Optimizing Care for Veterans with PROSTHETICs
MAY 16, 2012: Before the House Veterans Affairs Committee
Chairwoman Buerkle, Ranking Member
Michaud and distinguished members of the subcommittee, I would like to extend
my gratitude for being given the opportunity to share with you my views and
recommendations at today’s hearing regarding the Department of Veterans Affairs
Prosthetic and Sensory Aid Services, and how we can all work together in Optimizing
Care for Veterans with Prosthetics.
To fully understand the magnitude of
what we are about to discuss, we must start by examining the statistics of our
returning servicemembers, as well as forecasting what their needs will be. As
the face of warfare has so drastically changed during recent conflicts, so have
the injuries servicemembers are sustaining and thankfully surviving. Injuries
that would have been fatal 20 years ago are now being treated and survived
through advances in military field medicine. In the decade since the Sept. 11, 2001
terrorist attacks, 2,333,972 American military personnel have been deployed to
Iraq, Afghanistan or both, as of Aug. 30, 2011 according to the Department of
Defense (DOD). Of that total, 1,353, 627 have since left the military and
711,986 have used VA health care between fiscal year 2002 and the third-quarter
fiscal year 2011.
Currently, 58.2 percent of those still
currently in uniform have served a deployment or multiple deployments since
9/11. These are the same men and women that will turn to VA after their
service. These men and women, approximately 800,000 servicemembers, will
transition back into civilian life over the next several years. It is of the
utmost importance that VA be prepared and equipped with only the finest
personnel, prosthetics and technology to care for these men and women. As a nation, we must be able to ensure that
when our wounded warriors return from the battlefield, they will have access to
the highest quality of care possible.
As previously stated, recent
conflicts have given way to a surge in the survival of physical injuries such
as, but not limited to, amputations, hearing and sight loss, spinal cord
injuries and brain injuries; all conditions which will be treated by or
provided resources from the Veterans Health Administration (VHA), more
specifically Prosthetic and Sensory Aid Services (PSAS).
When someone thinks of prosthetics,
they usually think of a prosthetic arm or leg. Which is correct, however
prosthetics encompasses so much more. I believe the simplest way to describe
the care and services PSAS provides, is to say if something is in a veteran (surgical),
on the veteran, or for a veteran, it falls under the responsibilities of the
PSAS department. For example, items such as: prosthetic limbs, surgically implanted
devices, such as heart valves, specialized footwear for diabetics, walking
canes, eye glasses, wigs, wheelchairs, hearing aids, Service and Guide Dogs and
thousands of other items or services needed to ensure only the highest quality
of care to our veteran community will be provided through PSAS.
Astoundingly, the number of veterans
requiring the services and care of PSAS has risen from 25 percent to nearly 50
percent over the past five years. When compared to the total growth in the
number of veterans seeking care from every other VHA department, which is about
13 percent, PSAS has grown by more than 78 percent during the time same period.
PSAS also saw a huge growth of approximately 1,800 percent in the number of
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) women veterans
under their care from 2005-2009. This number is projected to steadily rise with
our continued involvement in Afghanistan until 2024 and our presence in Iraq or
Operation New Dawn (OND).
It is a known fact that VA has long
been a leader in the development of new prosthetics and groundbreaking research.
Over the past several years, VA’s prosthetic development has revolutionized the
way in which prosthetics work around the world. However, with these new prosthetics
and medical advances also come new challenges for VA and PSAS, including
ensuring that prosthetists, both inside the VA and those with whom the
Department contracts, have the skills and proper training to service these new
devices. If we are to optimize prosthetic care, we must ensure the
credentialing, training and abilities of the PSAS personnel tasked with
treating veterans.
That being said, I believe an issue
hindering PSAS and veterans equal access to care, is what I believe to be a
broken qualification standards and credentialing for prosthetic orthotic
professionals. This lapse in uniformed standards across the nation are hurting
veterans’ access to quality and timely PSAS care and services. Currently, VHA
has established requirements for VA prosthetists and orthotists, and the
position requirements vary by General Schedule (GS) grade level. Certification
is required at the GS-12 grade level or above. However, many times these
prerequisites for credentialing are not properly enforced. While OIG was able
to verify that all required prosthetists and orthotists staff in Regional
Amputation Center (RACs) and Polytrauma Amputation Network Sites (PANS) were
certified according to VA policy in their March 2012 report, I have serious
concerns as to whether or not all other PSAS departments around the country are
adhering to the same requirements for their prosthetists and orthotists staff.
Furthermore, in regards to women veteran’s
care there is also a distinct lack of certified mastectomy fitters in the
VA. There is actually a shortage of
fitters and technicians throughout the system.
These broken qualification standards are the reason for this. They do not allow medical centers to properly
recruit and retain qualified individuals into these roles. The government needs to maximize an
individual’s function. Having a
certified prosthetist orthotist fitting shoes is not an efficient use of that
clinical practitioner’s time. VA should
have the ability to hire GS 5/6/7 fitters and technicians to accomplish this
work and free up certified prosthetists and orthotists to do more direct
patient care to maximize a Veteran’s function and independence.
I urge PSAS to immediately develop
and implement uniformed qualification standards that shall encompass all areas
of orthopedic and prosthetic care, beyond the GS level. I would further
recommend regular continuing education and credentialing verifications to
accurately verify that the prosthetists and orthotists treating our severely
disabled veterans are providing cutting edge, quality care to every single veteran
they care for.
Amputations are another injury PSAS
serves as the primary care and rehabilitation providers. According to the
Defense Manpower Data Center, the numbers below illustrate the number of
amputations sustained during service, as of November 2011.
- There
are 1,286 service members who are now amputees as a result of the Iraq and
Afghanistan wars.
- In
2011, 240 deployed troops had to have at least an arm or a leg amputated,
compared with 205 in 2007, the height of the surge in Iraq, according to
data published by the Armed Forces Health Surveillance Center.
- The
increase in 2011 coincides with the surge of troops in Afghanistan, who
often dismount on foot patrols in the country’s austere and rugged
terrain.
Troops wounded in Iraq and Afghanistan
also have suffered the loss of multiple limbs — of the 187 service members with
major limb loss in 2010, 72 of them lost more than one limb, according to the
report from the Army’s Dismounted Complex Blast Injury Task Force.
While the number of veterans having
sustained a battlefield amputation has steadily risen, it is also very important
to remember that PSAS not only cares for those veterans having sustained
battlefield amputations. They also perform and care for thousands of veterans
every year who undergo amputations related to other medical issues while already
under VA care. This can be due to a number of medical issues, such as diabetes
or infection.
For example, in FY 2011, 6,026 veterans
underwent an amputation, with 2,248 having major amputations. Of the 6,026
veterans, 107 (1.8 percent) were female and 24 of the 107 women were veterans
of OEF/OIF/OND. The chart below provided
by VA OIG in March 2012 shows the distribution of amputations performed at all VA
facilities in FY 2011.
Regardless of the cause, PSAS is
tasked with providing and caring for all amputees and that is why they must get it right for
every veteran amputee they care for.
This is another issue in which I believe
PSAS could be more effective and improve their care models, specifically
speaking to female amputees. The number of women veterans utilizing PSAS has continued
to rise over the past five years. From FY07 to FY11, the number of items
provided to female veterans rose 191% from 638,000 to nearly 1.9 million. With
that in mind, VHA decided to update VHA Handbook 1330.01 in 2010 to reflect
this change. VHA Handbook 1330.01 as amended states:
“Women Veterans
Program Manager (WVPMs) need to work closely with the Prosthetics Service and
Supply, Purchase and Distribution Department to ensure that supplies specific
to women’s health are properly stocked, easily requested, and provided in a
timely manner (e.g., intra-uterine devices (IUDs), breast pumps, compression
stockings, etc.).”
While I absolutely agree with this
part of the amended handbook, I also believe that this handbook and several
other internal publications still fall short when outlining the policies and
procedures that guide the care of VA’s female amputee population. I strongly recommend
that PSAS immediately adapt several policies, as well as the limb prosthetics
they purchase to better fit and meet the needs of women veterans undergoing
care for amputations.
While I can give my recommendations
to this committee, I felt that it would be more appropriate for an actual
female double amputee to share her concerns with you regarding this issue. A
very close friend of mine, Sue Downes, lost both of her legs in Afghanistan when
multiple Improvised Explosive Devices (IEDs) hit her convoy in the winter of
2008. Sue was the only survivor in her Humvee that day. Sue is the first woman double amputee from
the war in Afghanistan. She is resilient to say the least and has a sense of
dedication to country and her fellow soldiers like I have never seen before.
Sue survived her grueling eight hour ordeal in Afghanistan and was transferred
to Germany to be stabilized and then to Walter Reed Medical Center where she
and her family would spend the next 20 months. Army doctors told Sue, that she
most likely would be confined to a wheel chair for the rest of her life. However, Sue was a wife and is a mother of
two young children, thus she told the doctors, that was simply not an option
and she would walk. Given the fact that Sue was the first female soldier
double amputee the hospital and staff struggled to find prosthetics legs that
would correctly fit and support her female frame. Up until this time, the
Department of Defense (DOD), and most VA facilities, had become accustomed to
treating, individualizing and fitting male amputees and thus only had the
equipment and experience fitting our male wounded warrior amputees. This was a
milestone for both DOD and VA. They now needed to be changed to meet the needs
of America’s new returning wounded warrior amputees- women.
While, VA PSAS does provide the
world’s leading limb and prosthetics care and equipment, many women amputees I
have spoken with strongly believe that their facilities in their VAMC’s PSAS
departments, more specifically limb care and fitting, are still designed to
primarily meet the needs of their male counter parts.
Sue told me that when she was first
being treated at Walter Reed Army Hospital they made a statement to her, that
it was very difficult to work with her injuries since her body was so different
from a male when it came to prosthetics. Sue stated, “Our bodies are totally
different than our male counterparts. So even though working with me was a challenge,
we got through and actually helped the physicians start to master treating
female double amputees.”
“I feel like that since I left
Walter Reed I have had to fend for myself within the VA system. I live in a
rural area of Tennessee and have to drive two hours each way for my prosthetics
visits. Thus far, VA has yet to meet my needs in fitting my two prosthetic legs
properly. While I have encountered several caring individuals from VACO PSAS
since Christina Roof has become involved in my case, I still feel like I am not
given the same care or respect as my male counterparts. I feel as though I am
often yelled at because of certain female issues beyond my control. For
example, I cannot help if I fluctuate in weight and that I retain water certain
times of the month, causing my sockets not to fit properly. I feel like I
always have to “beg” for new fittings because I’m constantly changing in volume
and water weight in my legs.”
Sue continued, “I can’t shave what
legs I have left either. It is embarrassing and prevents me from wearing
anything other than long pants. I am not going to walk around with hairy legs.
As a female double amputee life is hard enough, the fact that I just want to
feel like a normal woman should not be too much to ask. So, if VA PSAS does not
want women amputees to shave their legs then maybe they could provide us laser
hair removal treatments. I am not asking for special treatment, I am just
asking to feel as normal as possible. As far as the types of prosthetics go,
yes I would like to look like I have normal flesh colored legs, instead of two
metal rods. Again, I just want to look as normal as possible, so my kids do not
have to answer questions to schoolmates about why their mom has metal legs. I
love my country and would do it all again, but I, we, have sacrificed for our
country and would at least like somewhat of a normal life back. Is that too
much to ask? Yes, to women looks matter. My image and outer appearance means a
lot to me as a strong woman. While I have recently received a pair of much
better legs, I really just want a single pair of cosmetic legs. However, every
time I ask my VA PSAS department they tell me that it will cost too much and to
just “make due” with what they have already given me.”
Sue is not alone in feeling as if not
all of her needs as a woman amputee are being met. I have spoken with several
women who are encountering the same types of issues. I cannot say whether these
problems are due to a lack of education at the individual VAMC level, problems
in credentialing or purchasing, or purely a funding problem. Whatever the cause
may be, I sincerely ask this committee to immediately examine and take actions
on what can be done to meet the needs of our women amputee wounded warriors.
A problem I also believe to be
hindering the optimization of every veteran under PSAS for an amputation is the
lack of “Complete Patient Centered Care”. What I mean by this is, that I
believe veterans receiving care for amputations are not treated as a “whole”
person needing assistance in multiple areas, but rather are treated in a more
reactionary way by individual departments who might not always share
information with each other. While I am aware of and applaud VA’s initiative
called “Patient Aligned Care Teams” (PACT), however VA has been very slow
to implement this initiative even in their pilot sites, and I also believe that
this is a model of care that must be integrated into the care of all veterans,
not just amputees. That being said, I will keep my comments focused on amputees
today.
Amputees are a special population of
veterans and usually have more medical complex medical needs than other
non-amputee veterans have. This being said, the current broken system of
often-reactionary care has caused many problems and unnecessary stress for the
veterans already having to deal with the loss of a limb. While I understand
that several VAMCs are utilizing this team approach to a veterans care, I
strongly believe that all severely disabled veterans need to have the option of
receiving this team approach, regardless of location. If we are truly to
optimize a veterans quality of health care, we need to ensure that veterans in
all parts of the country have access to the same care approaches, such as the
team approach.
Veterans having sustained a single
or multiple amputations will need far more than simply “limb” care. This group
of veterans will have very complex medical needs that need to be addressed and
treated in conjunction with all other medical care they are receiving. For
example, an amputee will have most likely suffered a Polytraumatic Injury and
will need much more assistance and guidance than other veterans will. This will
range from medical care coordination between an army of doctors, social workers
and care providers. This may include, but is in no way limited to, people such
as a Neurologist for the treatment for Traumatic Brain Injuries (TBI), Plastic
Surgeons to repair physical wounds and skin grafts for burns or limb
re-construction, Psychiatrists and Psychologists for mental health care, Social
and Case Workers to inform the veteran about their eligibility for benefits
such as clothing allowances, home adaptations and so much more. This is why I
believe it to be critical that VA PSAS, and VA as a whole, start treating the
entire veteran in a proactive manner, instead of treating the veteran by
individual symptoms and needs that may arise. Each veteran receiving care for
an amputation should be assigned a dedicated “Care Team” that meets on regular
basis to discuss the veterans care and treatments by each of the individual
physicians and care providers assigned to the veterans “Care Team.” This is a very simple and cost free way of
ensuring every veteran undergoing care for their amputations and related
medical issues will receive the highest quality of coordinated care VA has to
provide.
This “Care Team” should be composed
of the veterans PSAS representative, social worker and every physician who
regularly treats the veteran. This will
help ease the stress the veterans experience trying to remember to tell their
different doctors about something they learned from another doctor, will
greatly improve the quality and safety of the care the veteran receives and
will provide the highest quality of coordinated care VA has to offer.
Another issue we must revisit, is
the issue of timely access to quality prosthetics care and services. I strongly believe that access to PSAS care,
services should be a top priority for VA, and that overall PSAS has done an outstanding
job developing several new methods to meet the needs of today’s veteran
population, I also believe that there are several factors actually hindering a
veteran’s access to timely and quality PSAS care and internal hurdles PSAS
staff must overcome every day in order to meet the most basic of today’s
veteran’s needs. In order to optimize the PSAS system of care and internal
issues there must be several changes addressed immediately.
An issue hindering a veteran’s
timely access to PSAS care and services is the fact that VHA has not established, nor does it maintain any system of
national patient records or the physician’s original corresponding request to
PSAS. I believe this not only negatively affects the veteran, but also poses a
threat to the integrity of VA’s purchasing policies and procedures.
The lack of a centralized tracking
and data exchange system available to physicians and purchasing agents simply
hinders a veteran’s timely access to care. Moreover, due to fragmented patient
records, veterans may not receive the care they need should they have to visit
any VA Medical Center (VAMC) or Community-based Outpatient Clinic (CBOC) other
than their home VAMC or CBOC. For example, if a veteran utilizing a wheel chair
is on vacation or on travel for their job, and the wheel chair requires
immediate assistance or service from PSAS, the veteran will most likely
encounter bureaucratic obstacles at the nearest PSAS department as result of
the missing PSAS data exchange system. This same fragmentation puts veterans at
a high risk in the event of an emergency.
Whether it is another Hurricane Katrina, or even a snowstorm in Buffalo,
VHA’s lack of a national record and request system means that a veteran’s order
cannot be processed if those local employees that are unable to get to
work. Moreover, if veterans are
displaced, there will be a substantial delay in replacing essential
equipment. This is a simple IT solution
that VHA has no ability to execute due to the centralization of VA’s IT.
A recent OIG report found that
Prosthetics was lacking some basic inventory controls, but this too indicated a
lack of appropriate IT resources to have a modern inventory system to track and
monitor stock and reorder levels. This
extends out to surgical implants where there is a high risk of expiration- costing
VA millions of dollars and possibly veteran lives.
VA’s issue, negatively affecting
PSAS, associated with not having a comprehensive modern inventory solution goes
back to the calamity of the Core Financial and Logistic System (Core FLS) programs, and more
recently the abandoning of Financial and Logistic Integrated Technology
Enterprise (FLITE) and Strategic Acquisition Management (SAM) programs. Although VHA is trying to salvage some
aspects of these programs, any real implementation is several years away. I
urge VA to act swiftly on developing a data exchange system for the use of PSAS
personnel to avoid a potentially large backlog where veterans would be unable
to obtain the immediate resources and care provided to them by VHA PSAS.
Currently, VA has no way of tracking
vital information on patients’ care and purchasing orders, thus opening
themselves up to potential fraud and abuse, and the inability to provide the
highest quality care to the veterans they serve. The inability to provide all
veterans equal access to care through centralized purchasing units—instead of
the current fragmented paper copy system—also prevents PSAS from maximizing
efficiencies.
Over the past couple years, VA has
been moving to professionalize the acquisition workforce and adhere to archaic
federal acquisition laws and regulations, none of which were written with an
individual’s health care needs in mind.
It is my understanding that VHA has concluded a pilot to move
procurements from the Prosthetic and Sensory Aids Service to VHA Procurement
for those items over the micro purchase threshold.
I implore the committee to make it
clear to VA that not only do they have the authority to procure outside of
Federal Acquisition Regulations (FAR)- 38 USC 8123- they have a duty to do so
to ensure that our veterans are provided the most appropriate devices in the
most expeditious manner possible. We
have slowly begun to hear rumors of delays where veterans, even those most at
risk such as amputees, spinal cord injuries, and those with ALS (Amyotrophic
Lateral Sclerosis) are having their life critical devices held up in a
bureaucratic nightmare. Congress and VA must
recognize a clinician’s autonomy and ability to prescribe what is best for that
individual veteran.
While VA’s Senior Procurement
Executive has repeatedly touted a new Strategic Acquisition Center, the fact
remains that this is simply in addition to the National Acquisition Center, the
Denver Acquisition Logistics Center, and the Technology Acquisition
Center. At the department level, VA
seems to be building a substantial level of duplication, all in an attempt to
standardize prosthetics procurement for veterans. Duplications of efforts are
not the fiscally responsible way to run any federal agencies, nor is it helpful
in optimizing a veterans care and access to PSAS services.
However, when this executive is
asked, the Department will state that this is not meant to reduce the ability
to give veterans the most appropriate items, their actions run contrary in that
without these contracts, VA is forcing these orders to be competed. Even within a given contract award, there is
a push for procurements to be distributed amongst all awardees. This means there is still a complete lack of
respect for a veteran and their clinical team’s decisions. These inefficient
practices must immediately be addressed and corrected, if we wish to provide
timely and quality access to PSAS services for our veteran community.
Finally, a large problem that poses
a hurdle to care to veterans requiring PSAS resources is the location and
availability of resources to veterans living outside of major metropolitan
cities. Over 4 million of the veterans enrolled in the VA Healthcare System
live in rural areas. There is an overwhelming national misconception that all
veterans in need of PSAS have equal
access to the comprehensive care and other programs provided by VHA’s PSAS. Unfortunately, this is not true. Access to
the most basic primary care is often difficult in rural America, let alone the
extensive individualized care that accompanies amputations or other serious
conditions in which PSAS would provide care. Currently, PSAS does not have the
necessary prosthetic or orthotic professionals in-house needed to meet the
demand for services by the veterans’ community. This is especially true for
veterans living in rural areas. Some veterans have to drive hours for something
as simple as getting their prosthetic limb adjusted or for physical
rehabilitation. PSAS has approximately 600 contracts with local vendors across
the nation to provide care closer to home for these rural veterans. However, as
VA moves to their new procurement model, I am sincerely concerned that when a veteran
has a unique situation, or medical need, requiring the services of a vendor not
on contract with PSAS that this will no longer be an option under this new
model of care where PSAS procurements are accomplished through VHA’s
acquisition service. I concur with the
IG’s recent report on limb procurement that VA needs to assess its internal
capabilities and determine the correct number of contracted vendors to have in
a particular area. This should not
preclude a Veteran from being able to utilize a vendor not on contract when
that Veteran has a unique medical need or lives in an extremely remote
area. I believe strongly in the
authority granted PSAS by Congress in 38 USC 8123.
Alarmingly,
a 2006 study of the Carsey Institute reported that the death rate
for rural veterans is up to 60 percent higher than the death rate of veterans
residing in urban areas. Given the difficulties that already accompany being an
amputee then couple it with the multiple obstacles rural veterans often face in
their efforts to receive medical and PSAS care is resulting in many veterans
missing appointments or foregoing care for a number of reasons beyond the long
distances they must travel. VA has
stated that over 50 percent of the veterans they treat live in areas of the
country they consider to be “remote” or “highly rural”. This statistic alone
should be more than enough of a reason to establish a better system of care of
locations were that care can be received.
I do however applaud several VAMCs
PSAS departments who are actively seeking out and treating rural veterans. For
example, PSAS teams from Colorado and Wyoming have established a Prosthetic
Treatment Center Mobile Laboratory. According to VA “A certified
Prosthetist-Orthotist will travel to rural areas in Colorado and Wyoming in a
van equipped with a mini prosthetic-orthotic fabrication laboratory, computer
assisted design and manufacturing capabilities, and telehealth equipment. This
program will bring expertise in high end-orthotics and in prosthetic
fabrication and fitting to rural Veterans, and the van will be used for
tele-consultations with prosthetic and orthotic rehabilitation specialists, the
Amputation Rehabilitation Coordinator, podiatrists, and wound care specialists
from the Denver VAMC. This mobile laboratory will provide rural Veterans with
access to the Regional Amputation System of Care (RAC) based in the VA Eastern
Colorado Health Care System. This mobile laboratory will provide a more
consistent standard of care for rural veterans than is currently possible with
community vendors.”
I would lastly like to note that PSAS
has been under “acting leadership” for nearly a year and a half. A
department offering services of this magnitude cannot hope to improve the services
they provide to to veterans as long as they are languishing without a leader to
provide the proper direction. Prosthetics needs to have a senior leader
appointed as soon as possible. I believe this leader should at minimum be
currently serving at the Chief Consultant level, if not Chief Officer given the
unique nature of the program and it's far reaching, significant impact it
has on all veterans, especially our most vulnerable veterans with severe
disabilities.
In closing, the current conflicts,
along with an aging veteran population and tighter budgets have placed VA PSAS
under tremendous strain. Congress and VA
have both made an effort to ensure that the budget for medically prescribed
devices is substantial enough to ensure that veterans receive the highest quality
devices. Unfortunately, many at VA seem
to be devolving themselves into a bureaucracy where the people who were successfully
procuring prosthetic items are no longer going to be involved. VA PSAS has IT systems that are woefully out
of date, placing veterans at risk for not receiving their required care, while
also putting VA at risk for increased fraud, waste and abuse. High-risk populations, such as rural and
women veterans, continue to be the ones in danger of not receiving the care
they have earned through their selfless service. Congress has already recognized that federal
procurement laws and regulations do not always work for the personalized health
care many of our most severely disabled veterans require. I beseech you to ensure VA respects the
autonomy of their physicians and the preferences of veterans by continuing to
use 38 USC 8123 to provide medically prescribed devices to veterans in the most
efficient way possible. I also urge this subcommittee to have the strictest of
oversight to ensure VHA PSAS is provided with the necessary resources to develop
and implement a national prosthetics record, a modern inventory system and the
clinical and administrative staff required to properly support our veterans and
optimize their prosthetics care.
Madam Chair, and distinguished
members of the subcommittee, I would like to again thank you for inviting me to
share my views and recommendations on this critical matter with the
subcommittee today. I stand ready to
address any questions or concerns you may have for me. Thank you.
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STATEMENT OF CHRISTINA ROOF (AMVETS)
Mr.
Chairmen
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STATEMENT OF CHRISTINA ROOF (AMVETS)
HEALING THE WOUNDS: EVALUATING MILITARY
SEXUAL TRAUMA ISSUES
May 2010
By way of background and clarification, AMVETS understands
that Military Sexual Trauma (MST) is in no way exclusive to the female veterans
population, however much of our testimony today will be based on specialized
treatments for women whom have experienced and are being treated for MST.
Women veterans are the fastest growing subgroup of the American
military veterans’ population today. In fact, 2009 estimates show that women
compose 14% of today’s military forces and more recently DOD has indicated that
number has grown to approximately 18 percent, and within the next 10 years this
number is expected to nearly double. If those estimates hold true than upwards
of 30% of America ’s
military forces and veteran community will be comprised of women. Women are
also being deployed to combat zones at a rate in which this country has never
seen and are carrying out vital roles on the frontlines. A 2008 VA study showed that 45-49% of female
OEF/OIF veterans were enrolled in the VA Health Care System and were using VA
provided services on a regular basis. This same study also showed that over 50%
of the women currently enrolled in the VA health care system, 46% were under
the age of 30. Now, more than ever, we
must make sure that VA is ready and equipped with the necessary staff,
facilities, and gender specific care programs to offer the best available care
to today’s returning women servicemembers. According to VHA officials more than
1,000 new cases involving MST are uncovered each month, yet little is known to
VHA staff about mental health needs of MST-exposed patients, or access to and
utilization of services by these patients. While AMVETS understands that the VA
health system is facing a very large endeavor in providing and implementing
effective care models to their patients regarding MST, we also find self-proclaimed
lack of knowledge on the subject unacceptable. VA’s health care providers must have
the experience and knowledge to treat all wounds of war.
Treatment and care models of MST do not differ so
dramatically from VHA to care provided by private sector physicians to the
extent that VHA should be having trouble understanding MST and the related
metal disorders that often accompany it. There are already many established and
long used models that can serve as guiding principles for VA in the
establishment and implementation of care relating to MST. If VHA believes they
are lacking in the prior experience needed to effectively provide care, AMVETS
believes VHA may be best served in reaching out to private sector or other
agency care providers for guidance and assistance. In fact, on March 3, 2009 VA’s Principal Deputy under
Secretary for Health, Dr. Gerald Cross, stated “We believe it is essential that
our medical professionals across the system be able to effectively recognize
and treat the manifestations of sexual trauma and PTSD,” further proving VA’s
agreement with AMVETS on this matter.
VA defines Military Sexual Trauma as sexual or psychological
trauma resulting from sexual harassment or abuse that either men or women are
subjected to while serving in the military. Due to further research by AMVETS,
we were able to gather a further breakdown of the terms used to define MST as
recognized by VA. AMVETS research of current VA policies produced the following
definitions:
1. Sexual Assault is
defined as intentional sexual contact, characterized by the use of force,
psychical threat, and/or abuse of authority when the victim does not consent.
2. Sexual Assault is further
defined as encompassing force or the threat of force, coercion is used, or when
the un-consenting party is asleep, incapacitated, or unconscious.
3. Sexual Abuse is defined
as, but not limited to, insistence on unwanted touching, forcing of unwanted
sexual acts and demeaning remarks, treating as a sexual object with no regards
to emotional well-being.
4. Sexual Harassment is
defined as a form of gender discrimination involving unwanted sexual advances,
the requesting of sexual acts, and any
other verbal or physical conduct of a sexual nature when a person job, pay or
rank are placed in jeopardy, creates an intimidating or hostile workplace,
and/or offensive work environment.
5. Sexual Misconduct is
defined as act is committed without intent to harm another and where, by
failing to correctly assess the circumstances, a person believes unreasonably
that effective consent was given without having met his/her responsibility to
gain effective consent. Situations involving physical force, violence, threat
or intimidation fall under the definition of Sexual Assault, not Sexual
Misconduct.
AMVETS believes that it is very important to bring attention
to the fact that the Department of Defense does not currently include “Sexual Harassment” in their definition
of sexual assault, as VA does. This difference of definition poses a problem in
itself. AMVETS believes there needs to be a single definition on what
constitutes “Military Sexual Assault”
used by both VA and DoD to better recognize and treat victims of MST, as well
as removing any questions regarding reporting of sexually related incidents.
Studies conducted by VHA and private sector organizations
from 2006-2009 show that on average 24% of all female veterans screened during
their initial VA healthcare assessment displayed the criteria necessary for
having experienced a MST event during their service. One must remember that
these numbers were obtained during initial screenings and do not factor in the female
veteran population that were later given a diagnosis of a condition stemming
from a MST event. Furthermore, with DoD and VA using separate definitions of
MST it is impossible to know how many veterans have truly experienced a
sexually traumatic event during their service.
MST and it’s correlation to a magnitude of mental health
disorders has been long documented and accepted within the medical community. However,
it has not been until recently that women veterans under VA care have been
specifically studied for the correlations of MST to PTSD and other mental
health disorders. In 1996, a survey to determine
the prevalence of physical and sexual abuse experiences, during and outside of
military service, was conducted among 828 women veterans at the Baltimore Veterans Affairs
Medical Center
Research has shown that veterans who have experienced MST
are at a high risk for developing a range of mental health conditions such as
PTSD, major depression, anxiety, and panic disorder. MST victims may also
struggle with other problems, including low self-esteem, difficulties with
interpersonal relationships, and sexual dysfunction. To the best of AMVETS
knowledge there have only been two scientifically valid studies conducted since
2001 that examined rates of DSM-IV PTSD diagnoses in women veterans with MST. First,
Suris et al.,[2] using
a sample of female Veterans Administration (VA) patients, compared rates of
PTSD related to two types of civilian sexual trauma with PTSD rates related to
MST. Suris found that MST was more frequently traumatizing than civilian
assault. Thus, the data indicates that MST is more predictive of PTSD than are
other types of military trauma or civilian sexual trauma.
The second study was conducted in 2006 by Dr. Deborah
Yaeger Dr. Yaeger Wald χ2=20.3,
df=1, P=.0001) and Other Trauma group (Wald
χ2=5.4, df=1, P=.02) significantly predicted PTSD,
but MST predicted it more strongly. This finding is significant because the
number of women positive for MST was less than half of those positive for Other
Trauma, yet the relationship of the MST group with PTSD was stronger.[4]
This is only one example of data showing the almost unquestionable link between
MST and PTSD. Finally, in 2007 the Medical University of South Carolina wrote
an article that reviewed the literature documenting the nature and prevalence
of traumatic experiences, trauma-related mental and physical health problems,
and service use among female veterans. Existing research indicates that female
veterans experience higher rates of trauma exposure in comparison to the
general population. Emerging data also suggest that female veterans may be as
likely to be exposed to combat as male veterans, although not as directly or as
frequently. Female veterans also report high rates of posttraumatic stress
disorder, which has been associated with poor psychiatric and physical
functioning. USC concluded that while sexual assault history has been related
to increased medical service use, further research is needed to understand
relationships between trauma history and patterns of medical and mental health
service use. Researchers also are encouraged to employ standardized definitions
of trauma and to investigate new areas, such as treatment outcomes and
mediators of trauma and health.[5]
AMVETS believes this review further
demonstrates the importance of a uniformed definition of MST throughout all
agencies, more specifically DoD and VA. AMVETS also believes these studies to show the
importance of integrating mental health care, as outlined by VHA 1160.01, into
all VAMCs and CBOCs providing primary care.
In 2005, VHA published VHA Directive 2005-015, authorized
under P.L. 102-85 outlining specific policies, procedures and staffing
requirements as they relate to the treatment and care of veterans who have
experienced military sexual trauma (MST). To build upon this directive VHA 1160.01 as
published in September of 2008 provided even more policies and procedures that
all Veteran Affairs Medical
Centers
The measures are as follows:
- The constant availability, isolation and safety of “women only” areas in each medical facility treating women veterans.
- That all medical directors
ensure that every patient receiving care is screened for MST.
- The use of MST software that
allows tracking of VA’s screening of veterans. The Women Veterans Health
Program and the Mental Health Strategic Work Group utilize the national
MST report to respond to Congressional inquiries and for expansion of MST
programs and initiatives.
- Veterans receiving
MST-related counseling and treatment are not billed for inpatient,
outpatient, or pharmaceutical co-payments; however, applicable co-payments
may be charged for services not related to military sexual trauma or for
other non-service connected conditions.
- Scheduling priority for
outpatient sexual trauma counseling, care, and services is consistent with
the VHA performance standard of scheduling within 30 days for special
populations and mental health clinics.
- Accurate documentation of
screening, referral, and treatment services provided to veterans,
aggregated by gender, is maintained. This process includes use of the MST
software and the MST clinical reminder to track and monitor the level of
compliance with the standard (100 percent of enrolled veterans screened). The
nationwide tracking system to ensure consistent data on screening and
treatment of victims of military sexual trauma must be used.
- MST counseling is provided
by contract with a qualified mental health professional if it is
clinically inadvisable to provide in Departmental facilities or when VA
facilities are not capable of furnishing such counseling to the veteran
economically because of geographic inaccessibility or the inability of the
medical center to provide counseling in a timely manner.
- Veterans who report
experiences of MST, but who are otherwise deemed ineligible for VA health
care benefits based on length of military service requirements, may be
provided MST counseling and related treatment only.
- The MST software
application that activates the MST Clinical Reminder within CPRS has been
installed at the facility. All veterans receiving VHA health care must be
screened for MST using this clinical reminder.
- Veterans screening
positive and requesting treatment are provided free care, with no inpatient,
outpatient, or pharmacy copayments, for mental and physical health
conditions resulting from their experiences of MST. Determination as to
whether care is MST- related is made by the clinician providing care. All
MST-related care must be designated by checking the MST box on the
encounter form for the visit.
- The time frames for
evaluations of veterans for possible mental disorders resulting from MST
must follow the requirements in paragraph 13, of VHA 1160.01.
- Evidence-based mental
health care is available to all veterans diagnosed with mental health
conditions resulting from MST.
While AMVETS does realize that VA has been making efforts to
provide better care to all women veterans, we were quite troubled by two recent
GAO reports on the standards of care our female veteran population has been
receiving at VAMCs and CBOCs, especially in the areas of mental health and MST
treatments. In March 2010, GAO published
a report entitled “VA Has Taken Steps
to Make Services Available to Women Veterans, but Needs to Revise Key Policies
and Improve Oversight Processes,” as a
follow up report to the July 2009, GAO report entitled “ VA Health Care: Preliminary Findings
on VA's Provision of Health Care Services to Women Veterans.”
AMVETS believes that what GAO reported in March 2010 is
unacceptable and quite negligent by many VAMCs in providing the most basics of
care to our women veterans. For example, in the 2009 report GAO found that none
of the facilities they visited were compliant with privacy requirements
outlined by VA. Regrettably, in the more recent 2010 report, GAO reported that most facilities still had not improved their
measures to provide the required privacy to women veterans. Another area in
need of compliance, as pointed out by GAO numerous times, are the requirements
for treating veterans who have experienced any sort of MST, as outlined by P.L.
102-85 and 38 U.S.C. § 1720D. Federal
law specifically requires VA to establish a program to provide these
MST-related services and to provide for appropriate training of mental health
professionals and such other health care personnel as the Secretary determines
necessary to carry out the program effectively. These laws state that every VA
facility to be equipped and able to provide immediate care for any veteran who
has experienced any psychological trauma as a direct result of a physical
assault or harassment that was sexual in nature during their time in service.
VA’s MST-related policies require that VAMC directors
appoint an MST Coordinator and that necessary staff education and training be
provided. The MST coordinators are
responsible, among other things, for monitoring and ensuring that VA policies
related to MST screening, education, training, and treatment are implemented at
the facility. GAO reported that VA had taken some steps internally to make
information about MST programs more readily available to VA providers.
Specifically, VA has conducted monthly, nationwide MST conference calls which
have included basic information on the structure and focus of the various
residential and outpatient programs offering MST or sexual-trauma-specific
treatment, as well as detailed presentations by key providers from several
programs. VA also has a list of the various programs on its internal Web site,
which is accessible by VA providers. However,
GAO went on to say that VA had not made the same information accessible to
veterans through VA’s external Web sites or printed literature accessible to
all veterans. As of November 2009, the website
pages reviewed by GAO from VA’s national website did not provide complete lists
of facilities that have MST-related treatment programs or specialized programs
for women veterans. The sites that did list specific residential treatment
programs usually listed a single program, while nine VAMCs have relevant
programs. AMVETS is quite concerned that VA’s outreach to women veterans is
falling short. While most of us here today are very familiar with VA programs,
the average veteran is not. It is the responsibility of VA to not only design
and implement these MST specific programs, but to also educate the veterans
living in all parts of the country on the services available to them.
How can a
veteran receive the care and assistance they need if they do not even know that
the care exists?
It was the understanding of AMVETS that ensuring the privacy
and integrity of all women veterans seeking care in a VAMC or CBOC was a
requirement of federal law, not a suggestion. Women veterans seeking care for
the most private and potentially damaging experiences, such as MST, must feel
safe and that only their best interests are at hand by VA medical providers.
What sort of message are we sending our returning female servicemembers, who
have suffered a traumatic sexual experience, when VA is not able to offer them
something as simple as an OB table facing away from the examine room door or a
private and separate sleeping area from the male patients? Can VA honestly say,
to this congressional subcommittee and to all veterans, that the oversight they
have exercised over the implementation of these care measures has been nothing
less than their best? Can AMVETS be assured
that every VAMC and CBOC is doing everything in their power to correct the deficiencies
that have been repeatedly pointed out to them regarding the care of America ’s
returning war fighters?
AMVETS offers the following recommendations regarding
military sexual trauma care and treatment issues:
- AMVETS recommends these Subcommittees
set forth a strict timeline in which VA will have to report all updates on the
implementation of MST policies and procedures in every VAMC and CBOC, and
that the committee holds VA accountable to a specific date of system wide total
implementation. AMVETS further recommends that any requests for exception
on meeting the specified deadline are required to be made in writing
directly to the Secretary for final approval.
- AMVETS recommends VA immediately
update the information on their website, as well as written literature, to
guarantee that all veterans are aware of the services available to them
and where they may go to receive said services.
- AMVETS recommends these
Subcommittees maintain strict oversight on the implementation of VHA
1160.01 as it pertains to the availability of treatment for MST and all
mental health care provided by VA, in efforts to implement and maintain
uniformed mental health care system wide.
Thank you again for giving AMVETS the opportunity to share
with you our thoughts and recommendations on Military Sexual Trauma care within
VA. AMVETS applauds the subcommittees dedication and actions to this very
important, and often overlooked, issue. This
concludes my testimony and I will be happy to answer any questions the
subcommittees may have for me.
[1] Coyle BS, Wolan DL, Van Horn AS.
[2] Suris A ,
Lind L, Kashner
M
[3] Deborah Yaeger , MD , Naomi Himmelfarb , PhD , Alison Cammack , BS, and Jim Mintz ,
PhD.
[4] Deborah Yaeger , MD , Naomi Himmelfarb , PhD , Alison Cammack , BS, and Jim Mintz ,
PhD.
[5] Zinzow HM, Grubaugh AL, Monnier J,
Suffoletta-Maierle S, Frueh BC. Trauma among female veterans: a critical
review. Trauma Violence Abuse. 2007 Oct;8(4):384-400. Review. PubMed PMID
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