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29–681 2018

VA SPECIALIZED SERVICES: LOWER EXTREMITY 

CONDITIONS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

TUESDAY, MAY 2, 2017 

Serial No. 115–13 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DAVID P. ROE, Tennessee, Chairman 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

BRUCE POLIQUIN, Maine 

NEAL DUNN, Florida 

JODEY ARRINGTON, Texas 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JACK BERGMAN, Michigan 

JIM BANKS, Indiana 

JENNIFFER GONZALEZ-COLON, Puerto 

Rico 

TIM WALZ, Minnesota, Ranking Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

J. LUIS CORREA, California 

KILILI SABLAN, Northern Mariana Islands 

ELIZABETH ESTY, Connecticut 

SCOTT PETERS, California 

JON TOWERS, Staff Director 

RAY KELLEY, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

BRAD WENSTRUP, Ohio, Chairman 

GUS BILIRAKIS, Florida 

AMATA RADEWAGEN, American Samoa 

NEAL DUNN, Florida 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JENNIFER GONZALEZ-COLON, Puerto Rico 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

ANN MCLANE KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

LUIS CORREA, California 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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(III) 

C O N T E N T S 

Tuesday, May 2, 2017 

Page 

VA Specialized Services: Lower Extremity Conditions ......................................... 1 

OPENING STATEMENTS 

Honorable Brad Wenstrup, Chairman ................................................................... 1 

Honorable Julia Brownley, Ranking Member ....................................................... 3 

WITNESSES 

Steven L. Goldman DPM, MBA, President, American Board of Podiatric Medicine ........................................................................................................................ 3 

Prepared Statement ......................................................................................... 26 

Seth Rubenstein DPM, Treasurer, Board of Trustees, Immediate Past Chairman, Legislative Committee, American Podiatric Medical Association .......... 6 

Prepared Statement ......................................................................................... 29 

Col. James Ficke MD (ret.), Member, American Orthopaedic Foot and Ankle 

Society, American Association of Orthopaedic Surgeons .................................. 8 

Prepared Statement ......................................................................................... 32 

Jeffrey M Brandt CPO, Member, American Orthotics and Prosthetics Association ........................................................................................................................ 9 

Prepared Statement ......................................................................................... 33 

Jeffrey Robbins DPM, Chief of Podiatry, Veterans Health Administration, 

U.S. Department of Veterans Affairs ................................................................. 11 

STATEMENTS FOR THE RECORD 

Clifford James Buckley, M.D. ................................................................................. 38 

Lawrence B. Harkless, DPM ................................................................................... 39 

Paralyzed Veterans of America (PVA) ................................................................... 40 

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VA SPECIALIZED SERVICES: LOWER 

EXTREMITY CONDITIONS 

Tuesday, May 2, 2017 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON DISABILITY ASSISTANCE

AND MEMORIAL AFFAIRS, Washington, D.C. 

The Subcommittee met, pursuant to notice, at 2:54 p.m., in Room 

334, Cannon House Office Building, Hon. Brad Wenstrup [Chairman of the Subcommittee] presiding. 

Present: Representatives Wenstrup, Dunn, Higgins, Brownley, 

Takano, and Kuster. 

Also Present: Representative Abraham. 

OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN 

Mr. WENSTRUP. The Subcommittee will come to order. Good 

afternoon, and thank you all for joining us. 

Before I begin, I would like to ask unanimous consent for my 

friend and colleague and former Committee Member, Dr. Ralph 

Abraham, to sit on the dais and participate in today’s proceedings. 

Without objection, so ordered. 

Today’s hearing is the first of what I hope will be a series of 

hearings to examine specialty care access and quality in depth. 

Given the high rate of lower limb injuries and conditions among 

veterans of all ages and the issues this Subcommittee has been discussing since 2015 regarding recruitment and retention among professionals trained to treat foot and ankle issues in the Department 

of Veterans Affairs, I thought it most appropriate to begin today 

with a discussion of lower extremity injuries, conditions, and treatment. 

Musculoskeletal injuries are the top concern among veterans 

newly separated from service in the armed forces and are also a 

primary concern among older generations of veterans with conditions that may be exacerbated, not only by military service, but 

also by aging and chronic illnesses like diabetes. 

According to a February 2017 VA white paper, almost 2 million 

veterans in the VA health care system are at risk for major foot 

wounds, infections, and amputations. And there is increasing demand among VA patients, particularly those with polytraumatic injuries, spinal cord injuries, and major limb amputations, for primary and specialty podiatric services. 

I ask unanimous consent to insert that white paper into the 

record. Without objection, so ordered. 

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Mr. WENSTRUP. Given increasing demand, it is imperative now 

more than ever that the VA be equipped with the highly trained 

workforce necessary to provide timely access to quality foot and 

ankle care within VA medical facilities. The VA’s ability to do that, 

however, is hampered by antiquated statutory requirements that 

have held podiatrists practicing within the VA’s walls back and, as 

a result, limited access to podiatry care for veteran patients. 

The podiatry profession has been transformed over the last few 

decades, yet due to a law developed in 1976, 41 years ago, the VA’s 

podiatry practice has fallen far short of the private sector in terms 

of pay and advancement opportunities. According to the VA, this 

has led to an inability to recruit and retain the most experienced 

podiatrists, the ones we want treating our most vulnerable veterans, as well as recent graduates just starting out. Needless to 

say, it has also led to lengthy hiring delays, averaging 14 months 

for new podiatry positions. At a time when veteran demand for foot 

and ankle care is growing, this is unacceptable. 

I have introduced a bill, H.R. 1058, the VA Provider Equity Act, 

that would address this issue by including VA podiatrists within 

the definition of VA physicians and, in turn, ensure that podiatry 

pay is more in line with industry standard and allow podiatrists to 

attain promotion and leadership positions in the VA health care 

system. Similar language passed the House last Congress, and for 

our veterans’ sakes, I am hopeful it will see the President’s desk 

this Congress. 

During today’s hearing, I look forward to hearing our witnesses’ 

and Committee Members’ thoughts on H.R. 1058 and on what else 

this Subcommittee can do to guarantee timely access to specialized 

foot and ankle care veterans have earned and deserve. 

I also want to discuss today how the VA can improve the provision of both foot and ankle care and orthotic and prosthetic care 

in the community for veteran patients. As the American Orthotics 

and Prosthetics Association states in their written testimony, 90 

percent of the orthotic and prosthetic care that our veterans receive 

is in the community. However, there are persistent concerns about 

care coordination and communication between VA and community 

providers treating veterans with major amputations. 

Unfortunately, this is not just an issue of concern for prosthetics. 

During a Full Committee hearing earlier this year, Dr. Dunn 

shared a story about a veteran constituent of his whose delayed 

and disjointed experience seeking podiatry care through the Choice 

Program led to an unnecessary lengthy and burdensome episode of 

care. 

I ask unanimous consent to insert that constituent’s story into 

the record for this hearing as well. Without objection, so ordered. 

Mr. WENSTRUP. As we continue to move forward to develop the 

next generation of VA care and community programs, we must take 

those stories to heart and ensure that they are not repeated. 

I appreciate our panelists and audience members for being with 

us this afternoon, and I very much look forward to today’s discussion. 

I will now yield to Ranking Member Brownley for any opening 

statement that she may have. 

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OPENING STATEMENT OF JULIA BROWNLEY, RANKING 

MEMBER 

Ms. BROWNLEY. Thank you, Mr. Chairman. And thank you for 

holding today’s hearing. 

The ability of the VA to hire and retain skilled medical professionals to treat veterans with lower extremity medical conditions is 

vitally important. Many veterans who receive VA care have lost 

limbs due to combat, others develop serious medical conditions affecting the lower extremities later in life due to their military service. These conditions and injuries can significantly affect a veteran’s quality of life. 

I want to thank Chairman Wenstrup for being willing to work in 

a bipartisan way to address this issue impacting the VHA and the 

veterans it serves. I appreciate his insight into the issue as a podiatrist and appreciate his leadership on this issue as Chairman. 

The number of veterans receiving amputations has tripled since 

2000, according to the VHA Amputation System of Care. While 

many of these amputations were the result of injury, some were 

the product of a preventable or treatable illness or disease such as 

diabetes, hypertension, or obesity. Podiatrists often act as the first 

line of defense against these types of illnesses by providing preventative care that allows veteran patients to improve their quality 

of life and avoid amputation. 

I look forward to the discussion today. I hope that we may use 

the testimony and information we receive to shape solutions to 

these pressing problems. We cannot expect to solve the VHA’s access problems without the providers, supplies, and resources that 

are urgently needed. I look forward to continuing the bipartisan 

work on this issue in this Committee. And I yield back. 

Mr. WENSTRUP. Thank you. 

We are fortunate today to be joined this afternoon by several distinguished witnesses. Joining us this morning on our first and only 

panel is Dr. Steven Goldman, the President of the American Board 

of Podiatric Medicine; Dr. Seth Rubenstein, Treasurer of the Board 

of Trustees and Immediate Past Chairman for the Legislative Committee for the American Podiatric Medical Association; Dr. James 

Ficke, the Chairman of Orthopedic Surgery at Johns Hopkins 

School of Medicine and a member of the American Association of 

Orthopaedic Surgeons and the American Orthopaedic Foot and 

Ankle Society; Jeffrey Brandt, Chief Executive Officer and Founder 

of Ability Prosthetics and Orthotics and a member of the American 

Orthotics and Prosthetics Association; and Dr. Jeffrey Robbins, the 

Department of Veterans Affairs Chief of the Podiatry service. 

I want to thank you all for being here today and taking time 

from your schedules to join us. 

Dr. Goldman, we will begin with you, if you will, and you are 

now recognized for 5 minutes. 

STATEMENT OF STEVEN L. GOLDMAN 

Dr. GOLDMAN. Dr. Chairman, Ranking Member, distinguished 

Members of Congress, and guests, at the outset, I would like to express my appreciation for the honor to address this Committee 

today. In discussing this topic, I do so as a private citizen, not as 

the chief of podiatry and the director of a podiatric residency trainleonard.horne on VACREP0180 with DISTILLER

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ing program at a Veterans Administration medical center; I do so 

not as the former interim chief of surgery or the site director of 

surgical services at a second VA medical center; and I do so not as 

a retired lieutenant colonel in the United States Air Force, who 

served as a podiatrist and also as a surgical operation squadron 

commander for the last 4 of my 20-year career in the Air Force. 

I am testifying as a private citizen, one who graduated almost 35 

years ago and was an associate professor at the New York College 

of Podiatric Medicine for nearly 15 of those years, during which 

time I have witnessed firsthand the metamorphosis of my profession. 

I am currently the president of the American Board of Podiatric 

Medicine, and in this position I represent thousands of podiatrists 

across the country, many of whom are employed by the Federal 

Government. 

As a veteran myself, I am also now the consumer of the medical 

services of the system about which you have invited me here to testify. 

I have witnessed the best of our profession as it has grown over 

the past 35 years since I graduated in 1982. I am in awe of how 

far we have come. Today, all graduating podiatrists are 3-year residency trained in podiatric medicine and surgery, and we are an integral part to the collaborative health care delivery system providing essential services alongside our distinguished allopathic and 

osteopathic specialists. 

Today’s podiatrists manage the complex nature of foot and ankle 

deformities and are a part of the multidisciplinary team serving 

the needs of a seemingly ever-growing diabetic population. We take 

call, provide inpatient and outpatient care, respond to emergencies, 

prescribe medications, and independently perform surgery of the 

foot and ankle. Fundamentally, we perform a vital role in the continuum of health care, equal to other physicians, often for a patient 

population whose choice for health care is only the VA. More often 

than not, those patients present with more multiple comorbidities 

than the average population. 

In the Veterans Administration, podiatry is often the first specialty consulted for foot and ankle services, and we provide more 

of these services than any other specialty. 

Podiatrists in the private sector have witnessed salaries commensurate with the profession’s growing skills. By contrast, salaries in 

the Veterans Health Administration, VHA, have not kept pace, and 

the gap grows larger every day. Podiatrists in 42 percent of the regions across the country have reached legislatively capped rates of 

pay under VHA. What that practically means is that a podiatrist 

at the absolute top end of the pay charts will earn exactly the same 

as much less senior podiatrists, with no hope of ever being further 

remunerated commensurate with the added time of service or experience. 

Podiatrists are defined as physicians under Title XVIII of the Social Security Act, section 1861(r)(3). The VA definition of podiatry 

is a vestige of a 41-year-old antiquated 1976 VA Omnibus bill and 

is sorely outdated. Consequently, podiatry salaries under the VA 

Health Administration are locked into that same 41-year-old pay 

scale. As a result, it is becoming increasingly harder to fill posileonard.horne on VACREP0180 with DISTILLER

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tions and keep people with the vital skills under the VHA. I think 

we can all agree that all of us, but particularly our veterans, deserve the very best of care. When looking at the bell curve for salaries in podiatry on salary.com, virtually no matter where you look 

by ZIP Code, podiatry salaries in Federal services are in the lowest 

10 to 15 percent of that curve. 

Podiatrists in leadership positions within the administration 

have been members of pay panels, making salary decisions for their 

medical colleagues who enjoy salaries that are at the very least 40 

percent greater than the top end VHA podiatry salaries. 

Heretofore, the demographic for those seeking employment under 

VHA used to be board certified, seasoned professionals who came 

with many years of experience and who wanted to make careers in 

Federal service. Podiatrists currently employed by VHA remain in 

the system primarily for one of two reasons: either they have a refined sense of purpose and wish to give of themselves out of a sense 

of commitment to our veterans, or they do so because they themselves are veterans and they are compelled by a continued sense 

of mission tending to the medical needs of their comrades in arms. 

I have said many times the VA hospital system is the only health 

care system that I have ever known where you will see a patient 

with one leg being pushed to his appointment in a wheelchair by 

a patient or volunteer with one arm, and they don’t know each 

other. Veterans get this. 

These good-hearted providers are getting harder to find and even 

harder to keep. Podiatrists with less than 10 years of experience 

make up 60 percent of the new hires at VHA. The VHA podiatry 

workforce has effectively become the private sector’s farm team 

now being filled by younger, often nonboard certified providers who 

seek to acquire the required case volume and diversity to qualify 

to sit for their board certification examinations, and after passing, 

take those skills to the private sector where they can manage— 

where they can make a fair wage in order to repay a student debt 

burden that often averages and exceeds $194,000. 

Specifically in 2016, only 30 percent of new hires were board certified. Until then—until we can offer better compensation, this has 

and will continue to trickle down to affect patient access, because 

skilled, board certified, experienced practitioners can manage larger patient populations more efficiently than inexperienced, younger 

professionals. 

To make matters even worse, in 2016, the VA’s average delay in 

hiring a podiatrist to fill a vacant position was 14 months. That 

means 14 months of patients having to seek care elsewhere or forego necessary foot and ankle care all together. 

Based on the salary.com data mentioned earlier, the takeaway 

message is that the VA’s top performing podiatrists, those making 

the highest possible salaries in the VA, are paid about 25 percent 

less than the median salaries of their non-VA counterparts, and in 

most cases, only about half of what the top non-VA performers 

earn. 

In hospital leadership positions, both in the public and private 

sectors, podiatrists have had the oversight of numerous surgical 

and medical subspecialties, utilizing an insight of core and fundamental medical and surgical principles. These principles, coupled 

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with consultation and input from the chiefs of the respective medical and surgical colleagues that they oversee, provide for an effective leadership model. 

Should a podiatrist be the chief of a subspecialty like neurosurgery or orthopedists, should—or orthopedics? The answer has to 

be, no more than a neurosurgeon or orthopedist should be the chief 

of podiatry. But that does not mean a podiatrist who is the overall 

chief of all the surgical subspecialties can’t work with and oversee 

and provide effective administrative leadership of those departments with collaborative input from the subspecialties with whom 

they work. 

In conclusion, Dr. Chairman, Ranking Member, and Members of 

the Committee, I thank you again for inviting me here to share my 

thoughts with you all and for your efforts and your desire to discuss this topic to hopefully right this inequity. I am available to address any questions you may have for me. 

[THE PREPARED STATEMENT OF STEVEN L. GOLDMAN APPEARS IN

THE APPENDIX]

Mr. WENSTRUP. Thank you, Dr. Goldman. 

Dr. Rubenstein, you are now recognized for 5 minutes. 

STATEMENT OF SETH RUBENSTEIN 

Dr. RUBENSTEIN. Chairman Wenstrup, Ranking Member 

Brownley, and Members of the Subcommittee, I welcome and appreciate the opportunity to testify before you today on behalf of the 

American Podiatric Medical Association. I commend the Subcommittee for its focus to assist and direct the Veterans Administration to effectively and efficiently recruit and retain qualified 

medical professionals to treat veteran patients and improve access 

to quality health care in the VA. 

I am Dr. Seth Rubenstein, member and trustee of the American 

Podiatric Medical Association. I am before you today representing 

the APMA, the podiatric medical profession, and specifically our 

members currently employed and those seeking to be employed by 

the VA. I do not represent the Veterans Administration in my capacity today, though I bring with me knowledge of widespread disparity between podiatric physicians and other VA physicians. 

Dr. Chairman, the VA’s qualification standards for podiatry were 

written and adopted in 1976. Podiatry starkly contrasted with 

other physician providers at the time and, for that matter, with 

what podiatry is today. Unlike 41 years ago, current podiatric medical school curriculum is vastly expanded in medicine, surgery, and 

patient experiences and encounters, including whole body history 

and physical exams. Back then, residencies were few and not required for licensure. Today, there are mandated standardized, comprehensive 3-year medicine and surgery residency positions of sufficient number to satisfy the full number of our graduates, with 63 

positions housed within the VA, each requiring completion of a 

broad curriculum comparable with medical and osteopathic residency training. 

Today’s podiatrists are appointed as medical staff at the vast majority of hospitals and they serve in leadership roles within those 

institutions, including but not limited to chief of staff and chief of 

surgery. Podiatric physicians also serve as members of their State 

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medical licensing board. Many of my colleagues have full admitting 

privileges and are responsible for emergency and trauma call. 

The competency, skill, and scope of today’s podiatric physicians 

has vastly improved since 1976. Because of this, CMS recognizes 

today’s podiatrists as physicians and TRICARE recognizes us as licensed independent practitioners. 

The veteran patients we treat, often plagued by socioeconomic 

and psychosocial issues, are ailing, have more comorbid disease 

and disproportionately poor health status compared with their nonveteran counterparts. Such patients suffer from a greater burden 

of diabetic foot ulcers, amputations, and associated complications. 

As documented in my written testimony, almost 2 million veterans 

are at risk of amputation secondary to diabetes, sensory neuropathy, and nonhealing foot ulcers. 

Dr. Chairman, the veteran population is far more complex to 

treat than patients in the private sector. One of the major missions 

of podiatrists as providers of lower extremity care is amputation 

prevention and limb salvage, which provides a cost savings to the 

VA and plays an integral role in a veteran’s quality of life. 

As part of an interdisciplinary team, podiatrists independently 

manage dermatologic, rheumatologic, and orthopedic pathology and 

trauma within our relative scope of practice. We assume the same 

clinical, surgical, and administrative responsibilities as any other 

unsupervised medical or surgical specialty. Despite this equality in 

work responsibility, there exists a marked disparity in the recognition and pay of podiatrists as physicians within the VA. 

The majority of new podiatrists recently hired within the VA 

have less than 10 years of experience and lack board certification. 

The majority of these individuals will separate from the VA within 

5 years. 

Seven years ago, APMA leadership made VA recruitment and retention a top priority. Since then, we have alerted the VA to our 

concerns, and in response, former Under Secretary Petzel created 

a working group, with whom we participated in several meetings 

and from whom we received support for a legislative solution to address this issue. 

I come before this Committee today to respectfully request that 

Congress help the VA and its patients by passing legislation to recognize podiatric physicians and surgeons as physicians in the physician and dentist authority. We believe that changing the law to 

recognize podiatry, both for the advancements we have made to our 

profession and for the continuing contributions we make in the delivery of lower extremity care for the veteran population, will resolve recruitment and retention problems for the VA and for veterans. 

Dr. Chairman and Members of the Subcommittee, thank you 

again for this opportunity. This concludes my testimony. I am 

available to answer your questions. 

[THE PREPARED STATEMENT OF SETH RUBENSTEIN APPEARS IN THE

APPENDIX]

Mr. WENSTRUP. Thank you, Doctor. 

Dr. Ficke, you are now recognized for 5 minutes. 

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STATEMENT OF COLONEL JAMES FICKE 

Dr. FICKE. Chairman Wenstrup, Ranking Member Brownley, and 

Members of the Subcommittee, on behalf of the American Association of Orthopaedic Surgeons, which represents over 18,000 board 

certified orthopedic surgeons, and the American Orthopaedic Foot 

and Ankle Society, which represents over 2,200 orthopedic surgeons specializing in foot and ankle disorders, I thank you for the 

opportunity to speak to you today about lower extremity care for 

veterans. 

My name is Colonel James Ficke, retired, and I am an orthopedic 

surgeon specializing in foot and ankle care. I am currently the 

chairman of orthopedic surgery at Johns Hopkins School of Medicine. I served in the United States Army for 30 years, deploying to 

Iraq from 2004 to 2005 as a deputy commander and chief medical 

officer for the 228th Combat Support Hospital in Mosul. I have led 

the Extremity War Injuries Project Team for 12 years, an effort focused upon improving care of warriors who have sustained battlefield injuries. This effort has identified the gaps in knowledge as 

well as research needs that have shaped the generous congressional funding of over $330 million for veterans with limb injuries 

commonly sustained in combat. 

There are many orthopedic surgeons serving the veterans proudly through the VA and many others caring for veterans through the 

Choice Program. Orthopedic surgeons play a role in saving limbs, 

reconstructing function, and returning veterans to a healthy, active 

lifestyle. The AAOS was honored to receive a Joint Warfighter Program award in collaboration with the Major Extremity Trauma Research Consortium, the purpose of which was to determine the best 

evidence for treatment of injuries to our warriors, including lower 

extremity injuries. We are honored to receive that support with 

your effort—through your effort, Dr. Chairman, and we appreciate 

your many years of support for orthopedics and our patients. 

We acknowledge the significant need for access and for care of 

veterans through the VA with lower extremity conditions. Current 

statistics are staggering regarding the burden of injury and the disability. My own teams have reported and published literature 

showing that up to 92 percent of warriors with battlefield injuries 

will have permanent disability of the musculoskeletal system. As of 

April 2017, 6,920 men and women have given their lives in the defense of our Constitution, and 52,540 men and women have sustained wounds in action, of which as many as 80 percent involved 

a limb injury, and many of these are lower extremity. 

We absolutely agree that musculoskeletal care for veterans is imperative. We will only meet these needs with a strong force of welltrained providers of all backgrounds, including podiatric surgeons 

and physicians and orthopedic surgeons. 

Concerning H.R. 1058, the VA Provider Equity Act, the orthopedic surgeons of the AAOS strongly agree and support that high 

quality podiatric surgeons should be more equitably compensated 

to support their recruitment and their retention. Podiatrists are an 

essential part of the care team at the VA and provide excellent 

service to veterans. During my service in the Army, I practiced 

alongside podiatrists in many military bases and had a podiatric 

surgeon on my staff at Mosul, who served in a nonclinical leaderleonard.horne on VACREP0180 with DISTILLER

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ship role, Lieutenant Colonel John Gouin, Doctor of Podiatric Medicine. 

The American Association of Orthopaedic Surgeons and the 

Orthopaedic Foot and Ankle Society are concerned with two aspects 

of the legislation that are not essential to the goal of paying podiatrists what they are worth at the VA. Firstly, this legislation would 

label podiatrists who have the Doctor of Podiatric Medicine, or 

DPM, within the VA as physicians, including them in a category 

currently reserved for doctors of medicine and doctors of osteopathy. Secondly, the bill would allow DPMs to attain clinical leadership positions over MDs and DOs. 

Podiatrists and orthopedic surgeons are trained differently. The 

lower extremity is one of the more complex areas of the human 

musculoskeletal system, and an orthopedic surgeon will attend 4 

years of medical school, serve a 5-year orthopedic surgery residency, and then typically take an additional year of subspecialty 

fellowship training. All MDs and DOs are trained in multisystem 

clinical care and disease management, which is not the case for all 

podiatrists, and it is a prerequisite for peer review of physicians. 

While recent changes have improved podiatric education, it is not 

the same as the multisystem medical education required to become 

a DO or an MD, nor is it the same accreditation process. Podiatry 

does not participate in the United States Medical Licensing Examination, which is the standard for all advanced medical care and 

essential to practice as a physician. We believe that the title of 

physician should be attained through the accreditation process and 

not the legislative process. 

The AAOS and the AOFAS stand ready to work with the Subcommittee in good faith to improve this legislation and to improve 

the care of veterans provided by both orthopedic surgeons and 

podiatric surgeons. 

Thank you for the opportunity to appear before the Subcommittee and for your work on behalf of our Nation’s veterans. I 

look forward to answering any questions you may have. 

[THE PREPARED STATEMENT OF JAMES FICKE APPEARS IN THE AP- PENDIX]

Mr. WENSTRUP. Thank you very much, Dr. Ficke. 

Mr. Brandt, you are now recognized for 5 minutes. 

STATEMENT OF JEFFREY M. BRANDT 

Mr. BRANDT. Chairman Wenstrup, Ranking Member Brownley, 

and Members of the Committee, thank you for inviting AOPA’s insights regarding lower extremity care for veterans. My name is Jeffrey Brandt, and I am the CEO of Ability Prosthetics and 

Orthotics. We work with seven VAMCs to provide prosthetic and 

orthotic services to veterans across VISNs 4, 5, and 6. 

Nationally, 80 to 90 percent of veterans’ orthotic and prosthetic 

care, known as O&P, is provided within the community. The private sector’s procurement relationship with the VA and its workforce must be a part of any discussion of care for veterans with 

limb impairment or loss. 

TBI and amputation are signature injuries of Iraq and Afghanistan. As of June 2015, more than 327,000 servicemembers had suffered a TBI, which can require orthotic management. More than 

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1,600 amputations had been performed for wounded warriors, with 

80 percent affecting one or both limbs. But most amputations are 

a result of diabetes or cardiovascular disease. In 2016, the VA 

served 89,921 veterans with amputations. Seventy-eight percent of 

veterans undergoing amputation last year were diabetic. 

AOPA commends the VA for its leadership granting access to advanced prosthetic technology, often before Medicare or private insurance. AOPA is also deeply grateful to the VA for rejecting a devastating prosthetics proposal put forward by the Centers for Medicare and Medicaid Services in 2015. 

When it comes to O&P care for individual veterans, in my experience, it is very uneven. Some VAMCs have excellent clinicians, embrace innovation, and maintain cordial working relationships with 

the private-sector providers providing the majority of care to veterans. In other places, VA staff appear not to be very knowledgeable about O&P. Some treat private providers as though we are 

competing for patients, or we are just in it to take advantage of the 

taxpayer. 

There are many advantages to veterans from the private-sector 

partnership in O&P. Veterans receive the care they need more 

quickly. Care can be provided closer to the veterans’ homes or 

workplaces. We often adopt cutting-edge practices and implement 

innovations earlier than our Federal agency colleagues. For example, at Ability, every new patient receives three objective evaluations to establish their K-level, or capacity for activity, and determine what technology is appropriate given that classification. But 

the VA very often does not use such tests or even a consistent approach in determining those K-levels. 

Frequently, the VA won’t accept our evaluation, even if we have 

more O&P expertise and are using a more rigorous evaluation. If 

we call or write the VA to say our evaluation shows that the patient is, for example, a K2 and wouldn’t benefit from microprocessor control technology, we often hear comments like, ‘‘to be 

on the safe side, all my patients get that technology.’’ 

Conversely, when our evaluation shows the veteran needs more 

advanced technology than the VA perhaps recommended, we find 

ourselves accused of lining our own pockets. At that point, I have 

a choice: I can continue to advocate for my patient at the expense 

of my relationship with the VA, or I can fill a prescription my assessment tells me is not best for my patient. If the veteran comes 

back 10 times in the next 6 weeks because the prosthesis wasn’t 

fit properly, then the veteran hasn’t been served, and our reputation is damaged. 

All of this could be averted by use of proper clinical protocols by 

the VA, and better collaboration with outside providers. 

Sometimes patients come to us having heard about new technology. It is hard to tell a patient he or she doesn’t need the device 

that was featured on a magazine cover. Our tests and data help patients understand and accept those difficult determinations. The 

VA, with its concerns of fraud and abuse, should welcome an approach that objectively determines patients’ needs. 

I do see some things changing, though slowly, in some parts of 

the VA. Some recent RFPs have more emphasis on outcomes, data, 

leonard.horne on VACREP0180 with DISTILLER

11 

and objective evaluations. But that change is uneven and slow, and 

it is the veterans who suffer the most with those delays. 

Now I would like to turn to a challenge facing both the VA and 

private-sector providers, and that is maintaining a highly qualified 

workforce. Demand for O&P is increasing, experienced clinicians 

are retiring, and we have got a shortage. Already in California and 

Florida, an advertised opening can take longer than 12 months to 

fill. Currently, 13 universities offer O&P master’s degrees, graduating fewer than 250 students annually. These positions pay good 

wages and can’t be outsourced overseas, but master’s programs are 

costly to expand. 

The Wounded Warrior Workforce Enhancement Act, introduced 

with bipartisan support by Representative Cartwright in the last 

Congress would help. This bill is a limited, cost-effective approach 

to assisting universities in creating or expanding accredited O&P 

master’s degree programs. Priority is given to the programs that 

have a partnership with the VA or DoD facilities, so students learn 

to respond to the unique needs of servicemembers and veterans. 

We need this bill, and I ask for your support. 

AOPA looks forward to working with you to meet the needs of 

veterans with limb loss and limb impairment. No veteran should 

suffer from decreased mobility or independence because of lack of 

access to high quality care, regardless of where it is provided. 

Thank you for considering my comments today. I would be happy 

to answer any of your questions. 

[THE PREPARED STATEMENT OF JEFFREY BRANDT APPEARS IN THE

APPENDIX]

Mr. WENSTRUP. Thank you, Mr. Brandt. 

Dr. Robbins, you are now recognized for 5 minutes. 

STATEMENT OF JEFFREY ROBBINS 

Dr. ROBBINS. Thank you. 

Good afternoon, Chairman Wenstrup, Ranking Member 

Brownley, and Members of the Subcommittee. My name is Jeffrey 

M. Robbins, and I am the national program director for podiatry 

services for the VA’s central office. Thank you for the opportunity 

to discuss lower extremity injuries and conditions among veteran 

patients and the ability of VA to recruit and retain high quality 

providers. 

The VA’s podiatry service is dedicated to the mission of providing 

high quality foot and ankle health care to veterans. In fiscal year 

2016, the podiatry service cared for some 577,000 unique patients 

in over 1.4 million encounters. This is a 12 percent increase over 

fiscal year 2014. 

Podiatrists treat a wide variety of conditions, including major 

foot deformities from both battle and other service-related injuries, 

to wound and amputation care for those with traumatic and chronic disease-related amputations. Podiatry service performed almost 

16,000 operating room procedures in fiscal year 2016 alone. 

In addition to my role as national program director for podiatry 

services, I am also the national chairman for the VA’s Amputation 

Prevention Program, currently called Prevention of Amputation in 

Veterans Everywhere, or PAVE. 

leonard.horne on VACREP0180 with DISTILLER

12 

The VA has been engaged in amputation prevention since 1993, 

after Public Law 102-405 in 1992 established the importance of 

high quality amputee, and identified veterans with amputations as 

a special disability group. 

In 2006, the VA Oversight Committee recognized that we needed 

to address new traumatic amputees from Operation Iraqi Freedom 

and Operation Enduring Freedom. In order to determine those 

needs and write effective policy, I have visited Walter Reed to 

speak with veteran amputees, their families, and their caregivers. 

As a result of those conversations, the 2006 directive on this matter 

added a mandatory offer of a mental health consultation to any 

veteran who had or was about to undergo an amputation. This consultation was aimed to address the adjustment disorder common in 

those who have lost a limb, regardless of cause. 

In 2012, the VA’s Amputation Prevention Program was identified 

as an innovation by the Amputation Coalition of America, not only 

for its evidence-based program, but also for its continuous quality 

improvement. In fact, the latest directive was signed on March 17, 

2017. 

The VA cares for 1.7 million veterans at risk for amputation, of 

which 1.5 million suffer from diabetes, 46,000 suffer from end-stage 

renal disease, and 617,000 have peripheral vascular disease. Overall, the VA treats over 66,000 patients yearly who have suffered an 

amputation, with more than 6,000 veterans having undergone an 

amputation in fiscal year 2016. 

Podiatry services are provided in 134 medical centers and many 

VA community-based outpatient clinics, and VA podiatry is an extremely hardworking service. However, our compensation system 

has fallen behind the times, as the current pay authority is over 

41 years old and was established when podiatric medicine was a 

very different profession. As a result, it has been increasingly difficult in the past several years to recruit and retain experienced 

providers. 

To illustrate this point, in fiscal year 2015 and 2016, we brought 

in 142 new hires, for a net gain of 54. What this means is that 88 

providers left the system, or almost 62 percent of medical centers 

had to replace providers, disrupting patient continuity. Additionally, in 2016 alone, the national podiatry standards review board 

processed 53 new hires. Of those 53 new hires, 66 percent had less 

than 10 years of experience and only 30 percent were board certified. 

The pattern that has emerged that in the past several years is 

one of young providers coming into the system, gaining experience, 

as well as their cases for board certification, becoming board certified, and then leaving for the private sector, where the average 

compensation, the average compensation is $30,000 higher than 

the highest compensation in the VA. In fact, 58 percent of our pay 

regions have reached the legislative cap established in 1976, making it extremely difficult to recruit and retain staff. 

The podiatrists that make up the VA’s podiatry services are all 

proud to provide the best care they can to Americans’ veterans. We 

are also proud that this includes many veterans within our ranks. 

As a service, we are dedicated to continuous improvement and continue to look for ways to improve how we care for veterans. As 

leonard.horne on VACREP0180 with DISTILLER

13 

such, the Department of Veterans Affairs supports H.R. 1058, the 

VA Provider Equity Act. 

Thank you for this opportunity to address this Committee, and 

I look forward to your questions. 

Mr. WENSTRUP. Thank you, Dr. Robbins. 

I thank all of you. I am going to now yield myself time for questions and comment. 

First of all, Mr. Brandt, I want to thank you very much for your 

testimony today, and I look forward to working with you and your 

profession on how we can increase capabilities and fulfill the needs 

of so many of our veterans. And those numbers, as you know, are 

growing and the need for your profession is greatly needed. 

On the podiatry issue, it first came to my attention, not really 

because I am a podiatrist, but because I serve on this Committee, 

and it was brought to our attention by Secretary McDonald during 

the last term that there was a tremendous shortage of podiatry, 

there was a reason for the shortage, and the need was tremendous. 

And at that time, the Secretary and his staff put together a paper 

on the idea of being able to fix this problem by moving podiatric 

physicians and surgeons into the category of physicians and surgeons, which they are under Medicare and throughout the States. 

And that would solve the problem, increase the pay, and the problem would be solved. We ran into some roadblocks in the Senate, 

as we did get a bill to do that through the House of Representatives. 

You know, first of all, I want to say that this is not about the 

provider as much as it is about the patient. This is about the veteran in need of care. And you are going to hear of situations and 

the long waits, and you have heard about it today, for so many that 

seek the expertise of podiatry. And this is about recruitment, retention, and, therefore, access for our veteran patients. 

We say, do no harm. Right now, those that are being harmed are 

our veterans that do not have access to podiatric care because of 

the inability of the VA to recruit and retain in the way that they 

could if this problem was corrected. So I thank the Secretary and 

the current Secretary for their VA paper, which is now in the 

record. 

I want to be clear. This is not a scope of practice issue. This is 

not about expanding the realm of credentialing that a podiatrist 

has or has had. It is about access, access that is stymied by a classification, by a limited career path for podiatrists, and opposition 

that has come against the notion of moving podiatrists into the category of physicians and surgeons. 

We talk about education. Podiatry is a medical school curriculum, 4 years after 4 years of college. During that medical school 

curriculum, there are 2 years of lower extremity biomechanics that 

is unique to the profession. There is a 3-year surgical residency. 

When completed, podiatrists have a full prescribing license, and 

they are licensed to do complete body history and physical examinations. Now, that isn’t because it was just granted; it is because 

it is part of the training. 

Just for some comparison, because I am listening to some of the 

things that were said, so I have a question for Dr. Ficke. You have, 

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14 

within the American Academy of Orthopaedic Surgeons, a foot and 

ankle society. Is that correct? 

Dr. FICKE. Yes, there is a foot and ankle society. 

Mr. WENSTRUP. And you are a member of that? 

Dr. FICKE. That is correct. 

Mr. WENSTRUP. Okay. Is there a board that you need to take to 

become a member, like there is for hand, say, within orthopedic 

surgery? 

Dr. FICKE. There is a board of orthopedic surgery, and I sit on 

that board. I write questions for that board as a foot and ankle surgeon. 

When one is in the process for which you are asking, the person 

is eligible at the completion of 5 years of orthopedic surgery residency. They sit for a written examination. I am one of the question 

writing task force for the written questions. After 2 years of case 

collections, those cases are collected and submitted. Those cases are 

peer reviewed. When a person is, as a specialty of foot and ankle, 

like hand, they sit for their ABOS, the American Board of 

Orthopaedic Surgeons, on a panel of fellowship-trained, board certified orthopedic foot and ankle surgeons, at the end of 2 years of 

collection. When they are—they succeed in the oral boards, which 

is, again, 2 years after a 5-year residency, they are qualified as 

American Board of Orthopaedic Surgeons. There is not a certificate 

of additional qualification for foot and ankle surgeons. 

Mr. WENSTRUP. So when you—do you need—there are 1-year fellowships after the 5-year residency in foot and ankle that are available? 

Dr. FICKE. That is correct. 

Mr. WENSTRUP. Does everyone in the society, are they required 

to complete that fellowship? 

Dr. FICKE. Everyone in the—which society? The Foot— 

Mr. WENSTRUP. The foot and ankle. 

Dr. FICKE [continued].—and Ankle Society? No. The Foot and 

Ankle Society is, by its constitution, embraced for anyone who has 

a practice or has an interest in foot and ankle surgery after they 

have completed— 

Mr. WENSTRUP. But not specifically the fellowship— 

Dr. FICKE [continued].—a foot and ankle— 

Mr. WENSTRUP [continued].—like you have completed and— 

Dr. FICKE [continued]. That is not a requirement for the Foot and 

Ankle Society. 

Mr. WENSTRUP. Okay. And I hope things have changed, because 

I am looking at a study—you are familiar with Foot and Ankle 

International? Is that an orthopedic journal? 

Now, this is a while ago, so maybe things have changed. And 

your process for foot and ankle sounds like it is up to the same 

measure that exists for podiatry, as far as oral exam, written exam, 

and case presentation. But this abstract from this article, ‘‘Foot 

and ankle experience in orthopedic residency,’’ says: Current residency training in the United States does not universally require 

commitment to foot and ankle education. A large number of residency programs do not have a faculty member committed to foot 

and ankle education, and almost one-third have no time specifically 

allocated to foot and ankle education. 

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15 

Has that changed in orthopedic residencies? 

Dr. FICKE. Dr. Chairman, could you tell me the date of that publication? 

Mr. WENSTRUP. Yeah. It was a while ago. It was 2003. 

Dr. FICKE. 2003? Yes, I am familiar with that study. 

As a result of the 2003 paper, which is, you know, 14 years ago, 

there has been a radical change in education. The Foot and Ankle 

Society as an organization has put out a series of lectures, has— 

and, really, everyone who is board certified in orthopedic surgery 

is required to do a series of milestones, and the milestones project 

is accredited—the ACGME, the American Council on Graduate 

Medical Education, is really the entity that reviews the milestones. 

And the milestones, including foot and ankle surgery, require a rotation, require a certain number of minimums. 

Mr. WENSTRUP. So since that time— 

Dr. FICKE. Radically changed, similar to the podiatry residency 

that we all agree have changed. 

Mr. WENSTRUP. Requirements. 

Okay. One of the things that—I guess for Dr. Goldman, and I 

want to know if you agree with this statement or not from Dr. 

Ficke, it says: MDs or DOs participate in active clinical care and 

multisystem trauma and disease management, which is not the 

case for all podiatrists, and is a prerequisite for peer review oversight. 

Would you agree that is not the case for all podiatrists today? 

Dr. GOLDMAN. If you could repeat the question, sir. I am sorry. 

Mr. WENSTRUP. Yeah. Well, the comment was that—do podiatrists basically actively participate in multisystem trauma and disease management in their training? 

Dr. GOLDMAN. I would say we do, along with our medical colleagues. Certainly, we have scopes of practice that we all work 

within, and with that, certainly there is a collaborative effort with 

any system condition that we may experience, whether it be infectious disease, primary care, internal medicine, vascular surgery, 

that we will collaborate that effort. 

Mr. WENSTRUP. And participate actively in the care of that patient— 

Dr. GOLDMAN. Yes, sir. 

Mr. WENSTRUP [continued].—correct, especially in residency 

training? 

Dr. Ficke, you had a concern, I believe, when we talked before 

and today about the administration roles of podiatrists. And I think 

your concern predominantly was clinical oversight, podiatrists over 

orthopedists or, for that matter, any other specialty. 

Dr. Robbins, could you clarify for me, can a podiatrist have clinical oversight over an orthopedic surgeon in the VA? 

Dr. ROBBINS. No, not clinical oversight. That is actually a joint 

commission requirement that peers evaluate peers. So, for example, 

if a urologist was a chief of surgery, they couldn’t do an ongoing 

professional practice evaluation on an orthopedist, or a psychiatrist 

couldn’t do it, and so on. That has to be peer to peer. 

Mr. WENSTRUP. And that makes sense to me. You know, you 

should be able to be within your own section. So as far as that concern, it sounds like you can’t do it anyway, so hopefully that is 

leonard.horne on VACREP0180 with DISTILLER

16 

clarified. And I would agree with that 100 percent with you, Dr. 

Ficke. 

I want to applaud you for your 30 years, I believe, of military 

service, your deployments, and all that you have done for our 

troops. And I have enjoyed working with you on many issues and 

hope to continue to do that. We may have a little disagreement 

here on some things today, but I do extend that and truly mean 

that. 

One of the things—you talked about your roles in theater as deputy commander. I also served as a deputy commander of clinical 

services. I was the assistant to the DCCS, but for 3 months, I was 

the DCCS, and served at the same time as chief of surgery in that 

role, and things went well. And I think it is a small world story 

to be able to say that I was appointed to those positions by your 

medical school roommate, Jim Terrio. 

So I just wanted to clear some things up. And I want to give 

other people a chance to ask their questions. And with that, Ms. 

Brownley, you are now recognized. 

Ms. BROWNLEY. Thank you, Mr. Chairman. And I would agree 

with all of your arguments around the need for more services to 

our veterans. The only thing I would take objection to is when the 

problem arise that you weren’t sought out because you were a podiatrist but because you were a Member of the Committee. I think 

it has to be both. 

Mr. WENSTRUP. Well— 

Ms. BROWNLEY [continued]. Anyway, I wanted to ask Dr. Robbins, you gave some statistics about the rise of podiatric need within the VA. Can you just give me a quick explanation why that increase has occurred? It is pretty significant. 

Dr. ROBBINS. It is quite significant, and partially due to returning vets from the three theaters now, Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn, with new 

problems, these are young people, very complex problems, they 

want to stay active, and they require, especially if they have lower 

extremity injuries, they require good podiatric biomechanical care. 

We also have a significant aging population that are coming to 

us with diabetes, end-stage renal disease, peripheral vascular disease, that are at extremely high risk for an amputation. 

The VA also takes a much more enlightened approach about 

what kind of basic foot care we provide. So veterans who are blind 

can’t get podiatric care in the private sector, patients who have dementia cannot get podiatric services in the private sector, patients 

who have movement disorders, like Parkinson’s, anticoagulation 

therapy, severe debilitating arthritis. 

We expanded that scope of eligibility for veterans back in 2002 

as we saw that, especially with the aging population coming down 

the pike, that they were also at risk for amputation, and, more importantly, for quality of life. When you lose the ability to walk, your 

life expectancy goes down significantly. So we expanded that, and 

that is the reason that we are seeing increasing numbers of veterans seeking podiatric care. 

Ms. BROWNLEY. Thank you very much. And in terms of the salary schedules within the VA, it is my understanding that they have 

been in effect since 1976. Is that correct? 

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17 

Dr. ROBBINS. Yes, ma’am. 

Ms. BROWNLEY. And as someone responsible for these services to 

veterans, why is it that this hasn’t been revisited in terms of salary 

schedules? 

Dr. ROBBINS. I have actually revisited for the last 11 years writing legislative proposals to move podiatry into the same pay authority as other physicians and dentists. What has occurred is that 

we have gotten full support through VHA, but when it got up to 

VA and OMB, because it had a price tag on it of any sort, it was 

kicked back. 

In addition to that, the OMB looked at it and said, well, it looks 

like you can hire new podiatrists. We don’t really care about their 

experience. It appears you can hire podiatrists. So that also when— 

I made the argument that we can’t hire highly experienced providers, that we were getting inexperienced providers or older providers without board certification, that sort of fell on deaf ears, and 

here we are 11 years later. 

Ms. BROWNLEY. Thank you for that. It seems like it has been an 

ongoing issue. 

So, Dr. Ficke, if you could talk a little bit about—I think you 

mentioned it in your testimony, but—and I only have a minute left, 

but if you could talk a little bit about, going back to the accreditation requirements and, you know, comparing the two, but could you 

kind of explain the barriers, from your vantage point, barriers a podiatrist may have in providing administrative oversight and leadership as a medical director? 

Dr. FICKE. Yes, ma’am. I am seeing 30 seconds to try to answer 

this. We will do our best. 

The question, first of all— 

Ms. BROWNLEY. The Chairman is giving us a little more time. 

Mr. WENSTRUP. You can have more time. 

Dr. FICKE. Thank you, Dr. Chairman. 

And to attribute this, Dr. Chairman mentioned that he served as 

the assistant deputy commander for clinical services. And I will attest that at that time, Lieutenant Colonel and now Colonel—congratulations, sir—Wenstrup did a fantastic job, and by our mutual 

friendship with Jim Terrio, who was the deputy commander, said 

he was exceptional. 

There is no question that leadership is a character quality. Congressman Wenstrup demonstrates that, we all would agree. Leadership as a character quality has nothing to do with orthopedic surgeons, podiatric surgeons, or any other training. It is a character 

quality, bar none. 

So that the obstacles to these really have to do with administrative leadership, which is, as I have said—and we all agree, chief 

of staff, commander of a hospital, president of a hospital, those are 

roles that offer leadership enticement. And we completely agree 

that those are roles that if they provide incentives that are nonmonetary but job satisfaction for any provider, especially in this 

situation, podiatric surgeons, who we need in the VA, we completely endorse that. I hope that answers your question. 

Ms. BROWNLEY. It does. Thank you. 

And I yield back. 

Mr. WENSTRUP. Dr. Dunn, you are now recognized for 5 minutes. 

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18 

Mr. DUNN. Thank you, Mr. Chairman. And thank you also to the 

members of our expert panel here for devoting your time and your 

expertise to our veterans. 

Colonel Ficke, I am impressed by the vast—I too am impressed 

by the vast body of your military service and accomplishments. I 

served in the U.S. Army Medical Corps the same time as you did. 

I am sure I—we didn’t—I don’t recall crossing paths with you, but 

it is a big army. I think it would be fun for us to get together sometime and swap social stories. 

I want to ask you a couple of questions, and please don’t take 

any umbrage if it appears that I am disagreeing with your conclusions. I am just trying to understand how you arrived at those conclusions and how important you think your conclusions are to the 

questions that we are addressing here today. 

So the first one was, you evinced a concern that the term ‘‘physician’’ would be used to refer to podiatrists. I have been a civilian 

for over the last 20 years, and in the civilian world, the term ‘‘physician’’ has long since left the barn. It has migrated to a wide variety of health care practitioners. As a matter of law in Florida, 

chiropractors can use the term ‘‘acupuncturists.’’ 

So I wonder how important is it to our veterans, our patients, the 

ones that we treat in the VA that we continue to hue to the classic 

use of the term ‘‘physician’’ only to refer to MDs and DOs? And I 

will wait for your answer on that. 

Dr. FICKE. Thank you for your question. I certainly take no umbrage, Mr. Congressman. 

The statement that I made was that the definition by Merriam’s 

dictionary and several other organizations for ‘‘physician’’ is that 

they have passed the U.S. Medical Licensing Examination. There 

are many doctors, there are doctors of chiropracty, there are doctors of physical therapy. That is by no implication lesser or more, 

superior or inferior. It is a definition. 

I don’t think that—and so I would—you asked how important 

that is. I think it is the least important aspect of this testimony 

or this bill. 

The American Academy of Orthopaedic Surgeons, the Foot and 

Ankle Society, both agree that the VA desperately needs foot and 

ankle care. So we have more in common, I believe, than we do differences. 

Let me ask—let me make one clear point. The difference is there 

are six core competencies recognized by the double AMC, the American Association of Medical Colleges. Those six core competencies, 

one critical of those is systems-based practice. That creates the 

education, the basis for care of all systems. 

We are not trying to make something of this that it isn’t. That 

is not one of the core competencies of the APMA or the podiatric 

education process. They have six core competencies, but they don’t 

have systems-based practices. I don’t—I really— 

Mr. DUNN. So the actual term ‘‘physician’’ isn’t— 

Dr. FICKE [continued]. I think the most important aspect of this 

is that we are—that our public and our veterans need to understand that there are differences in training, make the decision. 

Mr. DUNN. All right. Let me go to the second question, then, also 

for you, Dr. Ficke. So you have evinced a concern about, and we 

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19 

have began to address this, right, just before, a podiatrist’s clinical 

leadership. And certainly in academia, such as Johns Hopkins, it 

would be unheard of to have a podiatrist be the chief of orthopedics. But in the military, when I was a surgeon, I had commanding officers and leaders in the hospital who were medical 

service corps officers, there was hospital administrators for the 

nonmilitary, and nurses and whatever, and I never felt that that 

was a problem for me or my patients in terms of how we applied 

our clinical judgment or our surgical practices. 

And I think that you mentioned, Dr. Robbins, that in the VA, the 

rough—you know, we wouldn’t have a urologist overseeing an orthopedic surgeon, even though that sounds pretty good to me as a 

urologist, but anyway. 

So what was your concern about the clinical leadership as it 

were? So is it okay to have a chief of surgery in a VA hospital who 

is not an MD or a DO? 

Dr. FICKE. Yeah. So—yes, sir. I had addressed that concern as 

far as the leadership opportunities. We agree completely. There 

was a point in my career not far—long ago that I had no single 

physician in supervisory roles over myself. 

Mr. DUNN. I am running out of time, so just let me say, Colonel, 

thank you very much again for being here, and thank you for the 

time you devote to our veterans. And I would seriously enjoy a 

chance to spend time with you in a smaller group and exchange 

ideas. 

I yield back, Mr. Chairman. Thank you. 

Mr. WENSTRUP. Ms. Kuster, you are now recognized for 5 minutes. 

Ms. KUSTER. Thank you, Mr. Chairman. 

I wanted to direct my questions to Dr. Robbins. Moving on from 

the credentialing issue, we have had a great deal of discussion, 

most recently, with regard to the Washington, D.C., VA, but I know 

this has been an issue all around the system about the delays for 

veterans needing prosthetics. We had a conversation just this week 

with our colleague, Tammy Duckworth, in the Senate about her 

own experience after her injuries and getting prosthetics and prosthetics that fit and prosthetics that worked and the delays. 

So could you comment about describing our national procedures 

currently and what we could be doing to make sure that our veterans who are in need of prosthetics can get those devices in a 

timely way, that they fit well, that they are effective for their quality of life, any other suggestions that we should be focused on in 

this regard? 

Dr. ROBBINS. Well, I can’t answer the question from the prosthetics side since I am not a prosthetist or have any authority over 

prosthetics. I can address it from the provider side. 

Ms. KUSTER. Okay. 

Dr. ROBBINS. So we will oftentimes need to work with prosthetics 

to provide a shoe with a special insert for a partial amputation in 

order to have that veteran ambulate properly. And so we will work 

very, very closely with prosthetics to provide that care. 

The variation in the prosthetic departments throughout the VA 

is quite significant. So we have some services that are outstanding, 

some prosthetic services, that work with podiatry get what they 

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need when they need it; others that don’t have the same resources 

in order to provide that care. 

And this is not something that is not something that we are 

aware of. This is something that we work on year after year to improve the work with the prosthetics folks. But, again, I don’t run 

prosthetics, so I can’t respond specifically to that portion of your 

question. 

Ms. KUSTER. Who at the VHA would be in charge of that? Is that 

the Chief Logistics Officer? Or who works with the prosthetic companies to make sure that—I am not so concerned about the companies; I want to know at the VA—to make sure that these devices 

are available for your patients? 

Dr. ROBBINS. We have a department of prosthetics and rehabilitative care services. 

Ms. KUSTER. And do you have any suggestions for us about improvements to that department? 

Dr. ROBBINS. If they are asking for more resources, they can absolutely use resources. Because, as we just heard, the VA is also 

having some issues getting well-qualified folks in prosthetics and 

orthotics that have the kinds of credentials that we now expect 

from those folks, and getting those people into the VA in order to 

provide that care. 

And also—and I think that the new Choice bill addresses some 

of this, if I am not mistaken, from my brief review of that—it also 

strengthens that relationship between the private sector, so that if 

we can’t do it, we should be able to outsource it to someone who 

can in time. Just-in-time care. 

Ms. KUSTER. Anybody else on the panel? 

And adding that dimension to it, should we be going the private 

route with prosthetics? Do you think we have the expertise inhouse? Can we get it? What recommendations do you have for your 

patients to get the prosthetics that they need for their quality of 

life in a timely way? 

Mr. BRANDT. Yes. Thank you. 

So, as I testified, 90 percent of prosthetics are provided from private providers outside of the VA. If there is an initiative to decrease that, then, you know, the VA would have to look at how are 

they going to increase the qualified providers on staff. And then 

you have a similar type conversation in the O&P realm that we are 

having about podiatry; how are you going to attract, retain highly 

qualified CPOs, or certified prosthetists/orthotists, within the VA 

system. 

If the VA believes that it still wishes to have 90 percent of that 

service provided through private contractors or outside contractors, 

then, at least through my own experience, where I start to see 

some of those gaps is the facilitation of those cases as a need is determined by the VA and a veteran chooses a provider. 

My recommendation for veterans to get quality care is largely related to the clinical protocol or the outcomes measures, those aspects of the care that is being provided. Our field, too, has sanctified over the years our educational requirements as prosthetists/ 

orthotists, we are now master’s-degree-holding practitioners with 1 

year of residency in each, orthotics and prosthetics, and pass board 

exams. 

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21 

We are also seeing—with the advent of the quicker movement of 

technology, we are seeing patients that want to come out of the VA, 

to a private facility. Most of our private practitioners at this point 

have biomedical engineering backgrounds. And we have to interface with the VA system, where qualifications, skill levels, protocols 

are a bit hit or miss. Patient evaluations may be a bit more anecdotal. That VA determination can, many times, come down to prior 

experience or what has worked in the past, not objective tests and 

assessments. 

We are sitting in the private sector with protocols, saying, all we 

need to do is follow these. It is not the be-all and end-all of quality 

care, but it is a start. Because all of us, whether private sector or 

VA, we all should be looking at evidence-based outcomes and supporting why we do what we do. 

Ms. KUSTER. Thank you very much. 

Mr. WENSTRUP. Mr. Higgins, you are now recognized for 5 minutes. 

Mr. HIGGINS. Thank you, Mr. Chairman. 

Dr. Goldman, from your posture as president of your board, is a 

podiatrist capable of making an accurate diagnosis of diabetes 

based on if it is an initial examination where a veteran has been 

sent to that? 

Dr. GOLDMAN. Certainly, using the entire scope of what is available to us as laboratory data, clinical evaluation, we can certainly 

make that diagnosis. I mean, it is, unfortunately, too easy to diagnose, as we can all speak to. 

Mr. HIGGINS. All right. I ask that because, in speaking with veterans—and I represent a district with one of the highest densities 

of veteran populations anywhere, certainly in my State. I represent 

133,000 veterans, and some of them, that their initial symptoms 

that they noticed were foot pain and problems with their feet. And 

that led them eventually to a diagnosis of diabetes. 

So nontreatment of diabetes leads to cholesterol and blood pressure problems, loss of vision or vision impairment. It doubles the 

risk of heart attack, kidney failure, neurological complications, and 

leads me to my next question, which will be for Mr. Brandt. Failure 

to treat diabetes also can lead to loss of lower limbs and amputations. People with diabetes have undergone 73,000 lower-limb amputations, on average, each year, or roughly 60 percent of total amputations. 

And you stated, Dr. Brandt—we have just heard Dr. Goldman 

say that a podiatrist, a modern podiatrist, can make an accurate 

diagnosis of diabetes. If you disagree with that, please tell me. 

But, in your written statement, you stated that ‘‘the VA staff 

making decisions, in some cases, affecting lower-extremity care appear not to be particularly knowledgeable about prosthetics and 

orthotics. Some VA prosthetic and orthotic clinicians welcome the 

partnership with private providers, while other VA staff seem to 

believe that some private-sector providers are in competition with 

them for patients.’’ 

So my question, Dr. Brandt, is: How would you suggest the VA 

improve coordination and communication with community prosthetic and orthotic providers? And what are the costs to veteran patients if effective coordination and communication is not in place? 

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22 

Mr. BRANDT. Thank you for your question. And to clarify for the 

record, I am not a doctor. I am just, for the record, Mr. Brandt. 

Thank you for that— 

Mr. HIGGINS. Did I call you ‘‘Dr. Brandt’’? 

Mr. BRANDT. You did. 

Mr. HIGGINS. Well, congratulations. You have been promoted. 

Mr. BRANDT. So, number one, the first part of your question—I 

am sorry. 

Mr. HIGGINS. I am asking regarding the coordination with private— 

Mr. BRANDT. Right. So— 

Mr. HIGGINS [continued]. Regarding prosthetics and orthotics. 

Mr. BRANDT. I am sure the association could put a detailed position forward on what could be done in the VA to facilitate more collaboration and coordination of care. 

As for me, my personal experience, that is a big topic. It ranges 

from the qualifications of those certified prosthetists/orthotists or 

their credentials, to continuing education, to— 

Mr. HIGGINS. But you believe your organization could provide for 

this Committee a specific recommendation regarding that? 

Mr. BRANDT. Correct. 

Mr. HIGGINS. Could you get that to us down the line? I have one 

more question for you. 

Mr. BRANDT. Yes, I can. Thank you. 

Mr. HIGGINS. Okay. 

Your testimony indicates that, in an effort to reduce costs and 

eliminate fraud and abuse, the VA dismisses clinical recommendations made by community partners. However, you also state, ‘‘The 

VA often will make unnecessary purchases for prosthetics which 

wouldn’t benefit the patient.’’ 

Could you speak more on that a little bit for us, please? 

Mr. BRANDT. Right. I think the easiest way to describe it is we 

see instances of overprescription and underprescription. Correcting 

this fits very nicely into outcomes measures, or attempting to baseline patients. There are ways to score patients regarding their 

functional levels, and then you can track that through the treatment of a veteran with limb loss, or any patient with limb loss. So, 

once you apply those measures, it is not a silver bullet, so to speak, 

but it can contribute to your overall determination of matching 

componentry to functional level. 

So there are methods—and this is a big topic in our profession 

right now, which is advancing outcomes measures so that we can 

qualify and quantify why we are doing what we are doing. And it 

is not just based on things that we can’t base decisions on that we 

might have in the past. 

Mr. HIGGINS. Yes, sir. Thank you. 

And I will ask, if possible, regarding both of my questions, that 

your organization perhaps provide to this Committee within a reasonable timeframe some specific recommendations that we may 

perhaps move forward to address both of these concerns. 

Thank you, Mr. Chairman. I yield back. 

Mr. WENSTRUP. Dr. Abraham, you are now recognized. 

Mr. ABRAHAM. Thank you, Mr. Chairman. 

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23 

For the panel, I am an M.D. by training. I graduated from the 

LSU School of Medicine in Shreveport. I have been very fortunate 

to practice medicine, family medicine, in the Louisiana and Mississippi Delta, treating thousands of veterans and certainly tens of 

thousands of civilian patients. 

And when I need a higher level of care, certainly in the lower extremity, I don’t look at the initials after the name; I look at the 

name before the initials. 

And, Dr. Ficke, you alluded to that when you referenced character. And whether you are an M.D., a medical doctor, a D.O., a 

doctor of osteopathic medicine, or a DPM, a doctor of podiatric medicine, the patients and the veterans—to your statement earlier, Dr. 

Ficke, about educating that veteran as to the different standards, 

the different educational training of those three different specialties—the veterans and the VA, they know, but, again, the initials 

don’t mean anything to them. These are all physicians in their 

mind and certainly in the mind of myself. Again, they want to be 

healed, and the definition of ‘‘physician’’ is one of a healer. 

We all, when we—and Dr. Wenstrup alluded to this—when we 

applied to our respective medical schools, whether it was M.D., 

D.O., DPM, we had to write out an essay, and if we were fortunate 

enough to get past the essay part, we got before an admission 

board. And the question was always: Why do you wish to become 

a physician? And I assure you, for every one of us in here that are 

physicians, the answer was: to take care of patients. That is what 

we do, as physicians. 

So I think it is tragic that we are arguing over semantics for our 

veterans when we have such a disparity of economy in the VA system between what podiatrists and other physicians get paid. 

Dr. Ficke, Dr. Wenstrup, you guys practiced your profession in 

what I imagine is the most trying conditions, where artillery shells 

were literally going off around you. In some cases, you were probably dodging bullets. But you did your job, and you saved lives, and 

you saved limbs. 

We heard today where podiatrists, D.O.s, M.D.s, we can all do 

physical exams. We all understand, certainly you guys, your specialties, in your specialties, you know bones, ligaments, tendons, 

nerves, blood vessels, and how they all are interrelated through the 

whole body. 

So, you know, I think it is unfortunate and, in fact, silly that we 

are arguing over this definition of ‘‘physician’’ between these three 

specialty groups of providers here. Whether it is a DPM, a D.O., 

or an M.D., we are all physicians. And the only thing that should 

matter here, especially for our veterans since 9/11—you guys have 

been under the most trying conditions, hundreds of thousands of 

patients, unfortunately hundreds of thousands of new veterans 

feeding into the VA system because of these ongoing wars that we 

have continuously. I think we actually need to come together instead of trying to fight each other here. 

And I understand, Dr. Ficke, that the USMLE doesn’t recognize 

their board, but they have their board, and I am sure it is as good 

as the USMLE board that you took. 

You know, I think we are better than this. I think we need to— 

I think we forget that, as physicians, our job, but not only that, our 

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24 

passion is to do thing in this world, take care of the patient, and 

that is our priority. 

So, semantics aside, you know, let’s get this behind us. Let’s get 

the podiatric profession and the VA up on the salary schedule, up 

on the respect schedule, and let’s take care of these veterans. 

And I appreciate it, Mr. Chairman. That is all I wanted to say. 

Mr. WENSTRUP. Thank you, Doctor. And I appreciate that. 

I am going to take another question here. And the statement was 

made about systems-based care. And I am not sure where you 

think that is missing in podiatry. You know, as a podiatrist, I 

sometimes am the first one to find someone’s hypertension, congestive heart failure, vascular disease, neuropathy due to diabetes or 

alcohol, take a skin lesion, find a melanoma, all those things. All 

those things, I can tell you, I have seen and been the first to suspect, do the proper tests, and make the appropriate referral to the 

specialist. That is what we do. 

I don’t know why you are saying systems-based care is missing 

there. Yes, we have a scope of practice surgically that pertains to 

the foot and ankle, but it doesn’t mean that the systems-based care 

and ability to diagnose or suspect or to order the appropriate tests, 

make the proper referral—that is what we do. That is what you do. 

That is what you do. If you took off a lesion on a foot and it was 

malignant melanoma, you are going to refer that, I would assume. 

And so I think we really need to take a look at this. And as far 

as the definition of ‘‘physician,’’ I have, you know, Webster’s right 

here: ‘‘a person skilled in the art of healing; specifically: one educated, clinically experienced, and licensed to practice medicine as 

usually distinguished from surgery.’’ And, in this case, we do both. 

Some of the definitions I looked at, it gave the example of M.D., 

but it didn’t limit it to that. 

And so for us to be hung up on this word, at the expense of veterans having a large pool of physicians able to take care of them, 

I think it is a shame. And I hope we can get beyond this as we 

move forward with this bill. And I know we will have continued 

discussions. 

And I just want to finish by saying I appreciate each and every 

one of you being here today, because I do know that it is on behalf 

of veterans that you are all here. And we will move on from here. 

And I want to thank you again for attending today. 

And Ms. Brownley? 

Ms. BROWNLEY. I just have one quick question. And my question 

really, I think, doesn’t directly relate to the essence of what we are 

talking about here relative to the specific bill. 

But, Dr. Robbins, I just wanted to ask you—I wanted to go back 

to the salary schedule again. And if you could tell me how the VA 

determines the minimum and maximum allowable salaries for physicians, for dentists? And then how do they do the same determination for minimum and maximum allowable for podiatrists? Are they 

different, or are they the same? 

Dr. ROBBINS. Yes, they are different as of 2006 when the physicians’ and dentists’ pay bill was passed. The physicians and dentists moved into different tables and tiers, and the podiatrists 

stayed in the same GS-12, -13, -14, and -15 categories as they had 

been, again, since 1976. 

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Within that process, the physicians and dentists are boarded locally, where in podiatry we are boarded nationally—and I am actually the chairman of the National Podiatry Board—and qualification standards are issued. And the ones in podiatry are from 1976, 

in VA Handbook 5005. And it is scary that I know that, but that 

is the directive that that information comes from. 

So we are obligated to use those qualification standards in order 

for us to provide a grade and rank for podiatrists, so much so that, 

in the past 3 years, we have had to go through there and write 

equivalencies to bring it up to 2017, because a lot of the stuff written in 1976 doesn’t really apply. So we had to determine equivalencies, which is a document that we use as the qualification standards now. 

Ms. BROWNLEY. Thank you. I guess my question was relevant to 

the essence of what we are talking about today. 

And just, you know, one final question quickly is, you know, how 

many podiatrists are really expected to retire from the VA in the 

next 10 years? And do we have a succession plan in place to fulfill 

those jobs for current and future needs? 

Dr. ROBBINS. We have a significant number—I don’t have the 

exact number, but we have a significant number of people I call 

‘‘less young’’ that are approaching retirement age and that are 

going to retire. And many of those folks are the mentors and the 

residency directors. And someone talked a little bit about access a 

little bit earlier. That has a profound potential negative effect on 

access, as the more experienced providers, who can deal with more 

complex problems see patients more effectively and efficiently, are 

leaving the system, and younger providers, who don’t have the 

same experiences, can’t see patients as effectively and efficiently as 

those providers. 

The best system, of course, is when you have mentor and mentee 

and develop that kind of succession plan. What we are hoping from 

this legislation is to give us the opportunity to start recruiting 

some of those mid-career folks who have board certification, have 

those experiences, to act as those mentors for our younger folks. 

That will provide us with that succession planning that veterans 

deserve. 

Ms. BROWNLEY. Thank you. 

And, Mr. Chairman, I yield back. 

Mr. WENSTRUP. Any other questions? 

Okay. 

To the panel, I want to thank you all once again for good conversation today. If there are no further questions, the panel is now 

excused. Again, I thank you all for coming. 

And I ask unanimous consent and all Members have 5 legislative 

days to advise and extend their remarks and include extraneous 

material. 

Without objection, so ordered. 

The hearing is now adjourned. Thank you. 

[Whereupon, at 4:18 p.m., the Subcommittee was adjourned.] 

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(26) 

A P P E N D I X 

Prepared Statement of Steven L. Goldman 

Dr. Chairman, Ranking member, Distinguished Members of Congress and Guests; 

At the outset I would like to express my appreciation for the honor to address 

this committee today. In discussing this topic, I do so as a private citizen and not 

as the Chief of Podiatry and Director of a Podiatry Residency training program at 

a Veterans Affairs Medical Center. I do so not as the former interim Chief of Surgery or the Site Director for Surgical Services at a second VA facility, and I do so 

not as a retired Lt Colonel in the United States Air Force Reserve who served as 

a podiatrist and also as Surgical Operations Squadron Commander for the last four 

years of my 20 year Air Force career. I am testifying as a private citizen, one who 

graduated almost 35 years ago and was an Associate Professor at the New York College of Podiatric Medicine for nearly 15 years, during which time I witnessed firsthand the metamorphosis of my profession. I am currently the President of the 

American Board of Podiatric Medicine and in this position I represent thousands of 

podiatrists around the country, many of whom are employed by the Federal Government. As a veteran, I am now also a consumer of the medical services of the system 

about which you have invited me here today to testify. 

I have witnessed the best of our profession as it has grown over the past 35 years 

since I graduated in 1982. I am in awe of how far we have come. Today, all graduating podiatrists are three-year residency trained in podiatric medicine and surgery, and we are integral parts of the collaborative health care delivery system, providing essential services alongside our distinguished allopathic and osteopathic specialists. Today’s podiatrists manage the complex nature of foot and ankle deformities 

and are part of the multidisciplinary team serving the needs of a seemingly evergrowing diabetic population. We take call, provide inpatient and outpatient care, respond to emergencies, prescribe medications, and independently perform surgery of 

the foot and ankle. Fundamentally, we perform a vital role in the continuum of 

health care equal to other physicians, often for a patient population whose only 

choice for healthcare is the VA. More often than not, those patients present with 

more multiple comorbidities than the average population. In the Veterans’ Administration, podiatry is often the first specialty consulted for foot and ankle care services, and we provide more of these services than any other specialty. 

Podiatrists in the private sector have witnessed salaries commensurate with the 

profession’s growing skills. By contrast, salaries in the Veteran’s Health Administration (VHA) have not kept pace, and the gap grows larger every day. Podiatrists in 

42 percent of the regions across the country have reached legislatively capped rates 

of pay under VHA. What that practically means is that a podiatrist at the absolute 

top end of the pay charts will earn exactly the same as much less senior podiatrist, 

and with no hope of ever being further remunerated commensurate with the added 

time of service or experience. Podiatrists are defined as physicians under Title XVIII 

of the Social Security Act a1861(r)(3) [42 U.S.C. 1395x] *. The VA definition of podiatry is a vestige of a 41-year-old, antiquated, 1976 VA Omnibus Bill, and is sorely 

outdated. Consequently, podiatry salaries under the Veterans Health Administration are locked into the same 41-year-old pay scale. As a result, it is becoming increasingly harder to fill positions and keep people with vital skills under VHA. I 

think we can all agree that all of us, but particularly our veterans, deserve the very 

best of care. When looking at the bell curve for salaries in podiatry on salary.com, 

virtually no matter where you look by zip code, podiatry salaries in federal services 

are in the lowest 10–15 percent of that curve. 

Podiatrists in leadership positions within the administration have been members 

of pay panels, making salary decisions for their medical colleagues who enjoy salaries that are, at the very least, 40 percent greater than the top-end of VHA podiatry 

salaries. 

Heretofore, the demographic for those seeking employment under VHA used to be 

Board Certified, seasoned professionals who came with many years of experience 

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27 

and who wanted to make careers in federal services. Podiatrists currently employed 

by VHA remain in the system primarily for one of two reasons; either they have 

a refined sense of purpose and wish to give of themselves out of a sense of commitment to our veterans, or they do so because they themselves are veterans and they 

are compelled by a continued service mission, tending to the medical needs of their 

comrades in arms. I have said many times, the Veterans’ Administration hospital 

system is the only healthcare system that I have ever known where you will see 

a patient with one leg being pushed to his or her appointment in a wheelchair by 

a patient or volunteer with one arm, and they don’t know each other. Veterans truly 

get this. These goodhearted providers are getting harder to find and even harder 

to keep. 

Podiatrists with less than 10 years of experience make up 66 percent of the new 

hires at VHA. The VHA podiatry workforce has effectively become the private sector’s farm team now being filled by younger, often non-Board Certified providers 

who seek to acquire the required case volume and diversity to qualify to sit for their 

Board Certification examinations and, after passing, take those skills to the private 

sector where they can make a fair wage in order to repay a student debt burden 

that averages, and often exceeds, $194,000. Specifically, in 2016, only 30 percent of 

new hires were Board Certified. Until we can offer better compensation, this has, 

and will continue to trickle down to affect patient access because skilled, Board certified, experienced practitioners can manage larger patient populations more efficiently than inexperienced, younger professionals. To make matters even worse, in 

2016, the VA’s average delay in hiring a podiatrist to fill a vacant position was 14 

months - that means 14 months of patients having to seek care elsewhere, or forgo 

necessary foot and ankle care altogether. 

Based on the salary.com data mentioned earlier, the take-away message is that 

the VA’s top performing podiatrists, those making the highest possible salaries in 

the VA, are paid about 25 percent less than the MEDIAN salaries of their non-VA 

counterparts, and in most cases, only about half of what the top non-VA performers 

earn. 

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In hospital leadership positions, both in the public and private sector, podiatrists 

have had oversight of numerous surgical and medical subspecialties, utilizing an insight of core and fundamental medical and surgical principles. These principles, coupled with consultation and input from the Chiefs of the respective medical and surgical colleagues that they oversee, provide for an effective leadership model. Should 

a podiatrist be the Chief of a subspecialty like neurosurgery or orthopedics? The answer has to be, ‘‘no more than a neurosurgeon or orthopedist should be the Chief 

of Podiatry.’’ But that does not mean that a podiatrist, who is the overall Chief of 

all of the surgical subspecialties, can’t work with and oversee and provide effective 

administrative leadership of those departments with collaborative input from the 

subspecialists with whom they work. 

In conclusion, Dr. Chairman, Ranking Member, and members of the Committee, 

I thank you again for inviting me here to share my thoughts with you all, and for 

your efforts and your desire to discuss this topic to hopefully right this inequity. I 

am available to address any questions you may have for me. 

f 

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Insert offset folio 1 here 29681.001
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Prepared Statement of Dr. Seth A. Rubenstein 

Chairman Wenstrup, Ranking Member Brownley and members of the Subcommittee, I welcome and appreciate the opportunity to testify before you today on 

behalf of the American Podiatric Medical Association (APMA). I commend this Subcommittee for its focus to assist and direct the Veterans Administration (VA) to effectively and efficiently recruit and retain qualified medical professionals to treat 

veteran patients and improve access to quality health care in the VA. 

I am Dr. Seth Rubenstein, member and trustee of the American Podiatric Medical 

Association (APMA). I am before you today representing APMA and the podiatric 

medical profession, and specifically our members currently employed, and those 

seeking to be employed, by VA. I do not represent VA in my capacity today, though 

I bring with me knowledge of the widespread disparity between podiatric physicians 

and other VA physicians. 

APMA is the premier professional organization representing America’s Doctors of 

Podiatric Medicine who provide the majority of lower extremity care, both to the 

public and veteran patient populations. APMA’s mission is to advocate for the profession of podiatric medicine and surgery for the benefit of its members and the patients we serve. 

Dr. Chairman, the Veterans Health Administration (VHA) qualification standards 

for podiatry were written and adopted in 1976. Podiatric education, training and 

practices in 1976 starkly contrasted with those of other physician providers of the 

time, and with podiatric medicine as it is today. Unlike 41 years ago, the current 

podiatric medical school curriculum is vastly expanded in medicine, surgery and patient experiences and encounters, including whole body history and physical examinations. In 1976, residency training was not required by state scope of practice laws. 

Today, every state in the nation, with the exception of two, requires post-graduate 

residency training for podiatric physicians and surgeons. In 1976, podiatric residency programs were available for less than 40 percent of graduates. Today there 

are 613 standardized, comprehensive, three-year medicine and surgery residency positions to satisfy the full number of our graduates, with 64 positions (or 10 percent) 

of those residency position housed within the VA. In contrast to 1976, today’s residency programs mandate completion of a broad curriculum with a variety of experiences and offer a direct pathway to board certification with both the American 

Board of Podiatric Medicine (ABPM) and the American Board of Foot and Ankle 

Surgery (ABFAS). These certifying bodies are the only certifying organizations to be 

recognized by the Council on Podiatric Medical Education (CPME) and VA. These 

bodies not only issue time-limited certificates, but they participate in the Centers 

for Medicare and Medicaid Services (CMS) Maintenance of Certification (MOC) reimbursement incentive program. Unlike the residency curricula in 1976 (which were 

not standardized, nor comprehensive), today’s residency curriculum is equitable to 

MD and DO residency training and includes general medicine; medical specialties 

such as rheumatology, dermatology, and infectious disease; general surgery; and 

surgical specialties such as orthopedic surgery, vascular surgery, and plastic surgery. CPME-approved fellowship programs did not exist in 1976, but since their creation in 2000, they offer our graduates opportunities for additional training and subspecialization. Today, podiatric physicians are appointed as medical staff at the vast 

majority of hospitals in the United States, and many serve in leadership roles within those institutions, including but not limited to chief of staff, chief of surgery, and 

state medical boards. Many of my colleagues have full admitting privileges and are 

responsible for emergency room call as trauma and emergency medicine are now 

also incorporated into post-graduate training. The competency, skill and scope of today’s podiatric physicians are vastly expanded and truly differ from the podiatrist 

who practiced when the statue was originally adopted. Because of this, CMS recognizes today’s podiatrists as physicians, and Tricare recognizes us as licensed, independent practitioners. 

The total number of VA enrollees has increased from 6.8 million in 2002 to 8.9 

million in 2013(1). While we are slowly losing our Vietnam veteran population, we 

are gaining a solid base of Operation Enduring Freedom (OEF) and Operation Iraqi 

Freedom (OIF) patients, returning from war with their unique lower extremity 

issues. The projected patient population of Gulf War Era veterans is expected to increase from 30 percent in 2013 to approximately 55 percent in 2043(1). The number 

of service-connected disabled veterans has increased from approximately 2.2 million 

in 1986 to 3.7 million in 2013(1). More than 90 percent of disabled veterans were 

enrolled in VHA in 2012(1). The likelihood of service-connected disabled veterans 

seeking VA health care generally increases with the veteran’s disability rating(1). 

The majority of male veterans who are currently seeking care from VA served during the Vietnam era(1). 

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30 

As a matter of fact, veteran patients are ailing and have more comorbid disease 

processes than do age-matched Americans(2, 3, 4, 5, 6). This includes major amputation, where age-specific rates are greater in the VHA compared to the US rates of 

major amputation(7). Elderly enrolled veterans have substantial disease burden 

with disproportionately poor health status compared to the same age enrolled in 

Medicare(8). The prevalence of diabetes is substantially greater among veteran patients compared to the general population, and unfortunately, the data reflect that 

the prevalence is trending up(6). While diabetes affects 8 percent of the US population, 20 percent of veteran patients carry this diagnosis(9).The aging veteran population combined with these increased rates of diabetes has increased the burden 

of diabetic foot ulcers and amputations(10). Veteran patients with one or more 

chronic diseases account for 96.5 percent of total VHA health care(9). In addition 

to diabetes, some of the most common chronic conditions documented in veteran patients manifest in the lower extremity such as hyperlipidemia, coronary artery disease; chronic obstructive pulmonary disease; and heart failure(9). 

Socioeconomic and psychosocial issues often plague our veterans and further complicate disease management. Veteran patients statistically have lower household incomes than non-veteran patients(1). Sadly, many of our nation’s veterans are homeless and suffer from comorbid conditions such as diabetic foot ulcers, sometimes 

with a level of amputation, so management of this patient population can be extremely challenging. Health care expenses combined with disability and compensation coverage account for the majority of VA utilization and have demonstrated significant growth since 2005(1). 

This is the VA patient population. Patients who are statistically comorbid with 

psychosocial and socioeconomic issues, all of which play a role in the delivery of care 

and final outcome. The veteran population is far more complex to treat than patients in the private sector, as a whole. Greater than 90 percent of the veteran 

podiatric patient population is 44 years and older, with the majority of patients of 

the Vietnam era, who are plagued by the long-term effects of Agent Orange. Because of this and because of the increasing number of OEF, OIF, and Operation 

New Dawn (OND) veterans with lower extremity conditions, one of the major missions as providers of lower extremity care is amputation prevention and limb salvage. 

Dr. Chairman, the value of podiatric care is recognized in at-risk patient populations. Care provided by podiatrists, as part of an interdisciplinary team approach, 

reduces the disease and economic burdens of diabetes. In a study of 316,527 patients 

with commercial insurance (64 years of age and younger) and 157,529 patients with 

Medicare and an employer sponsored secondary insurance, there was noted a savings of $19,686 per patient with commercial insurance and a savings of $4,271 per 

Medicare-insured patient, when the patients had at least one visit to a podiatric 

physician in the year preceding their ulceration(11). Nearly 45,000 veterans with 

major limb loss use VA services each year. Another 1.8 million veterans within the 

VA Healthcare Network are at-risk of amputation. These at-risk veterans include 

1.5 million with diabetes, 400,000 with sensory neuropathy, and 70,000 with nonhealing foot ulcers(12). Despite having a large at-risk patient population from the 

Vietnam era, VA podiatric physicians are seeing increasing numbers of OEF, OIF 

and OND patients who are at-risk for amputation. From FY 2001 to 2014, the number of foot ulcers increased in the OEF, OIF, and OND populations from 17 documented cases to 612(12). Despite these statistics for at-risk patients, lower extremity amputation rates among all veteran patients decreased from approximately 

11,600 to 4,300 between fiscal year 2000 and 2014(12). Given the magnitude of amputation reductions, podiatric physicians not only provide a cost-savings to VA, but 

we also play an integral role in the veteran quality of life(12). 

While limb salvage is a critical mission of the podiatry service in the VA, the care 

delivered by the podiatric physician is of much broader scope. As the specialist of 

the lower extremity, we diagnose and treat problems ranging from dermatological 

issues, to peripheral vascular disease. We perform falls prevention and orthopedic 

surgery. As one of the top five busiest services in VA, podiatry provides a significant 

amount of care to veteran patients, and the bulk of foot and ankle care, specifically. 

In fiscal year 2014, the foot and ankle surgical procedures rendered by the podiatry 

services totaled 4,794, while foot and ankle surgical procedures performed by the 

orthopedic surgery service was a sum total of 72. 

The mission of VA health providers is to maintain patient independence and keep 

the patient mobile by managing disease processes and reducing amputation rates. 

Podiatric physicians employed by VA assume essentially the same clinical, surgical, 

and administrative responsibilities as any other unsupervised medical and surgical 

specialty. Podiatrists independently manage patients medically and surgically within our respective state scope of practice, including examination, diagnosis, treatment 

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plan and follow-up. In addition to their VA practice, many VA podiatrists assume 

uncompensated leadership positions such as residency director, committee positions, 

clinical manager, etc. Examples include: 

• Steve Goldman, DPM, Chief of Podiatry and Residency Director, Department of 

Veterans Affairs - Northport Health Care System - Former Site Director for 

Surgical Service, Department of Veterans Affairs - New York Harbor Health 

Care System; 

• William Chagares, DPM, Research Institutional Review Board Co-Chair, Chair 

of Research Safety Committee and Research Integrity Officer at the James A. 

Lovell Federal Heath Care Center; 

• Aksone Nouvong, DPM, Research Institutional Review Board Co-Chair at the 

West Los Angeles VA; 

• Lester Jones, DPM the former Associate Chief of Staff for Quality at the VA 

Greater Los Angeles Health Care System for eight years, and podiatric medical 

community representative while serving on the VA Special Medical Advisory 

Group. 

Despite this equality in work responsibility and expectations, there exists a 

marked disparity in recognition and pay of podiatrists as physicians in the VA. 

These discrepancies have directly resulted in a severe recruitment issue of experienced podiatrists into the VA, and unfortunately have also been the direct cause of 

retention issues. The majority of new podiatrists hired within the VA have less than 

10 years of experience and are not board certified. As a result of the disparity the 

VA is attracting less experienced podiatric physicians. The majority of these new podiatrists hired into the VA will separate within the first five years. 

Compounding the recruitment and retention issues, there exist lengthy employment vacancies when a podiatrist leaves a station. The gap between a staff departure to the time of filling the position is in excess of one year. Because of employment gaps as a consequence of the inherent and chronic recruitment and retention 

challenges, wait times within the VA for lower extremity care are unacceptably long. 

Since October 2014, 22,601 of the 191,501 (11.8 percent) established patients suffered a wait time of greater than 15 days, with some greater than 120 days. During 

this same time period, 23,543 of the 25,245 (93 percent) new patients suffered a 

wait time of the same magnitude. The prolonged vacancy exists partly because the 

VA is not capable of attracting experienced candidates, but also because the 

credentialing process is ineffectively burdensome. 

It is precisely because of the aforementioned issues that legislative proposals to 

amend Title 38 to include podiatric physicians and surgeons in the Physician and 

Dentist pay band have been submitted by the Director of Podiatry Services annually 

for more than 10 years now. These proposals have been denied every single year. 

Additionally, several requests for an internal fix have been denied, despite written 

letters of support for this movement from former Under Secretary of Health, Robert 

Petzel, MD. 

Seven years ago, the APMA’s House of Delegates passed a resolution making this 

issue a top priority. Since then we have alerted the VA to our knowledge of this 

issue. In response, former Under Secretary Petzel created a working group composed of Dr. Rajiv Jain, former Assistant Deputy Under Secretary for Health for Patient Care Services; Dr. Margaret Hammond, former Acting Chief Officer for Patient 

Care Services; and Dr. Jeffrey Robbins, Chief of Podiatry Service. We participated 

in several meetings with members of the working group and received written support of Patient Care Services and Podiatry Service for a legislative solution to address this issue. 

Occam’s razor is a problem solving principle whereby the simplest solution is 

often the best. I come before this committee today to respectfully request that Congress help the VA and its patients by passing legislation to recognize podiatric physicians and surgeons as physicians in the physician and dentist authority. We believe that simply changing the law to recognize podiatry, both for the advancements 

we have made to our profession and for the contributions we make in the delivery 

of lower extremity care for the veteran population, will resolve recruitment and retention problems for VA and for veterans. Dr. Chairman and members of the Subcommittee, thank you again for this opportunity. This concludes my testimony and 

I am available to answer your questions. 

1. National Center for Veterans Analysis and Statistics, Department of Veterans 

Affairs, http://www.va.gov/vetdata/index.asp 

2. Singh JA. Accuracy of Veterans Affairs databases for diagnoses of chronic diseases. Prev Chronic Dis. 2009 Oct;6(4):A126. 

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3. Olson JM, Hogan MT, Pogach LM, Rajan M, Raugi GJ, Reiber GE. Foot care 

education and self management behaviors in diverse veterans with diabetes. Patient 

Prefer Adherence. 2009 Nov 3;3:45–50. 

4. Powers BJ, Grambow SC, Crowley MJ, Edelman DE, Oddone EZ. Comparison 

of medicine resident diabetes care between Veterans Affairs and academic health 

care systems. J Gen Intern Med. 2009 Aug;24(8):950–5. 

5. Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical 

resource use. Arch Intern Med. 2000 Nov 27;160(21):3252–7. 

6. Miller DR, Safford MM, Pogach LM. Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient 

data. Diabetes Care. 2004 May;27 Suppl 2:B10–21. 

7. Mayfield JA, Reiber GE, Maynard C, Czerniecki JM, Caps MT, Sangeorzan BJ. 

Trends in lower limb amputation in the Veterans Health Administration, 1989– 

1998. J Rehabil Res Dev. 2000 Jan-Feb;37(1):23–30. 

8. Selim AJ, Berlowitz DR, Fincke G, Cong Z, Rogers W, Haffer SC, Ren XS, Lee 

A, Qian SX, Miller DR, Spiro A 3rd, Selim BJ, Kazis LE. The health status of elderly veteran enrollees in the Veterans Health Administration. J Am Geriatr Soc. 2004 

Aug;52(8):1271–6. 

9. Neugaard BI, Priest JL, Burch SP, Cantrell CR, Foulis PR. Quality of care for 

veterans with chronic diseases: performance on quality indicators, medication use 

and adherence, and health care utilization. Popul Health Manag. 2011 Apr;14(2):99– 

106. 

10. Johnston MV, Pogach L, Rajan M, Mitchinson A, Krein SL, Bonacker K, 

Reiber G. Personal and treatment factors associated with foot self-care among veterans with diabetes. J Rehabil Res Dev. 2006 Mar-Apr;43(2):227–38. 

11. Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, Defrancis RR, 

Wang S, Bagalman JE, Christina JR. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. 

J Am Podiatr Med Assoc. 2011 Mar-Apr;101(2):93–115. 

12. Preventing Amputation in Veterans Everywhere (PAVE) Program 

f 

Prepared Statement of Colonel (ret) James Ficke, MD 

Chairman Wenstrup, Ranking Member Brownley, and members of the Subcommittee, 

On behalf of the American Association of Orthopaedic Surgeons (AAOS), which 

represents over 18,000 board-certified orthopaedic surgeons, and the American 

Orthopaedic Foot and Ankle Society (AOFAS), which represents over 2,200 

orthopaedic surgeons specializing in foot and ankle disorders, I thank you for the 

opportunity to speak to you today about lower extremity care for Veterans. 

My name is Colonel (retired) James Ficke, and I’m an Orthopaedic Surgeon specializing in foot and ankle care. I’m currently the Chairman of Orthopaedic Surgery 

at Johns Hopkins School of Medicine. I served in the United States Army for 30 

years, deploying to Iraq from 2004–2005 as the Deputy Commander and Chief Medical Officer for the 228th Combat Support Hospital in Mosul. I have led the Extremity War Injuries Project Team for 12 years, an effort laser-focused upon improving 

care from injury to final resolution of battlefield injuries. This effort has identified 

the gaps in knowledge, as well as research needs, that have shaped the generous 

Congressional funding of over $330 Million dollars for Veterans with limb-injuries 

commonly sustained in combat. 

There are many orthopaedic surgeons serving Veterans proudly at the VA, and 

many others caring for Veterans through the Choice program. Orthopaedic surgeons 

play a role in saving limbs, reconstructing function, and returning Veterans to a 

healthy, active lifestyle. AAOS was honored to receive a Joint Warfighter Program 

award in collaboration with the Major Extremity Trauma Research Consortium, the 

purpose of which was to determine the best evidence for treatment of injuries to our 

Warriors. We were honored to receive your support for this effort, Mr. Chairman, 

and we appreciate your many years of support for orthopaedics and our patients. 

We acknowledge the significant access to care challenges at the VA in lower extremity conditions. Current statistics are staggering regarding the burden of injury 

and disability. My own teams have reported and published literature showing that 

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up to 92% of Warriors with battlefield injuries will have permanent disability in the 

musculoskeletal system. As of 27 April 2017, 6,921 men and women have given their 

lives in defense of the Constitution, and 52,540 have sustained wounds in action, 

of which as many as 80% include a limb injury - the vast majority in the lower limb. 

We absolutely agree that musculoskeletal care for Veterans is imperative, and we 

will only meet their needs with a strong force of well-trained providers of all backgrounds. 

Concerning H.R. 1058, the VA Provider Equity Act, AAOS strongly agrees that 

high quality podiatrists should be more equitably compensated to support their recruitment and retention. Podiatrists are an essential part of the care team at the 

VA and provide excellent service to Veterans. During my service in the Army, I 

practiced alongside podiatrists in many military bases and had a podiatrist on my 

staff in Mosul, who served in a non-clinical leadership role, LTC John Gouin DPM. 

AAOS and AOFAS are concerned with two aspects of the legislation that are not 

essential to the goal of paying podiatrists what they’re worth at the VA. Firstly, this 

legislation would label podiatrists within the VA as ‘‘physicians,’’ elevating them to 

the category currently reserved for doctors of medicine and doctors of osteopathy. 

Secondly, the bill would allow podiatrists to attain clinical leadership positions over 

MDs and DOs. 

Podiatrists and orthopaedic surgeons are trained differently. The lower extremity 

is one of the more complex areas of the human musculoskeletal system, and an 

orthopaedic surgeon will attend four years of medical school, serve a five year 

orthopaedic surgery residency, and typically take an additional year of subspecialty 

fellowship training. MDs or DOs participate in active clinical care in multi system 

trauma and disease management, which is not the case for all podiatrists, and is 

a prerequisite for peer-review oversight. 

While recent changes have improved podiatric education, it is not the same as the 

multi-system medical education required to become a MD or DO, nor is it the same 

accreditation process. They do not participate in the United States Medical Licensing Examination, which is the standard for all advanced medical care and essential 

to the degree of MD and DO. We believe that the title of physician should be attained through the accreditation process, and not the legislative process. 

AAOS and AOFAS stand ready to work with the subcommittee in good faith to 

improve this legislation and increase Veteran access to the care provided by both 

orthopaedic surgeons and podiatrists. 

Thank you for the opportunity to appear before the subcommittee and for your 

work on behalf of our nation’s Veterans. I look forward to answering any questions 

you may have. 

f 

Prepared Statement of Brandt 

Ensuring High Quality Lower Extremity Care for Veterans 

TESTIMONY BY THE

AMERICAN ORTHOTICS AND PROSTHETICS ASSOCIATION

Chairman Wenstrup, Ranking Member Brownley, and Members of the Committee, 

Thank you for inviting the American Orthotic and Prosthetic Association to offer 

insights and recommendations regarding the Department of Veterans’ Affairs ability 

to meet the need for high quality clinical care and procurement of prosthetic and 

orthotic devices for Wounded Warriors and Veterans with limb loss and limb impairment. My name is Jeffrey Brandt, and I am a Certified Prosthetist/Orthotist as well 

as the Founder and CEO of Ability Prosthetics and Orthotics. Since I founded the 

company in 2004, we have grown to ten clinics in the states of Pennsylvania, Maryland and North Carolina. As part of our work, we work with seven VA Medical Centers to provide prosthetic and orthotic services to Veterans. We have active contracts 

with four VAMCs across VISNs 4, 5 and 6. 

I am pleased to be here today representing the Association. AOPA, as we call it, 

represents over 2,000 orthotic and prosthetic patient care facilities and suppliers 

that evaluate patients for and design, fabricate, fit, adjust and supervise the use of 

orthoses and prostheses. Still, sadly, fewer than half of all amputees in the United 

States ever receive a prescription for a replacement limb. The likelihood of receiving 

a prosthesis declines by 50% with every 10 years of advancing age. That results in 

percentages of US patients who are untreated that are much higher than several 

European countries. Our members serve Veterans and civilians in the communities 

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where they live, and our goal is to ensure that every patient has access to the highest standard of O&P care from a well-trained clinician. It is not widely known that 

80–90% of prosthetic/orthotic care delivered to Veterans is provided in a communitybased setting, outside the walls of a VA Medical Center. The vast majority of your 

constituents who are Veterans and who need a prosthesis or orthosis received a device that was provided and maintained by an AOPA member. 

The VA contracts with community-based providers to offer Veterans timely, convenient and high quality prosthetic and orthotic care near the locations where they 

live and work. Because such a high percentage of care is delivered by communitybased providers, the private sector workforce and procurement relationships with 

the VA must be a part of any discussion of lower extremity prosthetic and orthotic 

care for Veterans. 

Caring for Wounded Warriors 

Traumatic Brain Injury (TBI) and amputation are the signature injuries of the 

wars in Iraq and Afghanistan. Traumatic Brain Injury often manifests in the same 

way as stroke, with orthotic intervention needed to address drop foot and other challenges balancing, standing and walking. The Department of Defense Surgeon General reported to the Congressional Research Service that from the start of 2000 

through June 2015, more than 327,000 service members had suffered a TBI. 

Although the death rate from conflicts in Iraq and Afghanistan is much lower 

than in previous wars, the amputation rate has doubled. The Department of Defense 

and the Department of Veterans’ Affairs have reported that in past wars, 3% of 

service members injured required amputations; of those wounded in Iraq, 6% have 

required amputations. The DoD Surgeon General reported to CRS more than 1,600 

service-related amputations from October 2001–June 2015. More than 80% of amputees lost one or both legs. Concussion blasts, multiple amputations, and other conditions of war have resulted in injuries that are medically more complex than in previous conflicts. The majority of these amputees are young men and women who 

should be able to live long, active, independent lives if they receive timely, high 

quality, and consistent prosthetic care. 

Caring for Senior Veterans 

Most Americans are unaware that the majority of Veterans with amputations undergo the procedure as a result of diabetes or cardiovascular disease. According to 

VA statistics, one out of every four Veterans receiving care has diabetes; 52% have 

hypertension; 36% are obese. These conditions are associated with higher risk for 

stroke, neuropathy, and amputation. 

These underlying health conditions are the reason that the number of Veterans 

undergoing amputation is increasing dramatically, and is expected to increase at an 

even more rapid pace in the future. VHA Amputation System of Care figures show 

that, in the year 2000, 25,000 Veterans with amputations were served by the VA. 

By 2016, that number had more than tripled to 89,921. Between 2008–2013, an average of 7,669 new amputations were performed for Veterans every year; in 2016, 

11,879 amputation surgeries were performed. 78% of the Veterans undergoing amputation last year were diabetics. 42% had a service-connected amputation condition. 

AOPA commends the VA for its historical leadership in ensuring that Veterans 

who have undergone amputations have access to appropriate, advanced prosthetic 

technology, often before the same technology is made available to patients in the 

private sector. For example, when the first microprocessor-controlled knee came to 

market, it was initially considered beneficial for the fittest, most active amputees. 

The late Fred Downs, then National Director of the Prosthetic and Sensory Aids 

Service, was himself a Vietnam Veteran who lost an arm in combat. He had the 

idea that the greater stability offered by microprocessor control might actually be 

equally or more beneficial to older, less active Veterans with limb loss who were less 

steady on their feet. After testing the computer-controlled knees with older Veterans 

undertaking activities such as walking in the community and riding Metro escalators, the VA became the first payer to approve microprocessor-controlled knees for 

older and less active patients. Today, following the VA, Medicare and private insurance companies widely accept that microprocessor-controlled knees improve safety 

and increase activity levels for patients with limb loss across a wide spectrum of 

activity levels. 

AOPA also wishes to express its deep gratitude to the Veterans’ Administration 

for its feedback to the Centers for Medicare and Medicaid Services in response to 

a devastating proposed policy regarding eligibility for prosthetics. In 2015, CMS 

issued a draft Local Coverage Determination (LCD) that, if enacted, would have denied access to prosthetic technology to large groups of seniors with limb loss, and 

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potentially carried implications for denial of care to Veterans as well. The guidelines 

in the LCD were arbitrary, were not supported by clinical research or practice, and 

included provisions such as disqualifying amputees for advanced prosthetic devices 

if, during any part of the day or night, they used a cane, walker, or wheelchair. The 

VA’s leadership, combined with outcry by patients and advocacy by the O&P field, 

resulted in the suspension of implementation of this ignorant, unscientific and inappropriate policy. 

Partnering with the Private Sector to Provide Timely, Quality Care 

O&P care is unusual in that for decades, about 90% of care provided to Veterans 

has been through contracts with private sector providers - often small businesses, 

such as my own. 

My experience with the VA, and that of my colleague AOPA members and the 

Veterans we serve, is that the quality of care, the implementation of policies, and 

the approaches taken by the VA to prosthetic and orthotic services, are extremely 

uneven, variable, and in many circumstances, dependent upon personalities. Unquestionably, some VA medical centers have excellent clinicians, embrace innovation 

and best practices to the extent the bureaucracy allows, and maintain strong and 

cordial working relationships with private sector providers who are responsible for 

the majority of care for the Veterans that Medical Center serves. 

In other places, VA staff making decisions affecting lower extremity care appear 

not to be particularly knowledgeable about prosthetics and orthotics. Some VA prosthetic and orthotic clinicians welcome the partnership with private providers as a 

needed resource to meet the growing demand for care. Other VA staff seem to believe that some private sector providers are in competition with them for patients, 

and are out to take advantage of the taxpayer with more expensive, unwarranted 

components. Some VAs have begun a practice of excluding community providers 

from the VA prosthetic clinic where patients are referred to providers, or to make 

attendance at those clinics dysfunctional. Contentiousness in relationships between 

the VA and the clinicians actually providing the prosthesis does not serve Veterans 

well. The best care is supported by a genuine rehab team approach. 

There are multiple advantages to the VA, and to Veterans, from this long-time 

public-private partnership in O&P. 

We are all familiar with stories about wait lists, delays in care, and the VA’s 

struggle to provide timely care to its patients. With a private sector network of O&P 

clinics supplementing care available from VA employees, wait times are reduced and 

Veterans receive the care they need more quickly than if they were relying solely 

on overburdened VA facilities and federal employees. 

Community-based providers, such as myself, are often closer to Veterans’ homes 

or workplaces. Frequently, we offer Veterans more convenient care, with less travel 

time and expense, less time away from work, and less interruption to their daily 

lives. 

Another significant advantage is that, in my experience, community-based providers are often more nimble in adopting cutting-edge practices, collecting data, and 

implementing innovations than our colleagues operating in a large federal agency. 

For example, at Ability, our practitioners work with every new patient to complete 

a series of questionnaires and three objective baseline outcome evaluations, to establish the patient’s physical capacity for activity. That capacity determination, called 

a ‘‘functional level,’’ indicates what kind of technology will best facilitate mobility 

for that patient. 

But the VA very often does not use such objective, validated tests, or even an observably consistent approach, to evaluating functional levels. 

Regardless of the VA evaluation, when a Veteran comes to us with a VA doctor’s 

prescription for a prosthesis, we give that Vet the same expert care that we give 

all our patients. Before we start work on the prosthesis, Ability uses our own assessment process to evaluate what will best suit the Veteran’s needs. Sometimes, our 

evaluation confirms the prescription provided by the VA. 

When our evaluation differs from the VA’s - maybe the VA evaluated the Veteran 

at a K3 but we put the Veteran at a K2 - we call the VA clinic, and ask to talk 

with the staff there. We ask for additional information, including the prosthetic 

evaluation notes, so we can understand why the VA recommended something different. Most of the time, the VA staff don’t welcome our call. It can take two weeks 

to get a call back - two weeks when the Veteran is waiting for the medical device 

that makes it possible to walk. Then the Veteran has to become the squeaky wheel, 

calling the VA on our behalf to try to open the lines of communication. When the 

VA staff calls us back, they’re often annoyed. They tell us that they can’t share the 

evaluation notes with us. They tell us that the VA’s electronic medical record has 

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no way to extract and send information. They treat us like a vendor, instead of a 

professional. They accuse us of making them look bad. 

Here’s the irony: in an effort to reduce costs, supposed fraud and abuse initiated 

by community-based providers, the VA often won’t accept our expert professional 

recommendations. If we call to say our evaluation shows that the patient is a K2 

and wouldn’t benefit from a microprocessor-controlled ankle, we hear comments like 

‘‘I don’t want the Veteran to complain’’ or ‘‘to be on the safe side, all my patients 

get that ankle.’’ When our evaluation methodology shows that the Veteran needs 

more advanced technology than was recommended by the VA’s subjective exam, we 

can find ourselves accused of trying to line our own pockets by providing more advanced devices. 

At that point, I have a choice. I can continue to advocate for my patient, at the 

expense of my relationship with my VA client. Or, I can proceed to fill a prescription 

my evaluation assessment tools tell me is not necessarily best for my patient. If the 

Veteran comes back ten times in the next six weeks because the prosthesis isn’t appropriate, then the Veteran hasn’t been served, and my reputation is damaged. I 

have to sit down with the patient and explain what the problem is. The Veteran 

often has to go back to the VA and do his or her best to articulate why a change 

in componentry might be appropriate. The VA staff may become defensive, and accuse the outside provider of not just providing what was initially discussed, looking 

for more money, and putting the Veteran up to asking for something different. All 

of this could be averted with proper clinic protocol, use of outcome metrics and better communication. 

All of us - patients, clinicians, and taxpayers - would benefit from a more consistent, and more data-driven system. Sometimes, patients come to our office having 

seen or heard about more expensive, advanced new devices. Maybe a buddy with 

a similar injury received one. Sometimes, that device is absolutely appropriate for 

our patient. Sometimes, it would help the Veteran reach his highest activity potential, and engage in activities he used to do before losing a leg. But sometimes we 

find, when we go through our assessment, that that Veteran can’t really take advantage of that advanced technology, and probably shouldn’t get it. It’s always hard to 

tell a patient that he or she really doesn’t need the new device that was featured 

on a magazine cover, generated buzz in a Veterans’ chat room, or that a buddy received. We find that our process, with its objective tests and data, is valuable in 

helping Veterans and other patients understand and accept those difficult determinations. We tell them that, as time goes on, we can always re-evaluate them by 

giving them the tests again, and upgrading the technology as the data warrants. 

And sometimes the opposite is true - our data helps us work with private insurance 

companies to get more advanced technology for our private patients. You might 

think that the VA, with its concerns about fraud and abuse, would welcome an approach that objectively documents advanced technology for their patients. In our experience, that’s rarely the case. 

There are multiple other challenges that can make it difficult for a communitybased provider, and particularly for a small business, to work with the VA to provide care to Veterans. In brief, these include, but are not limited to: 

• Contracts that expire and take more than a year to renew 

• Contracts that are not awarded until 12–18 months after the bid process closes 

• VISNs that allow contracts to expire, and then permit any provider to offer 

care, regardless of the quality of that provider 

• Outdated methodologies for evaluating the quality and capacity of private sector 

bidders (ie, how many band saws do you have on site?) 

• Accelerated approval processes for technology when provided by an in-house VA 

clinician, creating incentives for patients to shift care from a community provider to a federal employee. 

Before I close on this point, I would like to make one additional observation. 

Often, as Veterans, AOPA members and representatives discuss these issues with 

Members of Congress and their staff, policymakers are surprised that these problems were not solved by the Veterans’ Access, Choice and Accountability Act of 

2014. O&P is not covered by the Veterans’ Choice Act. Inconsistencies in the recent 

VA reforms only got part way to the target. Veterans located a distance from a 

VAMC can exercise the option to see a doctor in the community with the VA’s guarantee of payment at Medicare rates. But Veteran amputees are not accorded that 

option or guarantee. Nobody seems to be able to explain why. AOPA looks forward 

to working with you, and with the new Administration, to find solutions to these 

challenges. 

As you know, the VA is a large ship, and it is difficult to turn quickly. I do see 

some things changing, slowly, in some places. There does seem to be a heightened 

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emphasis on outcomes in some of the recent RFPs that have been released. There 

are more questions being asked of private sector providers about data and objective, 

rather than subjective, evaluations of patients. But, from a small business perspective, that change is uneven, and it’s not coming quickly enough. And, unfortunately, 

it’s the Veterans who suffer the most. 

Demand for High Quality Care is Growing While Provider Population 

Shrinks 

I’d like to turn now from procurement issues to a different kind of challenge facing both the VA and private sector providers: maintaining and growing a highly 

qualified workforce. 

From the battlefield to the homeland, medical conditions requiring prosthetic and 

orthotic care have become more complex and more challenging to treat. New prosthetic and orthotic technology is more sophisticated. To ensure professional, high 

quality care that could respond to these shifts, earlier this decade the entry-level 

qualifications for prosthetists and orthotists were elevated from a bachelor’s degree 

to a master’s degree. 

Veterans need and deserve clinicians who can successfully respond to their battlefield injuries with appropriate, advanced technologies. As the population of amputees grows, many experienced professionals who were inspired to enter the field to 

care for Vietnam Veterans retiring. Providing high quality care to our Wounded 

Warriors, Veterans, seniors, and civilian amputees is going to require more master’s 

degree graduates from American universities to be the next generation of practitioners. 

The National Commission on Orthotics and Prosthetics Education (NCOPE) commissioned a study of the O&P field, which was completed in May of 2015. The study 

found that in 2014, there were 6,675 licensed and/or certified orthotists and 

prosthetists in the United States. It concluded that, by 2025, ‘‘overall supply of 

credentialed O&P providers would need to increase by about 60 percent to meet the 

growing demand.’’ Subsequent analysis conducted by NCOPE and AOPA suggests 

that the current number of providers is closer to 5,500, an even more significant 

shortage than than previously predicted. Already, my colleagues in states including 

Florida, California, and Texas tell AOPA that an advertised opening for a licensed 

prosthetist or orthotist can take more than twelve months to fill. 

Currently, there are thirteen schools in the US that offer master’s degrees in 

orthotics and prosthetics. The largest program, Northwestern, accepts 48 students. 

The majority of programs have classes of 20 or fewer students per year. Nationwide, fewer than 250 students are anticipated to graduate with master’s degrees in 

orthotics or prosthetics this year. 

Current accredited schools will barely graduate enough entry-level students with 

master’s degrees to replace the clinicians who will be retiring in coming years. Class 

sizes simply aren’t adequate to meet the growing demand for O&P care created by 

an aging population and rising incidence of chronic disease. 

Positions as licensed, certified prosthetists and orthotists are good jobs. Nationally, the average wage exceeds $65,000. These jobs pay good wages, support a family, and can’t be outsourced overseas. Most importantly, they help improve the 

health and quality of life for our fellow citizens - including Veterans. I am proud 

of my profession, and of the work we do. Veterans, and civilian amputees, need care. 

Companies need high quality employees. People want fulfilling careers. Schools are 

getting more applicants for O&P programs than they can accept. Why is this so 

hard? 

The Wounded Warrior Workforce Enhancement Act 

O&P master’s programs are costly and challenging to expand. The need for lab 

space and sophisticated equipment, and the scarcity of qualified faculty with PhDs 

in related fields, contribute to the barriers to expanding existing accredited programs. There are currently no federal resources available to schools to help create 

or expand advanced education programs in O&P. Funding is available for scholarships to help students attend O&P programs, but do not assist in expanding the 

number of students those programs can accept. 

One way to address this problem is by passing The Wounded Warrior Workforce 

Enhancement Act, introduced in the House last Congress by Representative Cartwright with bipartisan support. This bill is a limited, cost-effective approach to assisting universities in creating or expanding accredited master’s degree programs in 

orthotics and prosthetics. It authorizes $5 million per year for three years to provide 

one-time competitive grants of $1–1.5 million to qualified universities to create or 

expand accredited advanced education programs in prosthetics and orthotics. Priority is given to programs that have a partnership with Veterans’ or Department 

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of Defense facilities, including opportunities for clinical training, to ensure that students become familiar with and can respond to the unique needs of service members 

and Veterans. The bill was endorsed by Vietnam Veterans of America and VetsFirst, 

which recognized the need for additional highly qualified practitioners to care for 

wounded warriors. 

In May of 2013, the Senate Committee on Veterans Affairs held a hearing to consider the Wounded Warrior Workforce Enhancement Act and other Veterans’ health 

legislation. The VA testified that the grants to schools were not necessary because 

it did not anticipate any difficulty filling its seven open internal positions in prosthetics and orthotics. The VA testified that its O&P fellowship program, which accepted nineteen students that year, was a sufficient pipeline to meet its need for 

internal staff. The VA offered similar testimony at a House Veterans Affairs Health 

Subcommittee hearing in November 2015. 

The Senate rejected the VA’s argument. Acknowledging that more than 80% of 

prosthetic and orthotic care to Veterans is provided by community-based facilities, 

the Committee concluded that nineteen students could not meet the system-wide 

need. Committee members also agreed that Veteransand the VA would benefit from 

a larger pool of clinicians with master’s degrees, whether those graduates were 

hired internally at the VA, or by community-based providers. The Committee included provisions of the Wounded Warrior Workforce Enhancement Act in S. 1950, 

which passed Senate VA Committee unanimously in 2013. Due to factors unrelated 

to O&P, the omnibus bill did not advance. Related provisions were included in the 

Senate’s omnibus package Veterans’ legislation in 2016, but were not included in 

final legislation passed late last year. 

AOPA looks forward to working with you to expand the number of highly qualified prosthetists and orthotists who can meet the needs of Veterans with limb loss 

and limb impairment, and to reducing the barriers to timely, appropriate lower extremity care. No Veteran should suffer from decreased mobility or independence because of lack of access to high quality care, regardless of where it is provided. 

I am the principal in a private sector company with my foot on the gas pretty 

much all the time. I’ve got a good facility, and good practitioners ready to serve Veterans. I want to give back to the folks who have suffered in the service of our country. It just shouldn’t be this hard. 

Thank you for considering my comments today, and for your commitment to providing the highest level of O&P care for our Veterans. If you have any questions 

or would like more information, please do not hesitate to contact AOPA. 

f 

Statements For The Record 

CLIFFORD J. BUCKLEY, M.D., F.A.C.S. 

Commentary in Support of Improved Compensation Package for Podiatrists Employed in the Veterans Administration 

My name is Clifford J. Buckley, M.D., F.A.C.S. and I am providing a voluntary 

statement in support of efforts to improve compensation for podiatric physicians and 

surgeons that are employed by the Veterans Health Administration. I feel qualified 

to comment on this issue because I have relied heavily on the support provided by 

appropriately qualified podiatrists in caring for patients who have problems related 

to their lower extremities and especially their feet. By way of background, I am a 

Board Certified Vascular Surgeon and hold the rank of Professor of Surgery (unmodified title) Texas A&M University College of Medicine. I have spent 15 years 

on active duty with the United States Military, 15 years in the private practice of 

medicine and 24 years in academic medicine - nearly half of that time in association 

with Veterans Health Administration. Specifically, my work with the VA has been 

as Associate Chief of Staff Surgical Services, CTVHCS, Chief Surgical Consultant 

VISN 17 VHA and former chair and member of the Vascular Surgery Advisory 

Board to the National Director of Surgery. 

Throughout my entire time working with the Veterans Health Administration, it 

is my personal judgment that podiatric physicians and surgeons have been under 

compensated and undervalued with respect to their peers and to their overall role 

in providing comprehensive care for the feet and lower extremities of our Veterans. 

This observation spans a time frame of at least 15 years or more. In CTVHCS, it 

would be impossible for me to recruit and retain Board Certified and clinically wellqualified podiatrists if I did not have supplemental salary assistance for our 

podiatric faculty provided by our University Affiliate. Currently, VA Podiatrists appear to be compensated at a level substantially lower than their civilian counterleonard.horne on VACREP0180 with DISTILLER

39 

parts. In fact, when I attempt to recruit new podiatric faculty, my choices are usually limited to physicians with either medical/legal or substance abuse problems or 

new training graduates who have social reasons requiring them to remain in our 

local area. The primary driving factor for a young podiatrists seeking employment 

with the VA and who have a desire for some degree of academic affiliation in their 

practice has been access to VA research support - financial and administrative. Unfortunately, these young podiatrists often leave for a more lucrative and generally 

professionally satisfying practice environment once they have established at least 

their local reputation. 

I have been extremely fortunate to have had faculty staffing our podiatry section 

who are extremely well qualified, clinically experienced and for the most part, are 

rear foot and ankle surgery qualified through additional training and certification. 

My recent Chiefs of the Podiatry Section have earned promotion to the rank of Professor of Surgery because of their academic productivity, clinical outcomes, and their 

regional and national reputations. Podiatrists of this quality could not be retained 

at our institution without the disproportionate supplemental salary support provided by our university affiliate. 

Podiatrists are the main stay for appropriately managing problems related to the 

feet. Their knowledge and skills in wound management identifying sources for pain 

and soft tissue injury and recognizing the complications of systemic illnesses like 

diabetes mellitus, chronic venous insufficiency and renal failure have saved the extremities of countless Veterans from amputation. P.A.V.E program, which is generally managed by podiatrists across the VA, is a shining example of their success 

at quality improvement for all forms of foot care but especially in the elderly Veteran. The ability of the podiatrists to recognize and manage problems related to the 

foot is not duplicated by any other group of health care providers. Their perspective 

in this field is exceptional. Their critics have often said that ‘‘all the VA needs to 

do is hire some health technicians who can be trained to provide nail care, orthopedic surgeons are capable of providing care for the remaining foot issues as they 

occur’’. Nothing can really be farther from the truth. Podiatrists understand the biomechanics of the foot and all of the various factors, which can produce local tissue 

injury. Their ability to manage each of these issues by directly attacking the source 

of the problem rather than treating sequellae is invaluable. 

I hope my comments in the above text show the strong support that myself and 

my Vascular Surgery colleagues have for improving the compensation package for 

VA Podiatrists. If I can be of any further assistance in their behalf, please do not 

hesitate to contact me. 

Clifford J. Buckley, MD, FACS 

254–931–0818 

f 

LAWRENCE B. HARKLESS, DPM 

RE: COMMENTARY ON HR 1058, VA PROVIDER EQUITY ACT 

My name is Lawrence B. Harkless, DPM, FACFS and I am providing a voluntary 

statement in support of efforts to improve compensation for podiatric physicians and 

surgeons that are employed by the Veterans Health Administration. I am qualified 

to comment on this issue because of my personal experience and observations on the 

role provided by qualified podiatrists in caring for patients who have problems related to the lower extremities, and especially their feet. 

By way of background, I am a Board certified foot and ankle surgeon and have 

been serving for the past ten years as the Founding Dean and Professor of Podiatric 

Medicine and Surgery at Western University of Health Sciences in Pomona, California. For my over thirty-year career I have served as a professor in the Department of Orthopedics and Podiatry Division Chief, and Director of Residency for 

Podiatric Medicine at the University of Texas Health Science Center, San Antonio, 

Texas. This also included staff privileges at the Audie Murphy VA Hospital where 

I was an attending physician during my thirty-year career. I have had the unique 

opportunity to serve the county hospital population in addition to the veteran’s population of the San Antonio community and beyond. I also served on a Special Medical Advisory Group (SMAG) that advises the Secretary of the VA from 1995–2001. 

During my entire career of working at UT and Audie Murphy VA it IS my own 

opinion that podiatric physicians and surgeons have been undercompensated and 

undervalued in comparison to their peers, and to their role in providing comprehensive care for the feet and lower extremities of veterans. The VA continues to have 

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trouble recruiting and retaining experienced podiatric providers due to low compensation. The VA can recruit young providers out of residency but once they become Board certified and more experienced, they leave the VA for the private sector. 

Several of my former residents, who were destined for academic careers, have not 

taken VA positions due to this low compensation. Our veterans deserve better. 

The ability to attract and retain experienced podiatric providers has affected access. With a projected increase of over 400,000 additional veterans coming into the 

system, the VA will continue to struggle with access unless the VA can offer better 

compensation for podiatric physicians. Legislatively capped VA clinical podiatrists 

in nearly 58% of the regions receiving locality pay have reached the legislatively 

capped rate of pay for the executive schedule which has resulted in significant reduction in pay over the past decade for many of highly productive and experienced 

providers. 

The Center for Medicare and Medicaid Services (CMMS) is already defining podiatrists as physicians under Title XVIII. The VA’s definition is from the 1976 Title 

XXXVIII Omnibus Bill, and it is an outdated thirty-year old law. Podiatrists share 

the same inpatient/outpatient on call and rounding responsibilities as any other 

physician’s profession. 

The VA is central to residency education and training for podiatrists. It trains 

more podiatric medical residents than any health system. It’s important to attract 

the best and brightest as they will provide leadership in education, research and 

service to the next generation of podiatrists who will care for the veterans. Moreover 

they will have an impact with interprofessional teams in improving foot health for 

the veteran population. 

Podiatry has the most important role in keeping America walking. Their knowledge and skills in the management in foot problems in the areas of diabetes, aging 

and arthritis are noteworthy. Congress now finds itself with the opportunity to 

make long needed improvements in the VA health care delivery system, and I hope 

my testimony will encourage the House to do the right thing for our veterans and 

America. 

Sincerely, 

Lawrence B. Harkless, DPM 

LBH:mb 

PVA 

f 

PARALYZED VETERANS OF AMERICA (PVA) 

Chairman Wenstrup, Ranking Member Brownley, and members of the subcommittee, Paralyzed Veterans of America (PVA) would like to thank you for the 

opportunity to offer our views on VA specialized services for lower extremity conditions. PVA represents the voice of approximately 60,000 veterans in the U.S. who 

live with paralysis of the lower extremities due to spinal cord trauma, multiple sclerosis, amyotrophic lateral sclerosis, and other dysfunctions. We are grateful to be 

part of this discussion. 

Loss of lower extremity function related to the spinal cord often includes loss of 

other functions, such as genitourinary, digestive, and reproductive. It may also be 

accompanied by chronic nerve pain, muscle spasticity, muscle atrophy, and skin 

breakdown. For this reason, medical professionals who are trained in spinal cord injury medicine are best equipped to provide medical care for this population of mobility-impaired veterans. Paralyzed veterans are the largest cohort of veterans who 

rely of specialized services in VA and have the fewest alternative choices for care 

and long term institutionalization. The overwhelming majority of paralyzed veterans 

suffer lower extremity loss of use (exceptions include central spinal cord, which only 

affects the upper extremities, and some veterans with regressive MS). They rely on 

prosthetic devices such as wheelchairs, power chairs, power-assist chairs, patient 

lifts, auto adaptive equipment, home adaptive equipment, and other mobility solutions. 

No one is more affected by provider shortages than those veterans with complex 

injuries who rely on VA to treat their specialized needs. Unfortunately, VA has not 

maintained its capacity to provide for the unique health care needs of severely disabled veterans-veterans with spinal cord injury/disorder, blindness, amputations, 

and mental illness-as mandated by P.L. 104–262, the ‘‘Veterans’ Health Care Eligibility Reform Act of 1996.’’ As a result of this law, VA developed policy that required 

the baseline of capacity for Spinal Cord Injury/Disease System of Care to be measured by the number of available beds and the number of full-time equivalent emleonard.horne on VACREP0180 with DISTILLER

41 

ployees assigned to provide care.VA was also required to provide Congress with an 

annual ‘‘capacity’’ report to be reviewed by the Office of the Inspector General. This 

reporting requirement expired in 2008, and was reinstated in last year’s ‘‘Continuing Appropriations and Military Construction and Veterans Affairs Appropriations Act for FY 2017.’’ This report, a critical tool of oversight, should be made available to Congress by September 30 of this year. However, we have serious concerns 

about VA’s plan to re-implement this requirement. 

Additionally, VA Prosthetics has been problematic for quite some time in a number of ways. The gap between policy, where the Prosthetics National Director resides, and operations, under which the facility prosthetics office operate, has created 

sweeping inconsistency in how prosthetics policy is implemented. Individual facilities are allowed to enact or interpret policies that make it difficult for some veterans 

with lower extremity impairment to get needed devices in a timely matter. Resolving local problems is difficult because the National Prosthetics Office has no authority over the field prosthetics office, who report to the respective VISN. 

New prosthetics policies are being developed without the substantive input of external stakeholders. While stakeholders have been invited to participate in 

workgroups and on the Federal Advisory Committee for Prosthetics & Special Disabilities, the input from these groups rarely if ever affect the policy being developed 

(e.g. Clothing Allowance policy is still exclusive and punitive for those veterans who 

seek a second clothing allowance; power chairs are still not considered a factor in 

damaged clothing despite the consensus of the workgroup that argued otherwise, 

etc.). 

Existing prosthetics policies have not been properly followed in many locations, 

particularly in the area of customized wheelchair choice and backup wheelchair provisions. Some prosthetics offices allow for loose interpretations of policy that make 

it more difficult to get the mobility device that s/he chose and was supported by physician/therapist prescription. Documented cases of injury due to the issuance of illfitted mobility devices and the lack of a viable backup in the event a veteran’s primary mode of mobility becomes damaged have not been thoroughly addressed by 

VHA leadership. 

PVA supports H.R. 1058, the ‘‘VA Provider Equity Act,’’ bill to clarify the role of 

podiatrists in the Department of Veterans Affairs. Podiatrists at VA are currently 

classified among optometrists and other allied health professionals, rather than 

among physicians and dentists. The VA pay scale incorrectly differentiates podiatrists from other physician providers. The resulting salary discrepancies are significant and create further challenges for VA in the recruitment and retention of podiatrists. With an aging population of veterans, the demand for podiatrists is growing. 

Parity in pay among other physicians will allow VA to better resource the health 

care system to meet the needs of veterans. This legislation provides the VA with 

tools needed to address current and future demand. In order to transform the culture and timeliness of care, Congress must enable VA to quickly hire a competent 

workforce with competitive compensation that ensures VA is a first-choice employer 

among providers. 

Thank you for the opportunity to present our views on these issues. 

Æ 

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