Iowa Paralyzed Veterans of America

Two years ago, when a veteran received a customized wheelchair, porch lift, or some other “durable medical equipment” from VA prosthetics, chances are the consult or request went from a clinician or therapist to a prosthetics purchase agent, who either put out a competitive bid to vendors or ordered from a reliable major vendor, such as Invacare or Sunrise Medical. While the process was not 100 percent flawless, the veteran generally received the life-critical items without excessive delay.

So when VA decided to transition how it acquires prosthetics by placing limits on the use of “Title 38 authority” and open more government contract opportunities to veteran-owned and small businesses, it would foreseeably and disproportionately impact PVA members, most of which rely on high-cost prosthetics more than any other segment of the veteran population. Before getting into the details of the new policy and its impacts, readers should fully understand Title 38 authority and what it means to limit its application.

Title 38 of the United States Code, section 8123, grants VA authority to procure prosthetics and services in any manner “the Secretary may determine to be proper without regard to any other provision of law.” When exercising this authority VA may “procure prosthetic appliances and necessary services required …by purchase, manufacture, contract, or in such other manner as the Secretary [of VA] may determine to be proper” [emphasis added].

Why is this important for PVA members to understand? This flexibility was granted to ensure that veterans with disabling conditions received devices and supplies that met their clinical needs. It also permitted VA to limit bidding competition when physicians require specific devices or equipment for patient care. The Federal Acquisition Register and VA Acquisition Register, the primary directives for the procurement of VA prosthetics, further sanction this intent.

What has seemingly happened though is a decreased emphasis on the needs of veterans in order to meet small business quotas and cut budget corners. As the Veterans Health Administration continues updating its policies and directives to guide clinical and procurement staff on the interpretation of Section 8123, PVA’s concern is whether the intent of the statute will reflect a shift from a focus on patients to price tags, and veterans will see more and more instances of delayed or denied prosthetics orders.

Now if this new process works as intended, a consult or prescription submitted by a service provider goes to the local prosthetics purchase agent. If the cost exceeds the statutory “micro-purchase” limit of $3,000 (as most customized wheelchairs, patient lifts, etc. do), the request is forwarded to a network contracting agent. The contracting agent will solicit bids from vendors, the vendor will deliver the product, and the veteran can get on with life. The order seamlessly moves through the process in a timely manner. The clinical details of the order do not get questioned or modified by contract representatives bearing no clinical expertise. The chosen vendor is capable of meeting the time and spec requirements of the bid. That is what is supposed to happen under the new process. But here is what actually happened to a couple of PVA members:

A veteran with terminal, service-connected ALS (Lou Gehrig’s Disease) and his elderly wife were prescribed a whole house generator in order to keep his ventilator working in the event of a power outage. VA prosthetics delayed the request by referring it to a Major Medical Equipment Committee, which demanded that the veteran produce 4 years of records from the electric company and his spouse’s health records to substantiate the claim. PVA sought the intervention of the VISN Director, after which the request was immediately approved. The same veteran was later prescribed an artificial ventilator but died 10 days after the equipment order was submitted. Records show the prosthetics chief sat on the request for a week, deciding whether she should rent or buy the equipment. When questioned, she answered there are no established timeframes for procurement and delivery of such devices in instances of terminal illness.

A veteran with quadriplegia had his power chair ordered on August 15, 2012 by an SCI physical therapist. VA medical notes show that the order sat idle for about 4 weeks before being sent to the VISN contract office. The responsible contract representative sought three vendor bids then inexplicably closed the order after receiving none. The NSO contacted the VISN Prosthetics Representative (VPR) to find out why the order was delayed. The VPR attributed the breakdown to miscommunication between the VAMC and contracting, after which she directed her staff to bypass the system to procure the wheelchair locally. Two more orders were discovered to have similarly sat for 3-4 weeks before submission to contracting.

Stories such as these are becoming more common around the country. Although larger procurements like powered wheelchairs and porch lifts represent a small percentage of the total workload for the VA, they also represent the most critical equipment needed by the majority of PVA's members. Delays in these procurements prove costly to both the government, in terms of unnecessarily extended hospital stays while awaiting equipment, and to veterans, in terms of lost independence and quality of life.

Disheartening is the fact that PVA saw this coming and voiced these concerns to VA leadership well before the changes to the process were implemented. As predicted, the process has become broken for far too many veterans who depend on prosthetics items to function. In response, PVA has embarked upon a concerted, nationwide effort to aggressively confront these delays and make the case to VA leaders that immediate action must be taken to fix it. In order to do this, we need to track how often delays occur and tell the personal stories of the consequences. Thus, PVA members should immediately notify their local PVA National Service Officer of delays in the receipt of major prosthetics items, particularly when they result in longer hospital stays. Members may also notify the Veterans Benefits Department National office by phone at 866-734-0857 (TTY: 800-795-4327) or by e-mail at info@pva.org.