get the care that he deserved and was due. A follow-up to that, do you think it was a good 

use of taxpayer dollars if he actually received—and we can be open 

and frank here. That is what—we are trying to learn. Is it good use 

of taxpayer dollars to buy four prostheses that ultimately end up 

costing taxpayer dollars and then you end up with the fifth limb 

doing the job? 

Mr. ROGERS. Of course not. But I also think—as quickly as I say 

that, I don’t think that example is reflective of the balance of care 

that is received through Walter Reed or Bethesda. And I think in 

this particular instance it could have been timing or the influx of 

people. It could have been Jack’s personality and some of the adjustment disorders that he was going through with this, being 

without his family and so on. 

It is not as easy to say, gee, he just was not served well and that 

is the norm of care there and it was not a good expenditure of taxpayer dollars. I think what it really illustrates is the importance 

of that communication because I know of many veterans that I 

have seen in Kansas who got excellent care and appropriate technology and felt like the care they received coming through Walter 

Reed was exceptional. So although I don’t think it is a good use of 

taxpayer dollars in this instance, I don’t think that is reflective of 

the care that occurs at Walter Reed. 

Mr. DAVIS. So Jack was outside the norm? 

Mr. ROGERS. I think so, yes. 

Mr. DAVIS. In your opinion. Okay. 

Mr. Guth, you talked about Tom. Why do you think his new 

micro-processor was denied? 

Mr. GUTH. Well, he actually—he went to the clinic without telling me. So I wasn’t there as a patient advocate for him. And that 

is when they prescribed him and told him that the micro-processor 

knees were kind of experimental, they broke down constantly, he 

36 

probably wouldn’t enjoy it, go back to what you have here. You did 

well for 35, 40 years, you don’t need anything different. 

So he came in to me with the prescription. And I said, well, did 

you—and he said I asked them for a micro-process knee and they 

told me no. So I said, well, I don’t think they have that right. But 

why don’t—so he went back the next day not in a clinic and talked 

to the prosthetic chief and the prosthetic chief told him that you 

get this leg first and then you can go ahead and have your microprocess knee made. But first you get your spare leg and then—but 

you won’t have to go through clinic to get this new micro-process 

knee, you have already been through clinic. 

So he came running into me and he said, yes, you have to build 

me this one first but then I get my micro-process knee. I said, 

great, let me get on the phone to the VA and make sure that we 

are all on the same page. I got on the phone with the VA and they 

said no way, this man is not getting a micro-process knee without 

coming back through clinic. And then he went back 2 more days 

requesting the same thing and was turned down. And finally his 

health got bad and he had to go back home and he couldn’t pursue 

it any further. 

Mr. DAVIS. Was it your understanding from earlier testimony 

today that they can pick and choose their best equipment for their 

needs? 

Mr. GUTH. Well, if you listen to Fred, they say they can have 

anything they want, including five micro-process knees if that is 

what they need. But that is not what is happening. Okay? I have 

two patients at the VA that actually have two micro-process knees, 

and the reason for that is because they deserve a functional spare. 

And once you have walked on a micro-process knee, I don’t care if 

you have walked on this other knee for 40 years, you get used to 

that micro-process knee, you believe in it, you don’t think about 

your prosthesis so much, you go back to your old leg and you fall. 

So the only functional spare for one of these micro-process knees 

is another micro-process knee. Both of these patients that got the 

two knees—and the only reason that—I am sure they are the only 

ones in all of VISN 22 that have two micro-process knees—is because they were World War II amps. One has been on anger management paid for by the VA since the war and the other one called 

his Congressman and told him off. And that is how they got the 

second knee. And the VA said, of course, you can have one. 

Mr. DAVIS. Thank you. 

Mr. Smith, you talked about John. Why do you think it took 37 

years to provide him with the correct limb? 

Mr. SMITH. Well, that is hard to decisively say. But in my opinion, he transferred to Mountain Home from a previous facility that 

wasn’t run the exact way that the Mountain Home clinic is run. I 

think we are overlooking a simple solution to a lot of the problems 

that are coming forth today. And that is that in the clinic I participate in, there is a system of checks and balances. You know, it is 

not that somebody randomly chooses what is best for that patient. 

It is a team effort, everybody puts their head together to determine 

what is best for the patient. The patient goes to the chosen facility, 

he comes back and the follow-up care not only determines the need 

for physical therapy but it determines whether or not the device 

37 

prescribed to him worked. And I think that that is an injustice to 

the taxpayers and the patients and everybody involved to not have 

a system of checks and balances. 

You know, I am not going to be as politically correct as Jim to 

say that I don’t think it is the best use of taxpayer dollars to throw 

these limbs at these amputees right off the bat. There are several 

reasons for that. First and foremost, they don’t know what to expect. These amputees just went through a traumatic experience. 

They don’t know if they need a micro-processor to go to the job that 

they don’t have yet. They don’t know what the job is. In addition 

to that, every prosthetist sitting at this table knows that amputees, 

the dimensions of their limb changes over time. You know, you 

start off with a limb that has been through trauma, it has edema 

and swelling, the muscles have atrophied from nonuse. And to just 

fit someone randomly with four limbs is in my opinion ludicrous. 

In addition to that, I will take the time to say that I disagree 

with contracting with exclusive providers. You know, in the model 

that I described there is multiple orthotists and prosthetists 

present. I believe that this is in the best interest of the taxpayers, 

the patients and the VISN. And the reason for that is that again 

there is a system of checks and balances. It is not one prosthetist 

doing the work and then having no one to say, yes, that is a good 

prosthesis or it isn’t. 

The fact that ABC or BOC certification is a minimal requirement 

doesn’t mean that the prosthetist is good at what he does. We all 

know in different professions that there are people that are really 

good at what they do and others that aren’t. So I think it would 

be in the best interest of everybody if this clinic model was used 

as a standard and that the providers who want to be in the VA system should be allowed to do that, provided they meet the requirements of certification. To have one provider is unfair. Competition 

is what our country was based on; a competitive market. And I 

don’t think it is correct for the VA to disenfranchise that model. 

Competition makes better practitioners. That is just the way it is, 

whether in the private sector or the VA sector. 

So in this case, as far as John, I don’t think that there was 

enough follow-up care for this individual. He was a very difficult 

patient to fit. In the prior prosthetist’s defense, it wasn’t easy to 

fit him. Luckily I do continuing education constantly and I am always looking out for better technology and better techniques. And 

that is why in my testimony, I said I thought it was a good idea 

to have some type of a joint educational event that is specifically 

for VA vendors, providers and the VA personnel involved in that 

process. 

Mr. DAVIS. You have outlined success there at the Mountain 

Home VA Medical Center. How broadly is that used across the 

country? Is it limited to just Johnson City, Tennessee or do you see 

it in other VAs? 

Mr. SMITH. From my understanding, it is not used everywhere. 

Some of the participants in the clinic that I attend have been in 

different VA facilities and I have heard just from them that that 

wasn’t the way that it was conducted in the facilities they had previously worked at. So for me to say across the board it is a standVerDate Aug 31 2005 09:49 Aug 27, 2008 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6633 G:\CLERK SB-LD\HEARINGS\TRANSCRIPTS\42522.TXT RUSS
38 

ard or not a standard, I really couldn’t say, but I have heard personal testimony to say that this model is not used in every clinic. 

Mr. DAVIS. Can I get some of the other panelists to tell me, do 

you think that would be helpful if that was a standard? 

Captain BACIK. I have used—I have been in that clinic model in 

two different systems, the Tampa VA and the Montgomery VA. 

And the way it works is the patient will walk into the room and 

there will be a board of leg makers that are—that have that contract and then the doctor will be there. The doctor will say, okay, 

this is what this patient needs, and then you go around the room 

and the providers say this is what I think we can do based on your 

capabilities and what has worked well for you in the past. And in 

Tampa, it worked great. And I think that is probably the textbook 

answer. 

In the Montgomery facility, since Glenn didn’t have the contract, 

if he doesn’t bring you to that clinic as, hey, this is my patient, I 

am bringing you to the clinic, if you show up to the clinic on your 

own, only the person with the contract can reach out and say, hey, 

based on your capabilities and what you have done in the past and 

what you are wearing now, I think this would work well for you. 

In our clinic, you know, we have got—there is two providers and 

one of them has that voice and the other—you know, if the doctor 

says, hey, Glenn I think you should take care of this new patient, 

then Glenn is in the mix. If not, you know, he just kind of observes. 

Mr. GUTH. Excuse me. The doctor is not allowed to say that, not 

a VA doctor. He is not allowed to refer to your practitioner, period. 

Mr. DAVIS. That is good to know. And if you will bear with me, 

I am going to do one more question. And this will just be for anyone or everyone. How can the current VA model for orthotics and 

prosthetics be enhanced? 

Mr. GUTH. I think you have to set national standards and make 

sure that all 22—he said there is only 21 VISNs, I thought Fred 

Downs said. Our VISN is 22. That may be why we are out there 

on the edge, we are outside the network. But you need to have a 

national program and each one of those VISNs have to be educated 

on exactly how to run it. You know, we have a prosthetic clinic like 

they are talking about, and for 60 years it worked out wonderfully 

but they took all the providers who did all the work and got rid 

of all of them and put in all new providers who hadn’t seen any 

of these patients before, and none of us, the old providers, are allowed to attend those clinics unless our patient requests us to be 

there and we show up with our patient. We are only allowed into 

that clinic for that patient, and then we are kicked out. 

Now, I think that that is a terrible way to do it. And then they 

are also not told that if you don’t like these providers, you can go 

anywhere you want as long as the person is certified. And you can 

go to any State and go anywhere. We are not going to pay your 

transportation, but you have the right to go to any prosthetist that 

is certified in this country. And, in fact, I fit four or five patients 

that do not come from the VA in California. They come from—one 

of them comes from Tennessee because he wasn’t getting service at 

his Tennessee clinic, and so he came out to see me and we forced 

the VA in San Diego to do what was right. And one of those was 

a micro-process knee. So— 

39 

Mr. DAVIS. Thank you. And I yield back. 

Chairman BRALEY. Mr. Rogers, I want to follow up on your Jack 

story. One of the things you talked about was despite the fact that 

veterans have access to the best technology in theory, sometimes 

the VA fails to design prosthetics that specifically meet a veteran’s 

job or lifestyle. I think this gets back to what I was talking about 

earlier, which is whether there is a lack of institutional forward 

planning sometimes that tries to look at what a veteran’s future is 

going to look like and continues to track them as those needs 

change as they may be laid off from a job, going to a different type 

of job environment or their recreational needs change. In your opinion, what steps should the VA take to avoid that situation and 

what should be the role of the local prosthetist? 

Mr. ROGERS. I think before I answer your question a distinction 

needs to be made. He received the majority of his prostheses, three 

of the four, from the DOD, not from the VA. So, you know, my experience with the VA process is such that I think the local prosthetist does that by and large. You know, in the civilian model, 

that relationship that is formed ensures that that happens. When 

an amputee’s circumstances change or their needs change or their 

prosthesis is no longer serving them well, that is their function, 

that is their ability to get around day to day, things that we take 

for granted. They are going to come back to you if they have a relationship with you, and that is how you are going to know that. 

I don’t know that it is the VA’s responsibility to monitor that in 

any way or if that is even possible. I do think, though, that the VA 

can provide a mechanism for communication. I think that the Patient’s Bill of Rights is an excellent idea, if that can be disseminated so that amputees know that they can go outside of the contracted provider. I don’t know that you want to wholesale revamp 

the contracted provider process, but making sure that noncontractor providers like myself are available to amputees and that 

the amputees know what their rights are and what they can do 

would go a long way to solving some of the problems that you hear 

and that you have heard at this committee. 

Chairman BRALEY. Mr. Guth, one of the concerns you addressed 

was the increasing use at some VA centers of in-house staff to provide O&P services. What specific concerns does that raise to you 

in terms of the quality of care, the ability to monitor developments 

in technology and new advancements in O&P products and services? 

Mr. GUTH. Well, up to about 5 years ago, the VA employed no 

certified practitioners whatsoever. We were vendors, all the work 

was done outside. They didn’t have any certified people on board. 

The last 5 or 6 years, they have worked very hard, I think they 

now have, what, 60 practitioners and last time, about 6 months 

ago, I heard they had 40. The VA in San Diego is now hiring another prosthetist, orthotist to help take on the load, which if they 

are only doing 3 percent of the work they don’t need another prosthetist or orthotist to take on the load. 

When I was able just 2 weeks ago, I went to my clinic to show 

my patient off that had a new micro-processed ankle and they were 

all very impressed. But as I was being rushed out of the clinic, one 

of my old patients, who I had made a leg for 25 years ago and he 

40 

was still wearing it—and the reason I can tell that is because on 

the front we used to put our name and their Social Security number and their name. That was a VA requirement. They were carrying in four brand new legs. He is a BK, below the knee, four 

brand new legs made by the VA and he is wearing my leg that is 

25 years old. Well, obviously he has rejected these four brand new 

legs and they still haven’t solved the problem. Now, there is an example of lack—waste of taxpayers’ money. 

One of the problems when the VA does hire a prosthetist out of 

our industry, they are paid the lowest of anybody in the industry, 

below our standards. So they are not exactly hiring the cream of 

the crop but they are certified. And a lot of them are BOC, which 

is what we were just—even Fred said that is a little below ABC. 

Chairman BRALEY. Mr. Clark, I don’t think there is any doubt 

that the certification requirement has improved the overall quality 

of the service veterans receive when they have an amputation. But 

you have also expressed hope that we move toward facility accreditation as part of the standard for providers as well. 

So given the fact that provider certification has successfully increased the level of service received by veterans, why do you believe that facility accreditation is necessary? 

Mr. CLARK. Facility accreditation deals with much more than the 

governance procedures that are out there. We have to be able to 

communicate well, have excellent note taking, have communication 

back with the prescribing physicians, with other health care professionals. There has to be a process. If there is problem, what is your 

in-house process for dealing with a patient not being satisfied with 

the care or any conflict management that you might have internally. That facility accreditation goes way beyond just the physical 

specifications of the building; is it handicapped accessible, is it all 

this and that. It causes the provider not only to be good at the stuff 

working in their business, but good at the on their business stuff 

too. So they are working toward quality note taking, staying current and all those types of things with respect to running their 

business and running a quality organization. 

That is just another standard that we can put out there to make 

sure that the people that are providing care to these deserving veterans not only are good at what they do, but their organizations 

are run well so these conflicts can be managed. 

I am seriously hoping at some point also that some of this stuff 

that Tom and Zach and Jim have been talking about, once we start 

doing performance measurements, not only for the components of 

prostheses but for the functional levels of the people who receive 

prostheses, some kind of performance measurement—that takes 

some of this burden of who should provide this care and how can 

we select and how can we determine how this is done. 

Using some form of evidence based care I think is the next step 

in prosthetics—no pun intended—the next step in prosthetics and 

orthotics, and I think an absolutely critical one that we take, especially in light of this large number of young active group of men 

and women who are going to be needing these services for generations to come. 

Chairman BRALEY. Thank you, Mr. Davis. Do you have any further questions? 

41 

Mr. DAVIS. No. 

Chairman BRALEY. I just want to thank all of our witnesses for 

this very informative conversation. I just want to close with one of 

the concluding remarks from the Independent Review Group report. 

In the conclusion section where they wrote, generally the Nation 

must recognize that there is a moral, human and budgetary cost 

of war. When we engage in armed conflict, we must recognize those 

costs and be prepared to execute on those obligations. I can think 

of no area where that obligation is greater and our Nation has a 

higher calling than to take care of the needs of our wounded veterans. And I hope that as we move forward from this hearing, we 

can work together to address these concerns and provide them with 

the optimal care for the best possible outcome in their lives. 

And I just also have one more housekeeping matter to take care 

of. All members are advised that they have 5 days to submit statements and supporting materials for the record. I ask unanimous 

consent. Without objection, so ordered. 

This hearing is now adjourned. Thank you very much. 

[Whereupon, at 12:20 p.m., the Subcommittee was adjourned.] 

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