For several years, Congress has been focused on ensuring that veterans have access to timely and high quality prosthetic and orthotic care. In the wake of two wars over the past decade, O&P issues have enjoyed very favorable media coverage, particularly the access that wounded warriors have had to the latest technologies as active military under the Department of Defense health care programs. The Department of Veterans Affairs (VA) has been eager to highlight its role in serving our nation’s veterans in need of O&P care as well.
In recent years, the VA has invested in its internal capacity to provide O&P care directly to patients through 60 different VA locations to complement its 600 contracts with private O&P practitioners. VA leadership has touted the high-end technology and state-of-the-art care available to veterans after limb loss or other orthopedic injuries. Unfortunately, this glowing version of VA prosthetic and orthotic care is at odds with reality in many areas of the United States. Although many veterans are pleased with their O&P care, by most accounts, VA O&P care is inconsistent at best, depending on where one lives and under which Veteran Integrated Service Network (VISN) an individual falls.
Enter the Injured and Amputee Veterans Bill of Rights, federal legislation that has been pending for several years and actually passed in the House of Representatives 3 years ago. On Oct. 30, the Injured and Amputee Veterans Bill of Rights was reintroduced in the 113th Congress as H.R. 3408. This bipartisan legislation addresses persistent deficiencies in the prosthetic and orthotic care that veterans receive across the country and seeks to improve care for veterans with injuries and amputations. The bill calls for the VA to post a statement of rights in every VA O&P clinic and on the VA website. This bill of rights will inform veterans of what they can expect from the VA in terms of their orthotic and prosthetic care and simply condenses to writing the VA’s current practices.
This bill seeks to empower veterans to be their own best advocate and to obtain the O&P care they need and deserve, consistently throughout the United States. The new bill is virtually identical to the bill passed by the House in December 2010. Unfortunately, that bill was passed too late in the congressional session for the Senate to act.
At the end of last year, the bill’s chief sponsor retired from Congress and a new champion was needed. The National Association for the Advancement of Orthotics & Prosthetics (NAAOP) spent the first half of 2013 developing new sponsors of the legislation willing to spearhead this legislative initiative. In the end, Rep. Renee Ellmers (R-NC) stepped up to lead the effort to reintroduce the bill. Ellmers represents the 2nd district of North Carolina, an area with a huge veteran and military presence, which is home to Fort Bragg, the largest US Army installation. Along with Ellmers, who is a registered nurse, two members of Congress who are also physicians have become original sponsors: Rep. Phil Roe (R-TN) and Rep. Raul Ruiz (D-CA), both of whom sit on the House VA Health Subcommittee. Roe, in particular, has been very vocal in VA hearings while challenging VA officials on a wide range of O&P access and quality issues.
Finally, Rep. Julia Brownley (D-CA), the VA Health Subcommittee’s ranking member, is also an original sponsor, making the legislation strongly bipartisan. A number of other members of the North Carolina delegation have also sponsored the bill, including Reps. Mike McIntyre (D-NC), David Price (D-NC), Howard Coble (R-NC) and Robert Pittenger (R-NC). The strong military and veterans presence in North Carolina stimulated strong support from the state’s congressional delegation. This will be particularly helpful when the bill is considered in the Senate. Sen. Burr (R-NC), in fact, is the ranking member on the Senate VA Committee and has signaled a willingness to seriously consider this legislation in the past.
If enacted, the Secretary of Veterans Affairs would be directed to ensure that the Injured and Amputee Veterans Bill of Rights is printed on signage in accessible formats and prominently displayed in every VA O&P clinic. The Secretary of the VA would also be instructed to conduct outreach to inform veterans of these rights and to collect information relating to the alleged mistreatment of injured and amputee veterans. The veteran liaison at each VA medical center would be charged with submitting a quarterly report to the VA’s chief consultant of Prosthetics and Sensory Aids on such information and the chief consultant would be directed to investigate and address such information contained in these reports. Furthermore, VA employees who work at such clinics, as well as patient advocates of veterans who receive care there, would be required to receive training on the Injured and Amputee Veterans Bill of Rights.
The bill would establish the following rights of injured and amputee veterans:
1. The right to access the highest quality prosthetic and orthotic care, including the right to the most appropriate technology and best qualified practitioners;
2. The right to continuity of care in the transition from the Department of Defense health program to the Department of Veterans Affairs health care system, including comparable benefits relating to prosthetic and orthotic services;
3. The right to select the practitioner that best meets their orthotic and prosthetic needs, whether or not that practitioner is an employee of the Department of Veterans Affairs, a private practitioner who has entered into a contract with the Secretary of Veterans Affairs to provide prosthetic and orthotic services, or a private practitioner with specialized expertise;
4. The right to consistent and portable health care, including the right to obtain comparable services and technology at any medical facility of the Department of Veterans Affairs across the United States;
5. The right to timely and efficient prosthetic and orthotic care, including a speedy authorization process with expedited authorization available for veterans visiting from another area of the country;
6. The right to play a meaningful role in rehabilitation decisions, including the right to receive a second opinion regarding prosthetic and orthotic treatment options;
7. The right to receive appropriate treatment, including the right to receive both a primary prosthesis or orthosis and a functional spare;
8. The right to be treated with respect and dignity and have an optimal quality of life both during and after rehabilitation; and,
9. The right to transition and readjust to civilian life in an honorable manner, including by having ample access to vocational rehabilitation, employment programs, and housing assistance.
Since initial passage of this bill in the House, the House VA Health Subcommittee requested and received a total of three separate reports from the VA Office of Inspector General. It held three full-blown hearings and a listening session on VA prosthetics, heard testimony from numerous Veteran Service Organizations (VSOs), including John Register, an amputee veteran, and issued a number of reports on the state of VA prosthetics. Finally, it heard from Robert A. Petzel, MD, the Under Secretary for Health at the VA in July 2012. Petzel is the top VA voice on orthotic and prosthetic care. The testimony he provided was highly consistent with the need to pass the VA Bill of Rights for injured and amputee veterans.
Excerpts from the question and answer portion of Dr. Petzel’s testimony before the subcommittee include important exchanges regarding the issues of practitioner choice and access to appropriate O&P technology:
Ranking Member Michael H. Michaud (D-ME): Is the VA central office instructing VISNs to restrict access to contract prosthetists or orthotists? If no, what about the VISNs? Are the VISNs restricting access to contracts for prosthetists for veterans who rely on those prosthetics?
Dr. Petzel: Congressman Michaud, our policy is this is a veteran’s choice. That we have, as mentioned earlier, 600 contracts. Most of the prosthetics actually are fabricated and fitted by private vendors. Our policy very clearly states that there must be available in every one of the medical centers a list of the contractors, and this must be explained to the veteran, that they have a choice in doing that…but if there is a connection between a patient and a prosthetist that individual is invited in and is welcome to come to the clinic and we come to be a part of whatever activities are involved in our prosthetic clinic.
Congressman Michaud: Do you believe it is more cost effective for the VA to consolidate prosthetics fabrication internally within the VA, or is it more cost-effective to continue to rely on contracts?
Dr. Petzel: The question about whether or not the VA can do it less expensively than the private sector I think remains unknown. The IG had a limited amount of data…
Access to Appropriate O&P Technology
Congressman David “Phil” Roe (R-TN): It is amazing the technology now on prostheses. As that new technology occurs, it is like these things right here, as soon as you buy it, it is out of date. And so I see the same thing in prostheses. People are doing amazing things with this….can [a veteran with limb loss] get something from the new catalog or something brand new that happens?
Dr. Petzel: Dr. Roe, absolutely. One of the nice things about the VA and the procurement regulations is 8123, which basically says that with the proper justifications, we do not have to do competitive buying; that we can buy specifically what the doctor has ordered. So while we may have a catalog of things that are appropriate in certain kinds of circumstances, the important part of all of this is the doctor writes an order, and we will procure for that patient, what the doctor has ordered.
Congressman Roe: So this is not going to negate new technology that occurs?
Dr. Petzel: Absolutely not.
Congressman Roe: So our veterans can get the cutting edge. They are not going to get stuck in “it’s not in the book, so you can’t have it.”
Dr. Petzel: Absolutely not, Congressman.
It is important to note that the rights established under this legislation do not establish legal rights on which veterans can sue the VA for substandard care. The rights in the bill are intended to educate veterans, provide them with a set of expectations of VA O&P care, and empower them to become their own best advocate for their own O&P treatment. The bill as scored did not add cost to the VA in 2010 and that should still be the case. Numerous organizations support the bill including the Wounded Warrior Project, the Vietnam Veterans of America, the National Guard, the Disabled American Veterans, and, of course, the NAAOP.
It is important that O&P practitioners, patients, and especially veterans contact their legislators and ask them to cosponsor H.R. 3408, the Injured and Amputee Veterans Bill of Rights. — Written by Peter W. Thomas, JD, Principal and Sara Rosta, MA, legislative assistant; Powers, Pyles, Sutter & Verville, PC.