2014 treatment guidance to VA providers of patients with extra-hepatic HCV disorders

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Click to go to VA site

Providers are told that in cases where there is no “significant extra-hepatic disease” treatment can be deferred.  But they are told NOT to delay treatment, even with mild liver disease, when these are present (Table 12–scroll down). These are the urgent extra-hepatic disorders linked to HCV without reservation:

Leukocytoclastic vasculitis (Medscape images) (foundation)

symptomatic cryoglobulinemia (Medline–images right menu)

membranoproliferative glomerulonephritis (Medline symptoms etc.; Medscape–secondary cause: HCV)

A large VA database 2002 study, Extrahepatic manifestations of hepatitis C among tipUnited States male veterans,  compared HCV vets hospitalized from 1992 to 1999 (n = 34,204) with random controls (n=136,816)  and found other complications.  This study has been cited by 34 papers in Pubmed.  Although I’ve only read the abstract, the information is interesting but not current.  HCVets has more current information on extrahepatic conditions their website.  It would be useful to know ALL of the extrahepatic manifestions the VA acknowledges and what “significant” means in the case of each. 

A good 2010 NYU slideshow indicates that a lot of work is being conducted on this topic. The lists are getting so long it’s hard to image anyone with HCV (active or inactive) without at least one known complication.

Posted in HCV Health, HCV Risks (documented), Jetgun Claims evidence, Medical News | Tagged , , , , , , , , , , , , , , , , , , , , | 3 Comments

CAVC– THE BIRTH OF A WRIT

VetCourtAppealsPromoHappy New Year to all and an apology is in order. I have been deeply immersed in my Opera Dei with my rainmaker. This Writ which I mentioned in December is for the whole shooting match. As some of you who “do law” have recently witnessed, Mr. Gene Groves recently handed the VA their ass on a platter- not that it required Sherlock Holmes and his bloodhounds to find the corpus delicti.

VA’s legendary ham-handed tactics leave more fingerprints on that c-file than there’s quills on a porcupine. Conversely, their inaction is equally just as evident by the dearth of documents that should  have accompanied all his (Groves’) missives. This is evident when you read some of the extensive docket in 14-269. Contrary to VA’s law for us, absence of evidence in this case was most definitely horribly and indisputably negative evidence and butresses our newest and most Holy Proscript for the new year- the dreaded Presumption Of Regularity. From here on out, we will begin abbreviating this as the POR. Remember it and keep it holy. POR is gun in a rocks/paper /scissors VA game.

VA has long waved it’s own POR flag over the centuries and with great success. In VAworld, the first cracks in POR of the mail began with Rios v. Mansfield. back in 2007. Actually, Butler v. Principi touched on the general idea in 2001 (see below) I wrote it up to illustrate how it works from both sides. However, Jurisprudence runs far deeper on this whole POR game these days. Far too often in the judicial arena,  we are given the perfect opportunity for a roundhouse left sucker punch that could put Will. E Gunn’s new protégé, Leigh Bradley. out cold on the floor. Many attorneys, pro se Vets and, of course all VSO service reps. miss this legal opportunity to knock one out of the park. Hey, it’s a free shot. VA walks right into it. To give them a bye on it is foolish. Make them look like boobs.

In the haste to cite to regulations broken or ignored, all too often two priceless areas are overlooked. The POR- check. But what of the lovely 10 commandments sitting in there front and center at the start of 38 CFR § 4 ? When you get really immersed in it, you can start roaming the VA OGC Precedents for more ammo.

Without going that far afield, we see the early beginnings of POR back in 1983 but all jurisprudence in that vein was cited by those accorded the Presumption. They didn’t have to prove “actual compliance” because they were Poohbah’s with a capital P and were trusted to do the right thing always. Somewhere along down the line in VAland, it became increasingly obvious that VA didn’t always follow their own rules. VAOIG insists they’ve been telling us this about the VHA since 2005, but we just didn’t listen. And now we have another Phoenix VAMC rising from the ashes daily.- only in Denver, Seattle and Pittsburgh. Their criticism of the 58 Fort Fumbles across the fruited plain was far more muted.

The POR doctrine thus allows courts to presume that what appears regular is regular, the burden shifting to the attacker to show the contrary. United States v. Roses, Inc.,706 F.2d 1563, 1567 (Fed.Cir.1983).

download (1)Mr. Tommie P. Butler , with “Kansas Kenny” Carpenter (no relation to Karen of singing fame) as his shieldbearer, decided to disassemble this POR Rubik’s cube and see what happens when you stand on the other side of the mirror. This was the seminal case to point to and will be for a while for Vets. He lost as did Norm Gilbert and a host of others before him but an important concept began to metastasize. What appears regular is regular for VA. But this ax cuts both ways. Conversely stated, what appears irregular is irregular. If VA cannot, by the preponderance of evidence in the c-file, prove conclusively, as in Mr. Groves’ case, that they have done everything according to Hoyle, the grand POR façade crumbles.

What was left in Mr. Groves’ case was the reality that VA made absolutely no attempt to “listen” to him. You and I know this. Often we can’t get any definitive answers from the Puzzle Palace until we hire the law dog. Apparently they have all the phone numbers and email address of those we seek to inform. What? you guys and gals think Kansas Kenny calls the VA Prize Redemption Center at their toll-free 800-827-1000 hotline every time he has a question? That VSO Koolaid you’re drinking will kill you.

Mr. Groves will, very soon if he hasn’t already, be getting lots of correspondence from the Houston Regional Office which is his Agency of Jurisdiction. A lot of it should have been sent years ago, but hey, they still have Pony Express out there in Bugtussle. It’s not VA’s fault he decided to live at the ass end of nowhere. That’s the hubris the VA exhibits. You’ll be reading about VA hubris very soon in my new Writ.

tr6As for the “what appears irregular, is irregular”, this is the operable phrase for 2015. This is the smoking gun for us. If, by the sum of evidence, something essential is missing from your adjudication -say an SSOC that should by rights have been issued and wasn’t- this isn’t just a Cushman due process violation anymore. It becomes a double ticket- kind of like all those speeding while DUI I got back in the eighties when I was divorced and driving a fuel-injected TR-6 at 0201 Hrs Local. Correct. Think Cushman with Butler on top. The VA rater is no longer accorded the fig leaf of POR respectability if it can be shown he can’t adjudicate a claim correctly.

The teaching lesson today and for this glorious new year under the reign of Bob the Merciful is to look for that which doesn’t fit-i.e. irregular. If VA makes a broad, unsupported statement or grossly misinterprets a CFR, what you are really looking at is “irregular” which is synonymous with the word inept. If they are inept, the presumption that they are knowledgeable in all they do is rebutted . VA personnel, by virtue of POR, are presumed to be Superwo/men capable of leaping tall c-files at a single bound, more powerful than a Cray super-cool(ed) computer and faster mentally than a speeding VBMS word-searchable .pdf. By demolishing the foundation, little else is left standing. And here is the beauty of it. When you prove this violation, the burden shifts to the attacker (VA) to show the contrary. Boy howdy that’s a funny dance to watch.

Before the end of March this year and the twenty first anniversary of my 1994 filing, I hope to teach the finer points of POR.  Recognizing it sometimes can be as innocuous as VA just happening to inadvertently let drop that you were in Vietnam after vociferously denying the  idea for thirteen years. Or better, to accidentally grant a 10% Tinnitus claim for increase back to 1994 and think this chucklehead Vet is going to guffaw a few times like Gomer Pyle and go home.

2015 will be a banner year for VA CAVC and Fed. Circus jurisprudence. We’ve broken through the glass ceiling of VA’s respectability that has stymied us for so many decades. With almost twenty five years of VJRA-infused oversight and a more Veteran-friendly, paternalistic mindset finally being allowed to infect federal judges, we can expect to be greeted on a more even footing instead of feeling we’re climbing Mt. Everest without a Sherpa. With the 2007 revision finally allowing us real leagle beagles and not the VSO variety, our chances for a win increased astronomically on appeal. Just imagine what we could accomplish with a real attorney filing in our stead in the first instance at the VARO. They wouldn’t be forced to sweep up the broken glass caused by well-meaning service officers.

Gene Groves’ case taught me several things philosophically about the proper amount of umbrage to express but SquareBob Spongepants hit it perfectly from my perspective. His immortal words that kept me from diving off the deep end prematurely:

“You only have one chance at this to get it right Buckwheat. Think of it like this. You augered in with a dead engine. You’ve been waiting for an extraction for two days. The SAR txponder is dead (as usual). You only have one smoke grenade and you can hear that BUFF 53 pounding the jungle searching for you. You either hold up until you know you’ll get a visual when you pop smoke or you’re gonna be walkin’ home.”

Thank God ol’ Bob is going to roar in a week later waving my POA and do his Al Sharpton goes to Fenderson MO. imitation (“The Boy was dissed for twenty years, I say!). Great legal theatre is in store for all.   Act I -Poor pro se Vet shows up with Ferrari Writ from Hell authored by Clarence Darrow himself.

SquareBob Spongepants, Come on Down!

LawBob Squarepants, Come on Down!

This is the first of a multi-part series. Call it Act I. Scene one. Here’s the next scene

https://asknod.wordpress.com/2015/01/06/cavc-birth-of-a-writ-act-i-scene-2-fair-is-foul/

Posted in CAVC Knowledge, Extraordinary Writs of Mandamus, Presumption of Regularity, Veterans Law, Vietnam Disease Issues | Tagged , , , , , , , , , , , , , , , , | 7 Comments

The Phoenix VA Whistle-blowers

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Physical courage — something you find on athletic fields, for example — is very common, but moral courage is not. It is not easy to stand up for what is right when that might mean losing one’s job, one’s family or even one’s life. It is far easier to keep quiet and let things slide.  

Alice von Hildebrand (91), philosopher and theologian

This recent quote by von Hildebrand reminds us that it is not easy for anyone to confront evil deeds when we know that evil may prevail.  Retaliation for speaking out is common at the VA nationally.  Yet some people in Phoenix did confront evil and because of them, things should get better for thousands of people.  

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Ms. Pedene Has a new VA job as part of her settlement

Paula Pedene, a former VA spokesperson, reported financial mismanagement, and was removed from her $106,000-a-year job and exiled to a basement desk.

Damian Reese, a program analyst, complained to management about the wait-times and “had his annual performance rating downgraded by a senior official with knowledge of his email.”

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Dr. Mitchell

Katherine Mitchell was placed on administrative leave–but after the expose, received the VA’s public servant award last month.  The Republic writes, “Mitchell files a confidential complaint intended for the VA Office of Inspector General, channeled through Arizona Sen. John McCain’s office. Her list of concerns instead goes to the Office of Congressional and Legislative Affairs and eventually back to the VA, which responds in February 2013.”  Her video.

Pedene, Mitchell, Reese, have received confidential settlements/ video (9/14).

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He’s putting himself “out there” for veterans.

Dr. Sam Foote (61) started the national investigation (CNN video) by filing a complaint with the VA OIG.  He had complained to the OIG about a different administrator in 2011–who then quit. AZ Republic:  In early 2013, Foote lodged a complaint against another executive, but this time, he said, “They started coming after me.” Hours and caseloads increased, and Foote said he began to feel harassed. A planned 2015 retirement no longer seemed possible. He set a new date of Dec. 31, 2013 .” He  secretly co-operated with the Arizona Republic until his retirement and he was safe to contact members of Congress and go very public. Shades of Watergate.  The story is here.

These women also helped out:  Pauline DeWenter, scheduler video (6/14). A confession. K.J. Sloan, a clinical social worker video  (6/14)  She explains the scam.

*****Timeline: VA in Crisis

*****CNN Timeline--national VA scandals from 1921

Blinded+by+greed_be21f7_4648242

It’s sickening that Helman got off on the wait-times scandal but she’s gone.  And the man who gave her lavish gifts has lost his job too.

Dr. Foote, has, I believe, provided the VA with the names of some of the dirty rats at Phoenix’s VA.  I hope he’ll devote the rest of his life to the cause of reform at the VA. 

 

It’s good to know that everyone isn’t like the guys in the cartoon. So, thank you to the courageous citizens and the journalists who told your stories–“You did good!”

 

 

 

Posted in Guest authors, VA Health Care, VA Medical Mysteries Explained, VAMC Scheduling Coverup | Tagged , , , , , , , , , , , , , , , , | 6 Comments

U. S. Navy New Year’s 2015 celebration image from Japan

Yokosuka New Year's Eve

Fireworks explode in the air over U.S. ships docked in Yokosuka, Japan, Jan. 01, 2015, as part of a New Year’s celebration. U.S. Navy photo by Petty Officer 3rd Class Chris Cavagnaro

With 24,000 military and civilian personnel, this is a very large installation!

Fleet Activities, Yokosuka comprises 568 acres and is located 43 miles south of Tokyo at the entrance of Tokyo Bay and approximately 18 miles south of Yokohama. Yokosuka is on the Miura peninsula in the Kanto Plain region of the Pacific Coast in Central Honshu, Japan. CFAY is the largest overseas U.S. Naval installation in the world and is considered to be one of the most strategically important bases in the U.S. military.

My knowledge of Asian geography and history is sorely lacking.  If I hadn’t seen the fine japan nbimage by Petty Officer Cavagnaro, I’d never have looked Yokosuka up. It’s clear that this base remains an important part of our national defense.  Perhaps you or a family member has served there in the past or may in the future.

I don’t know how many Americans are so far from home as the new year begins but may everyone return home safe and sound and appreciated by a grateful country.

Posted in Food for the soul, Future Veterans, Guest authors | Tagged , , , , , , , , , , , , , | 6 Comments

FOOTLOCKER–NEW YEAR’S DAY 1971

DSC01052 I ran into a case of these at the Air Am Air Operations Center on New Year’s Day at Udorn and gave the warehouse dude a case of Marb reds  for one. For the record, at 17¢ a pack, that was a buck seventy. Even though they were all old WW2 reworks, I’d never seen a knockoff of a Fabrique Nationale Hi-Power. 

Not being a big fan of 9mm, I threw it in the Diplomatic Pouch and sent it back to my mom in Alexandria, Va. who had a growing collection of all kinds of these things piling up. Put your cursor on it and left click for zoom. Do it again for extreme magnification.

Browning permitted the Inglis Corporation of Canada to start producing these in 1942-43 for shipment to East Asia to ease the shortage of weapons there. No bluing or even a Parkerized finish. Just raw, black steel. How they came into Air America’s inventory forty years later will remain an enigma. I finally looked up the parentage of it several years ago. I’d just assumed Consolidated International Airlines commissioned some South American company to start stamping them out. It’s clean as a whistle inside with little or no wear and tear. 73 years young. I’ve never shot it.

DSC01053

Check out the rear sight. Someone in tech support must have had a ripsnorting sense of humor if they thought it was good out to 500 meters. He probably went to work for the VA after the war.

Posted in From the footlocker | Tagged , , , , , , , , , | 2 Comments

The head-to-toe “groom me” Asian street phenomenon

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Group providers perhaps outside a hotel?

HBV, vaccine but no cure; HCV, no vaccine, possible cures.  Both can be transmitted during pedicures and other personal care activities. In Asia, open-air barbers and pedicurists still ply their trades the old-fashioned unsterile way.

Helen Tryell of Hepatitis Australia, tries to raise awareness about  preventing these infections (article: That holiday pedicure may leave you with hepatitis C), for Aussies on vacation. Tryell says,

In places like Bali, Thailand, Vietnam and the Philippines, hepatitis C can be nine or 10 times more prevalent than at home, and this coupled with generally lower standards of equipment sterilisation in the average tattoo parlour or where you get pedicures can greatly increase the risk of infection.

This tourist could care less as he’s clipped and pampered near the beach by two ladies.

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Phuket, Thailand (tourist photo: Flickr)

These services are an everyday way of life for the native populations across Asia as these random images from travel blogs show.

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Shanghai, China

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Hanoi, Vietnam (Photo: Peter Anderson)

Kathmandu, Napal (Photo: Adrian Landin)

These women provide useful, valuable services but ones that are risky to themselves and the public they serve.  As long as they have customers and jobs are scarce, this form of self-employment will remain a popular occupation. “Pop-up” businesses can’t be regulated so Asian governments should offer free voluntary education, disposable implements and places where workers can sterilize their equipment since they can’t disinfect between customers.  Maybe they could offer a free educational certificate for participants as an incentive.  This might give them a competitive edge over other micro-entrepreneurs.

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Luang Praband, Laos (Photo: L. Price)

Many species seem to agree: the benefits of pampering outweigh disease risks.

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Kuala Lumpur, Malaysia. (photo: R. Mattei) No HEP here. Leave us alone!

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Jigokudani Monkey Park, Japan Ditto! Buzz off…

Ahhh…

Posted in Guest authors, HCV Health, HCV Risks (documented), Medical News | Tagged , , , , , , , , , , , , , , , , | Leave a comment

Phoenix VA finally rid of Sharon Helman for greed, not mismanagement

helmanBenjamin Krause has been following former Phoenix VAHC Director Helman’s firing on his blog. The firing was upheld a few days ago.  She improperly accepted lavish gifts from a lobbyist–and her former boss–and failed to report them. There are some whistle-blower hereos in his story and we shall acknowledge and praise them in another post.  

According to Judge Mish’s ruling, the VA brought three charges of misconduct against Helman: Charge 1: Lack of oversight. This was not sustained. Helman wins this one.

Charge 2,  Specification A.  Wrongly put a whisleblower physician on leave (sustained) and Specification B Took gifts from Dennis “Max” Lewis (sustained). Good evidence from the paper/email trail.

Charge 3:  Failure to report gifts in A. 2012 B. 2013  Both years sustained:  VA wins these easily because she lied on forms.

For an overview, this URL links to three good articles:

To read the 61-page ruling: helman pdf. It’s a slow upload but provides a balanced analysis of the case by Judge Mish. He wrote:

“I conclude [she] has little rehabilitative potential…She has steadfastly denied any wrongdoing in the course of this appeal and attempted to deflect attention from her own actions by pointing to political considerations and complaining that the agency has been looking into her private life.”

This is also interesting because the lobbyist works for a company that helps clients get billions in VA business (ex. CBOCs).

This ruling does not bode well for the VA’s ability to sustain charges of Lack of Oversight chillingby lousy administers in future attempts to remove the worst offenders at different VISNs since the judge is shifting that argument back to headquarters and elsewhere–and headquarter’s doesn’t want scrutiny applied to them.  So this ruling could have a chilling effect.  That’s my take on it but you may see it differently.  I also don’t think her administrative career is over for good because she won the first charge and a private healthcare company could hire her and look the other way with regard to her morals.

Link to Merit Systems Protection Board website where Judge Mish’s full 61-page ruling can be found (scroll down). Long loading time.  http://www.mspb.gov/vases/index.htm

Sharon Helman v. Department of Veterans Affairs, DE-0707-15-0091-J-1
(12/22/2014)

She had two lawyers and someone else.  The VA had five lawyers.

Ed. note. This is why I held back so long to pass judgement on Ms. Helman. I think the tip of the iceberg is barely in sight. Who, pray tell, is guilty at Phoenix VAMC if the boss is not?

Posted in VAMC Scheduling Coverup, VAOIG Watchdogs | Tagged , , , , , , , , | 6 Comments

Prejudicial Title: The Vietnam drug user returns; final report, September 1973

To the best of my knowledge, Vietnam veterans have been the victims of the coverlargest outbreak of HCV in the United States to date.  The largest cohort was born in 1954. We know that there are many transmission routes in which this blood-borne virus entered the bodies of our troops from the period beginning at bootcamp to the day of discharge. HCV has been circulating in the human population ineffectively (ex. sex, household contacts, etc…) for hundreds of years but it exploded exponentially in the mid-2oth century due to medical interventions like transfusions and vaccinations.  Vaccinations and IV drug use shared the same practice of re-using needles or needles and syringes and this is a highly effective way of transmitting HCV.

Given the ubiquity of heroin in Vietnam, how many soldiers were actually IV users in-service? Where is the data?  I’ve found one official document from 1973 that attempts to answer this and other drug-use related questions: The Vietnam Drug User Returns.  Isn’t that a demeaning and horrible title? The word “user” is singular but it might as well be plural, so harmful is the picture it paints.

I was sure it would indicate widespread IV drug use in our soldiers. I found the opposite.

This focused study used military records (page 9), urine tests, VA records, and follow up interviews.  Summary:  In Sept. 1971, 13,760 Army enlisted men returned from Vietnam to the U.S..  They had urine tests for drugs (except marijuana)at departure. Only 1,400 tested positive for any type of drug at the time of departure.Then they took 470 samples from the larger general group and 495 samples from the drug positive group and followed up with them months later.

The study tried to answer 11 questions, one of which was how the soldiers ingested narcotics.  “The most common method of administration was by smoking. Only 8% had injected a narcotic in Vietnam” (viii). Later it says that sniffing was the second most common method of administration.  

(Note: There is no solid evidence that sniffing a chemical has transmitted HCV according to a CDC slide I came across recently.) A chart indicates skin popping as a possibility but injecting was last method chosen and “rare.”

Question: Why so few soldier injectors?

 “Injection in Vietnam was not necessary because the heroin was so cheap and pure” and the tour of duty was only one year for most soldiers (page 32).

Pre-Vietnam, 7% had tried heroin.  And this group continued to smoke it in-service with about 8% using an IV at least once. And 91% of those who didn’t inject narcotics, stopped using them when they returned home (page 62).

The soldiers were highly critical of heroin and considered it dangerous even though it was the most available drug–available within an hour (page 26).  This is just one group selected from one month chosen by the study designers because they felt heroin use would be the highest at this time. But again, I repeat: they found injecting to be rare. 

The percentage of IV use was less than I expected but this small group was still capable of effectively transmitting HCV to other IV-users and non-users in combat. Studies on current IVDUers might shed light on just how dangerous contact with this group was to the health of their fellow soldiers.   Combat exposure and other types of contact with the blood of this small IVDU group WAS a risk factor for HCV transmission to the larger group. It’s obvious that exposure to IVDUers in Vietnam should be on a list of risk factors because even though HCV hadn’t been “seen” or cloned, they KNEW for decades prior to the Vietnam War that hepatitis was associated with needles, diabetic needles, etc…

My sense is that IV drug use in Vietnam among soldiers was not the smoking gun when it comes to the massive HCV outbreak but it must have contributed to it within certain clusters of soldiers.  It would be good to find an honest statistician to work on this problem.  We know that 99-100% of these soldiers got vaccinations with unsterile medical device guns. A large percentage of injured soldiers received blood.  Donating blood is also a risk factor.  I’ve seen percentages of unsafe contact with Asian sex workers at around 48%.  If a prostitute averaged three/four intercourses a day for the previous year, a soldier was exposed to someone who was consistently having rough sex with perhaps as many of 900 different clients.  A female’s internal organs aren’t designed for this and mucosal damage would be inevitable. She could become infected or pass hepatitis infections easily. If menses was present, the transmission risk F > M would be even greater.  Having physical contact with only one sex worker (M or F) could have transmitted hepatitis.

Soldiers (100%) also received unsterile haircuts and shaves in compounds or by village barbers.  At least 50% of the soldiers this study engaged in combat activities even though the war was winding down.

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Mud, blood and horror UK article–click image to see more brutal pics

An intriguing mention of hepatitis sticks out: “Hepatitis and infections at the administration site were not uncommon as they are among addicts in the states, because narcotics were seldom injected” (page 32).  I’d like to know the background on this–which virus were they referring to since HCV hadn’t been discovered?  I’ve lost track of all the government papers I’ve read that attribute the high rate of HCV in veterans to their in-country IV use (no) and blood transfusions (yes). This is because one crappy but influential researcher cites another ad infinitum until all the citations are like a chain letter that just keep multiplying in their circles.

I have a New Year’s goals for these phonies:  Resolve to dig deeper, ask better hour glassquestions, revise your sloppy work, and redeem your scholarly reputations while you still can.

Vietnam Drug User Returnees. Yup, that’s how Vietnam veterans were viewed by our government–a notion that persists.  Is it any wonder that these soldiers weren’t welcomed home until 2011 by the Senate? March 30 is Welcome Home Vietnam Veterans Day.  Hoorah?  I just want the facts about the HCV outbreak to be addressed.  Save the conciliatory speeches for someone else.

Posted in Guest authors, HCV Health, HCV Risks (documented), IMOs/IMEs, LOD and willful misconduct, Medical News, VA Health Care, Vietnam War history | Tagged , , , , , , , , , , , , , , , , , , , , , | 7 Comments

El Paso VA (EPVAHCS): OIG Healthcare Inspection (VISN 18)

This part of the country is on my bucket list of places I want to visit some day

DCF 1.0

“El Paso Skyline” by Camerafiend at the English language Wikipedia. Licensed under CC BY-SA 3.0 via Wikimedia Commons – https://commons.wikimedia.org/wiki/File:El_Paso_Skyline.jpg#/media/File:El_Paso_Skyline.jpg

because the   scenery looks spectacular.  However veterans in the region have a tough time accessing VA health services and their complaints to Rep. Beto O’Rourke resulted in a new OIG report (published Dec. 2, 2014).  This system illustrates the hodge-podge nature of care in West Texas which would be fine if it were managed well.  In this case, it’s not. Apparently, the VAMC in El Paso does not provide direct care to the 41,000 enrolled veterans (30,000 active patients).

The VAMC, which is located adjacent to an Army Medical Center, and Community Based Outpatient Clinics provide primary care and specialized ambulatory care services. The VAMC does not directly provide inpatient or emergency room services and instead purchases those services from the Army, local private hospitals, the New Mexico VA Health Care System in Albuquerque, or other VAMCs in the region.

A footnote explains that “The El Paso VAMC is located on Fort Bliss, the second largest U.S. Army installation, which is currently home to 30,000 soldiers and their families.” So is the El Paso VAMC staffed by administrators and clerical employees–no VA physicians?

There are two clinics for veterans but they are essentially competing with active duty servicemen and the civilian community for care.  New veteran patients had the longest waits. Low physician productivity was found in psychology, primary care, cardiology, and urology. Veterans had to wait an average of 73 days to see a cardiologist but I don’t see a cardiologist listed in their “Our Doctors” list although two doctors are certified in cardiac diseases.

El Paso Primary care providers have some valid complaints of their own:

…the “volume of non-credit workload was “astronomical.” One long-time provider reported seeing 18 to 23 patients on average per day when he first came to the facility 19 years ago. The provider expressed the perception that as a consequence of over-emphasis on metrics and “dotting I’s and T’s” his productivity has steadily decreased over time. The provider pointed to secure messaging as an example. Since implementation over the past year, the provider reports receiving between 50 and 100 secure messages from patients per day for which a response is expected. 

This seems like a completely reasonable explanation since I know the feeling of dread I feel if I’ve not checked my email for a few days.  My spouse uses (not abuses) secure messaging to keep an electronic record of his complaints and they are answered by his nurse within a few days. And yes, she sometimes sounds harried.  (If an El Paso PC doc is getting 100 messages a day, what are Minneapolis VA docs getting?)

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The East Side El Paso VA Clinic (CBOC) is out sourced but to whom? Tri-West?

My takeaways from this report is that it is not transparent or that helpful because it is silent on system-wide problems.  It doesn’t highlight the paltry number of physicians paid to provide care.  It doesn’t clearly tell us which company staffs the Community Based Outpatient Clinics (CBOC).  The report does not address number of veterans eligible for Veteran Choice cards although Tri-West Alliance is participating in the Choice program in El Paso at a private hospital according to one reporter!  The Tri-West website for veterans is confusing because it just covers the PC3 program.  The OIG report does not provide guidance on outreach even though the public relations department needs a kick in the pants.

OIG’s emphasis on physician productivity is a smoke screen since only a few providers are having severe problems in that area.  We don’t need to see more charts on how a doctor’s day is divided up, how long average lunch breaks are (very short), and so forth.  What we need to see is how they are going to hire (in-house, out-house) providers and retain good ones with appropriate incentives.  And how veterans who live over 40 miles from El Paso, can opt-in and use their Veterans’ Choice cards immediately. Blaming VA-paid private physicians, already suffering from workload burn-out, for VA administrative failures is just going to increase regional physician shortages.  This is a stupid approach if the VA is serious about backlogs and quality care.  (Harumph….)

Ed. Note Kiedove sure hit this one out of the park. We’re seeing this mentality ferment at VAMCs all over the fruited plain and it disturbs me mightily. VA’s mindset is “Okay, fine. We don’t know what we’re doing. Is that what you’re saying? Fine. Then here. You do it and see if you can do any better. Bet cha can’t!”

Instead, they should be looking at the format they’ve imposed and the impossible  regimen-versus-patient workload. A doctor should be allowed to doctor. Anytime you take him away from that primary responsibility and turn him/her into an admin. clerk is ill-advised yet this is what VA has done. It’s the VA micromanagement nightmare of the year. The civilian counterpart is simple.

1)Call nurse or email.

2)Leave message.

3)Wait for nurse to stick head in door and ask doctor quick question.

4)Report back to patient.

 

Posted in Guest authors, Medical News, VA Caregivers Act, VA Health Care, VA Medical Mysteries Explained | Tagged , , , , , , , , , , , , | 3 Comments

Naval Base San Diego Holiday Lights

Tomorrow’s veterans bring holiday spirit to communities across the globe.

Naval Base San Diego

San Diego, Cal., (Dec. 19, 2014) The guided-missile destroyers USS Kidd, left, and USS Wayne E. Meyer display their lights during Naval Base San Diego’s third annual Holiday Lights Open House. During the event, the public was invited to drive through and observe the decorated ships along the base’s waterfront. U.S. (Photo by Seaman Amanda Chavez)

Volunteers, young and old, have remembered our deployed troops.

cards

ARABIAN GULF (Dec. 16, 2014) Holiday greetings from schools in Virginia decorate the mess deck aboard the guided-missile destroyer USS Mitscher (DDG 57). U.S. 5th Fleet area of responsibility supporting Operation Inherent Resolve, strike operations in Iraq and Syria. (Photo: Anthony R. Martinez.)

 

iraq

BAGDAD, Iraq, (Dec. 21, 2014) Priya Butler USO Southwest Asia, hands a set of headphones to a soldier who won a raffle during a Christmas celebration. 7000 presents had been gathered for soldiers serving in Iraq.

 Veterans home residents are not forgotten.

christmas party

Barboursville, West Virginia, (Dec. 9, 2014) Christmas Party for the West Virginia Veterans Home.

Christmas visits from our grandchildren came earlier this week for us. Our packages have been distributed, a special meal served, decorations are up, and I can kick back, relax and offer good wishes to all.

 

Posted in All about Veterans, Food for the soul, Guest authors, Inspirational Veterans | Tagged , , , , , , , , , , , , | Leave a comment