VETERANS DAY 2014

downloadI was beseiged this afternoon with emails asking if my joke posting for today was all I planned on putting up. Well, not exactly. That space was supposed to be occupied by a long story with photos of Butch Long getting his long-overdue medals and most especially, his Combat Infantryman’s Badge. This time the Army Board of Corrections of Military Records (ABCMR) was the grinch who stole the show.

The ABCMR is  still our same old Army but with a more laid back “the day after” Army mentality. A cattle prod couldn’t spark them up any more than a U.S Congressman. We tried. This began in June of this year along about the time the corn went in.

The Real Story

I told you of my neighbor Butch Long who was short sheeted by the Army at the time of his discharge in 1970.  I was asked to help after Butch had been promised this about five or six times over 40 years and no one ever followed through. We’re talking VSOs stepping on their neckties here. Perhaps I was just the right guy in the right place with enough brains to figure it out. Please – no X files music. Unfortunately, once apprised of the mistake, the Army again took their sweet time and made us present evidence that Butch wasn’t just some PX Ranger looking for a good deal on military insignia. Hey. Guys do that. It’s embarrassing to be a man when you see it happen. If you’re a combat Vet, it pisses you off. Being gentlemen and bred better, most refrain from bodily harm or summarily “repossessing the illicit paraphernalia”. I’m sure it happens but I am equally sure you gentle readers would never partake. Emasculating the hoser with verbal acrimony is far more satisfying. You and I could never become masters of it like women in a vicious, ferally-worded catfight, but you get the idea.

THE CORDUROY FIASCO

IMG_6792Butch was to receive his regalia (to which, by now, he has been entitled to for forty five years, nine months and 21 days) this afternoon by our distinguished Congressman Derek Kilmer (26th District). Derek’s a real cut up. When he was trying to pin my medals on me through that corduroy sports jacket, we discovered why you never, never, never want to wear corduroy anything at an awards ceremony.  His paraphrased comment was along the lines of:

“Man. I haven’t had this much trouble since Prom night.”

Derek didn’t expand on that cryptic comment nor did I venture to ask for clarification. Fortunately he was far enough away from the microphone.  He is always available and is a Veteran’s friend. He ramrodded this through as soon as I began the quest with his VA interface Nicolas Carr. The Army was more than willing to throw in a Purple Heart based on the telegram notifying his parents that his face, right eye and upper body had been remodeled with a 60 mm mortar several nights previous. How this managed to escape the Army medal clerks then bears remarking on. Commanders and the REMF Paper Faeries around them never lose their own myriad commendations and medals requests. How could this have gone AWOL for half a century? One thing became apparent though. No CIBs were going to be awarded without documentation.

imagesTo add insult to Butch’s injuries, the ABCMR, knowing full well we were up against the clock for Veterans Day, let this sit in the out-basket for a week after the 24th of October before mailing. Considering they are located at Fort Meyer in Arlington Virginia, they had far more faith in the USPS than I do. Sure enough, when Nick Carr called them to politely ask if we could still expect to plan our presentation on Veterans Day, he discovered that someone forgot to put it in the mail. But, with any luck and a tailwind, it (might, could, could oughtta, quite possibly, with a high degree of probability, conceivably) [pick one] be there by Monday. As of yesterday’s mail we were still skinny on paperwork or any colored ribbons bearing the likeness of George Washington.

Which was okay. I was prepared to either run down to Fort Lewis and play PX Ranger myself  or have to temporarily requisition my Uncle Jay’s medal box for his CIB and Purple Heart. As for the rest, I had all the RVN “I was there” stuff from Derek’s presentation to me. Hell. They were still New In Box. Bruce “Mac” McCartney (no relation to Paul) from our Eastern outpost in Midway Georgia provided a period 1969 Army Commendation Medal. Bruce, for all of you who do not know him, is super in his own right. I’d have said he was an idiot for doing four tours as a combat Dustoff medic back then (1968-1972)  but now I’m merely in awe. He’s living proof of how you can dodge almost all the BBs. He has also come out of retirement to show us all ILP and how to obtain greenhouses.

Fate was just not on our side. The house of cards finally fell down because Butch’s daughter Carol, who was born while he was in-country, had to work on Veterans Day. I mean they were not going to budge on this. That’s worse than blowing a red light right in front of a cop on your way to your own wedding and you’re already ten minutes late… And you have a warrant out for, like, a gazillion parking tickets. I’m familiar with that scenario.

Carol, if you remember, is the one who told Christine about Butch’s plight. Christine’s light bulb went off at the KP Vets monthly meeting when the President announced the Air Force Board of Corrections of Military Records (AFBCMR), after sixteen long months of Ouija work, had finally acknowledged my medals. There’s method to this madness.

NEW DATE FOR PRESENTATION

Congressman KIlmer has graciously agreed to set family time aside and come out on Saturday, the 6th of December around the middle of the day to present Butch with a small tribute of what our Country owes him. Fortunately we didn’t have to water the Tree of Democracy with his blood on January 18th, 1969. We will celebrate that miracle and certainly remember the other two who did. Their testimony from the grave is the only reason why Butch will get his CIB. Pretty cool, huh? It’s like Buddy Letters from Heaven.

Personally, I think it’s one hell of a story. You can’t make this shit up. Well… unless you’re a PX Ranger.

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Posted in Inspirational Veterans, KP Veterans, Veterans Day, Vietnam War history | Tagged , , , , , , , , , , , , , , , , | 4 Comments

Veterans’ Day Greetings

My hubby’s late brother served in Vietnam in the Army Corps of Engineers. After the war, he worked in construction operating heavy equipment–hard work.  He ALWAYS took Veterans’ Day off.  To celebrate, he went to his favorite bar and enjoyed himself among his buddies.  He felt it was his due. (Then back to work the next day to support his family.)  Hope all vets are enjoying something pleasant today!

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A yeoman (F) on Submarine K-5 gazes through her binoculars. (80-G-1025873)

The VA has an overview of the history of the observation; the impetus was World War I.  Women played a broader role in this war.  Interestingly, the Naval Act of 1916 let women in.  Its”vague language relating to the reserve forces did not prohibit women.” So women, who were prohibited from joining the armed services, were able to enlist as yeomen.  For more information, this article makes for good reading.  The Nineteenth Amendment to the United States Constitution, giving women the right to vote, wasn’t passed until 1920 (August).

The BBC has a wonderful site about WWI from the British perspective. How did WW1 change the way we treat war injuries today? is just one interesting guide.

Blood transfusions were a big change but the science of them was very new:

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Top: First World War blood transfusion apparatus. Below: the Thomas splint introduced in 1916. Pictures BBC/ Getty and Wellcome Images.

The British Army began the routine use of blood transfusion in treating wounded soldiers. Blood was transferred directly from one person to another. But it was a US Army doctor, Captain Oswald Robertson, who realised the need to stockpile blood before casualties arrived. He established the first blood bank on the Western Front in 1917, using sodium citrate to prevent the blood from coagulating and becoming unusable. Blood was kept on ice for up to 28 days and then transported to casualty clearing stations for use in life-saving surgery where it was needed most.

The history of military blood transfusions, those life-saving procedures with unintended and sometimes tragic consequences years later, is an ongoing area of interest at ASKNOD. Apparently WWI is where the learning began for military doctors.

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PRESIDENT ANNOUNCES NEW DATE FOR VETERANS DAY

CaptureIn a bold move certain to upset the major Veterans Service Organizations across the fruited plain, President Obama today asserted his authority under his Executive prerogative to change the immutable date of Veterans Day. Numerous United States Postal Service workers, which encompasses the majority of Veterans,  have for years advocated a “fluid date” that comprehends three-day weekends, permits more quality time with your buds down at the VFW Bar getting sudsed and reminiscing about all those German babes of the evening you “conquered” in hand-to-hand combat between the sheets. 

In his Executive order, the President announced summarily that, predicated on his interpretation of what Congress really meant back in 1938, three-day weekends are paramount to the health of the current government workforce (excluding the standing military). He also cited to former President Gerald Ford’s misguided efforts in 1971 to move it to October 25-thereby carving out a niche of respectability for  his executive proclamation.

Veterans Day is now slated to be combined with December 7th and form a new, combined three-day weekend geared toward a much-needed break between Thanksgiving and Christmas. Again, due to the inviolate nature of having these holidays misguidedly relegated to specific dates rather than days, the newly combined Veterans Day/Pearl Harbor day, tentatively to be called Vet Dudes day (VD Day for short), has been chosen as the first Monday in December.

As you can imagine, this will cause consternation among many who served America, most especially in the Navy but certainly including the other services. The President explained his logic thusly:

obama-vpn“In order to keep America strong, we need more shopping days between Thanksgiving and Christmas where you- my fellow Americans- can exert your God-given right to go out and rescue our beleaguered economy. President Bush screwed this up horribly and we have striven to repair the poor choices of his administration. While the economy is coming back like an express train,  nothing will cement these gains unless I act unilaterally.  I have recently heard the desire in your collective voice and I feel this is the solution. Knowing the intractable nature of Congress and their inability to engage in bicameral, bipartisan legislation, it behooves me to act to enforce Americans’ wishes forthwith. In time, the wisdom of my choices will become self-evident. It always does.

In order to avoid confusion, I have instructed the Attorney General to make this effective next year although I feel we should just go ahead and, you know, like, do it maybe twice this year and bust out this new Vet Dudes Gig on the first Monday next month. However, I feel it would be inadvisable until we get all the Veterans and their advocates on board with it. That will entail time to acclimate them. Being responsible and transparent, and having America’s interests uppermost in my administration’s agenda, I feel we can sacrifice this year and give the negative Nancys time to get acclimated to the change.  Make no mistake. Three-day weekends are the wave of the future. America’s government workforce, excluding the active military, of course, demands this special dispensation. They are overworked and underpaid.

 Having an extensive background in these matters, I discussed this with the Joint Chiefs of Staff of America’s military forces and they concur that we simply cannot have everyone off that weekend. What the hey? Somebody’s got to protect us against this Ebonics-ah-Ebola thing. Besides, technically speaking, active military forces are not yet Veterans in the truest sense of the word and I know they will understand.  I also wish to thank all of you for your most recent mandate for my policies at polling places across America last Tuesday. Your trust in me is well-placed.  I feel this is one small step in repaying that trust. Happy VD Day and thank you for your service to America.

downloadLastly, I have instructed our new VA Secretary to drop what he is doing to restructure the VA and promptly promulgate new rules to effectuate my decision today. There will be ample time to fix those pesky waiting periods that are allegedly killing you Veterans. America’s economy is far more important that a bunch a whiny, malingering mentally deranged Veterans hanging around Veterans Affairs Medical Centers seeking sympathy and free medical services. Besides, that’s why I invented the Affordable Care Act. Hey, if you like VA medical care, you get to keep VA medical care. I’m not trying to take it away from you if you can get it. In fact, I modeled the ACA after the VA model. I’d like to think I am boldly going where no President has ever gone before. Thank you again. I wish I could be there today but this China gig came up suddenly and -well-what can I say? My tailor is in Hong Kong.”

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BVA–REMAND TO”READ THE C-FILE”

download (2)This is a proof-positive illustration why you and I, and indeed, everyone who enters this convoluted system is condemned to purgatory for years until someone tasked with making the decision actually cracks the books and reads the c-file. It borders on malfeasance. It also make one wonder why the VFW was AWOL on this.

 

REMAND

In its July 2011 remand, Board directed that the Veteran be afforded a VA examination, which was subsequently conducted in September 2011. The VA examiner opined that it is less likely than not that hepatitis C was incurred in or caused by in-service injury, event, or illness. The rationale was that a blood transfusion in 1976 (prior to service) was the Veteran’s only risk factor for hepatitis C.

In response to the Board’s remand directive to consider the Veteran’s in-service history of circumcision, vasectomy, and cyst excision, the VA examiner noted that the Veteran does not have any history of circumcision, vasectomy, or cyst excision. Service treatment records clearly show that the Veteran had a circumcision in November 1984; a cyst removed in 1989; and a vasectomy in 1999. As the September 2011 medical opinion is predicated on a grossly inaccurate medical history, the claim must be remanded.

And just to keep them on the reservation, the VLJ suggests:

The examiner must accept as fact that, after service the Veteran did not undergo any surgeries, did not have promiscuous sex, did not drink a lot, and did not get any tattoos.

And we wonder why it takes a lifetime to win these things.

 

Posted in BvA HCV decisions, HCV Risks (documented), Remanded claims, VA Medical Mysteries Explained | Tagged , , , , , , , , , , , , , , , , , , , | 5 Comments

BVA DECISIONS ARE OUT (AGAIN)

download (3)The latest batch of BVA HCV decisions, and, by extension, all decisions this year, was released late Friday night. I’ll peruse them to see what the  latest jetgun synopsae are. Seems the BVA and the Court of Appeals has finally noticed that little phrase “infection by jetgun is plausible.” Plausible, while not a strong pejorative, is still a legal finding that affords us a better assessment rather than the resounding”No!” we are accustomed to.

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CAVC–PROFFER V. McDONALD–TAILORING THE PRESUMPTION

VetCourtAppealsPromoI have written of reversals about all manner of cases. I have written of the Presumption of Regularity and it’s increasing importance in jurisprudence where the VA is fond of telling the truth partially but fudging on the “and they lived happily ever after.” It seems VA feels a compulsion to tell the truth just enough to satisfy themselves and anyone willing to listen and then go off the reservation to come up with a wild, incredible ending whereby Johnny Vet missed it by thaaaaaat much.  We at asknod call these folks Agent 86 VA examiners.

 Meet Ronald L. Proffer.

Proffer reversal by Coral Wong

Ron served at the same time I did and suffered much the same issues I did. Amazing coincidence. The AF, when I returned from two years in Laos/Vietnam/Thailand, was a far different place. The war was winding down and the number of slots available to make a career there were disappearing. A certain amount of weeding out and triage was afoot. One method was to ride your ass on personal appearance. I lost a stripe over it just prior to my untimely separation. Mr. Proffer was heading down the same road and they separated him after only two years.

The Presumption of Soundness

Ronald was declared fit for service and thus accorded the Presumption of Soundness. He was declared fit for duty and inducted. He served faithfully until the day when they began to ride him over Air Force Manual 35-10 (personal appearance). From then on out, he had a target painted on his back. I’d bet that if he arrived a minute late for an assignment, it was characterized as chronic and ongoing.

download (3)When he and the Military Order of the Purple Heart applied for a bent brain claim in 2008, he cited to his contemporary service medical records as we all do for proof. They showed his gradual descent into the mental maelstrom and eventual discharge. An easy win? Not exactly. In the course of a hospital admission for slicing himself up with a knife, he admitted that he had some “minor anger issues” before service. VA latched onto that as proof positive to rebut the presumption of soundness. But. And there is always that niggling “but”. In an attempt to rebut this as not being service connected, they tried to cherry pick some of the SMRs showing this proclivity to mental aberration and then characterize it as sub-brain disfunction-aka personality disorder- which is, of course, not compensable. Since they have only one setting on personality disorders, they reverted back to Adobe 2 and the M21 opined that all personality disorders are presumed to have been pre-existing automatically and therefore non service connected:

38 CFR §3.303(c)

…In the field of mental disorders, personality disorders which are characterized by developmental defects or pathological trends in the personality structure manifested by a lifelong pattern of action or behavior, chronic psychoneurosis of long duration or other psychiatric symptomatology shown to have existed prior to service with the same manifestations during service, which were the basis of the service diagnosis, will be accepted as showing preservice origin. Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation.

In addition, they declared this occurred increasingly more frequently and manifested itself repeatedly up to discharge. Wait until you see how this comes back to bite them on the ass.

Creating a plausible fish story

animals-the_strange_world_of_mr-fish-fish_story-fishermen-angler-wstn79_lowWhat the VA did here was to shoot themselves in the foot. They made a determination via the Holy VA examiner, that the Ronster had unequivocal proof of a problem in service. On top of that, he had admitted he had a “slight” problem with anger before but nothing near to approaching what manifested later in service. As with any fish story, this snowballed downhill into an account of how  all this anger surfaced “in early childhood” and somehow appended itself to a personality disorder as a secondary condition. I’m sure you’ve read how VA does this on HCV claims. Everything risky you did in the service (gonorrhea, drugs, tattoos) could not be the culprit. But boy howdy look at the fact that you had sixteen girlfriends and 3 tattoos in the intervening 20 years and there is where you got it. Ron got the same treatment. The problem for VA developed years ago  when a competent medical examiner, in this case the induction center doctor, declared him fit for duty. In order to overcome that, you have to prove CUE. That’s like trying to leap over tall buildings when you lack Superman’s attributes. This protected Mr. Proffer but it didn’t slow down VA’s theory on service connection one whit.

The Caluza Triangle

Mario Caluza pulled a boner in 1994. His memory was too good. His case set the bright line rule, heretofore unwritten by VA, of what was needed to prevail. Disease or injury in service; same thing now and a doctor’s nexus letter that ties the two together.  Collect all three and you get what’s behind door number 3.

VA went on to acknowledge all the Caluza elements including nexus. He had it in service. He has it now. The defect  in their logic was to say he had it before service. Now they have a stool with three legs but if fails to support their suppositions. Judge Coral Wong-Pietsch (wow is that a mouthful) opined as much. She pointed out that personality disorders under 38 CFR §4.127 are not compensable as an illness. However, a secondary mental illness to the personality disorder is. VA had by now shot themselves in the foot and admitted he suffered this in service. That was the first Caluza element. They freely admitted he had the second element-i.e. a current disability. But they attempted to glue this onto his admission that he had a few angry moments before service. This effectively rebutted the presumption of soundness and thus he lost in their minds.

The Ronmeister’s shield bearer  promptly turns the tables against VA’s examiner and says “Au contraire, ma cher. The presumption of validity attaches to all VA examiners’ nexus findings. We can rebut some and leave others intact. Therefore, we claim the presumption of soundness at entry has not been rebutted by clear and unmistakable evidence and the other finding of explosive anger, secondary to a personality disorder is hunky dory with us What do we need a JMR for?”.

Please, sir. May I have another JMR?

 

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Read my neck. No do overs.

As usual, when the dichotomy is revealed and VA’s souffle logic falls flat, they immediately retreat and ask for a do over to “get it right” the second time. We know that is nothing more than a request to find a stronger limb to throw the noose over and a fresh horse to sit on. Sure enough, The OGC begged for exactly that.  They wanted to keep the hardest thing to prove (the rebuttal of the presumption of soundness). They also begged leave  to “rebuttress” the other findings in place (i.e. query the VA examiner and beg her to rewrite the ‘less likely’ more clearly). That’s where they sawed off the branch they were standing on.  They were  admitting they’d stepped all over their neckties and were moonwalking backwards to save face.

Judge Coral administered the coup d’ grace without fanfare or acrimony. She simply pointed out that VA had done a piss poor job of rebutting the presumption of soundness. When you set out to prove clear and unmistakable error, you set before yourself an immense task. It makes no difference if it is the Veteran or the VA. The bar is extremely high. By going down the “personality disorder is not a disability” road, they were committed. The whole case hung on an assumption of a noncompensable preservice disability. Unfortunately, that is not where the matter ends. Once Judge Coral reinstated the presumption, Ronbo suddenly had all three legs of his Caluza triangle needed to win. By admitting he started manifesting this in service, they had inadvertently given him the nexus on a silver platter. At this point, it’s too late to retract the findings. They would have to have proven they were in error and CUE themselves on them as well.

The Aftermath 

p10773532_b_h6_abMr. Proffer’s claim will now be returned to Veterans Law Judge Barbara B. Copeland. She, in turn will have to write a detailed, new decision explaining why she has shit for brains and allowed her underlings to sway her thinking. Surely it cannot be that she came to this misguided decision on her own? VLJs are infallible. Following that mea culpa, it will reverse-matriculate back to the Saint Louis Regional Office from whence it arose and they will have the unenviable task of doing a Fenderson rating awarding Mr. Proffer that which they have withheld since his June 2008 filing. We can assume the initial rating will be for 10% and a new battle will ensue over a proper award. I can almost predict they’ll give him a brand new C&P next month and proclaim him (gasp!) 30% disabled —but not before this new C&P proving it. By 2019 he’ll be up to 70%.

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One smart cookie

You will notice that Mr. Proffer had none other than the esteemed Amy F. Odum of the NVLSP as his shield bearer.  You may remember her from her recent Beraud route up at the Fed. Circus last month.  If it seems the Military Order of the Purple Nurple has no lawyers on its staff who are accepted at the Court of Veterans Appeals, you are not the first to notice. Ah, Padawan. That’s one of the shortcomings of having one of the Big Six represent you. Their CEOs and upper management are pulling down $350,000 dollar a year salaries and there simply is no financial room for a law dog on the staff. Thus, when you lose, you’re on your own, cousin.

 

Posted in CAVC Knowledge, CAVC ruling, Presumption of Regularity, Tips and Tricks | Tagged , , , , , , , , , , , , , , , | Leave a comment

Focused VA dental care for Class III and Class VI veterans

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Click me to read report.

This post is a follow-up to July post, HCV infection and veterans’ oral health.  Can we decipher this VA-speak together?

The Fact Sheet, Dental Benefits for Veterans (IB 10-442, February 2014) lists the eligibility for different veterans by class.  These classes are described in VHA Handbook 1130.01, pages 10 -14.

Class III and VI are of interest to us at ASKNOD, but not just because of HCV.

From Handbook 11130.01, page 3.

(6)  Class III. Veterans referred by a treating physician who have a dental condition professionally determined by the VA dentist(s) to be aggravating or complicating the management of a service-connected medical condition under active treatment are eligible for care to treat the dental condition. However, there is no provision granting eligibility for dental care under this classification in case of the opposite relationship, where a medical condition (e.g. Post Traumatic Stress Disorder (PTSD)), may be contributing to a dental condition (e.g bruxism) because the dental condition identified is not professionally determined to aggravate the medical condition. The goal is to provide focused care to treat only the oral conditions that directly impact the clinical management of the service-connected medical condition. Eligibility for each episode of dental care must be predicated on referral (consult), followed by a new dental evaluation.

 Class VI covers non-service-connected cases.

(9) Class VI. Any Veteran scheduled for admission or who is receiving care under chapter 17 of title 38, U.S.C., may receive outpatient dental care if the dental condition is clinically determined to be complicating the medical condition currently under VA treatment. Eligibility for each episode of dental care will be predicated on referral and consultation, followed by a decision based upon clinical judgment. The goal is to provide focused care to treat only the oral conditions that are complicating impact the clinical management of the medical condition currently under treatment. This classification includes medically necessary dental care for Veterans receiving care for Military Sexual Trauma under Title 38 U.S.C. 1720D.

Does ANY veteran really mean ANY veteran?  The VA uses these terms regarding care types:  Comprehensive (includes preventative), Focused, or Emergent. From the handy dandy Fact Sheet Chart for Class III:

IF YOU, Have a dental condition clinically determined by VA to be associated with and aggravating a service-connected medical condition YOU ARE ELIGIBLE FOR Dental care to treat the oral conditions that are determined by a VA dental professional to have a direct and material detrimental effect to your service connected medical condition.

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Woe is me. Does chronic mouth pain count?

Almost the same language for Class VI:

IF YOU Are receiving VA care or are scheduled for inpatient care and require dental care for a condition complicating a medical condition currently under treatment. YOU ARE ELIGIBLE FOR Dental care to treat the oral conditions that are determined by a VA dental professional to complicate your medical condition currently under treatment.

What oral conditions might apply? I’m guessing here but chronic dry mouth comes to mind because it’s caused by a multitude of medications, medical conditions and creates an unhealthy mouth.  This must-see presentation–with images–summarizes some of the linked problems.  Diseases/Infections include hepatitis, radiation of neck/head; diabetes (slide 9). Medication examples are on Slide 11. Inhalants diseasestick out since lung ailments among veterans are common and inhalants are often required.  Inhalants can cause dry mouth which leads to gum disease.  This is expensive to treat and the farce known as “dental insurance” rarely covers it.  Dry mouth is a recognized complication of HCV infection but if a veteran is SRV, and still has HCV-related oral diseases, will he be covered by the VA?

So what actions can you take if you have lung disease, dry mouth, pain, your gums are a mess and you suspect your VA-prescribed Symbicort?  Use secure messaging to notify your PCP and get it in the record! Your meds may get changed. If nothing helps, ask for a VA dental examination consult.  “I want to obtain a formal dental classification.”

Your medical records and results of your dental exam will be reviewed by the Dental Service and your dental classification will be issued. If you don’t like their answers, it’s NOD-time.  Now, I could have the flow of this all wrong so if you have experience with this process, please let us know.  We are not VA employees and are fumbling around their documents for those elusive answers. 

Posted in Guest authors, HCV Risks (documented), Medical News, VA Health Care, VA Medical Mysteries Explained | Tagged , , , , , , , , , , , , , , , | 4 Comments

Mileage exception for “geographically challenged” veterans in NH, Alaska & Hawaii

When I first read about the 40-mile distance from place of residence as the standard for the Veterans Choice Act, I assumed, as did many, that meant 40-miles from a VA hospital.  Wrong!

…Veterans may qualify based on their place of residence if they live more than 40 miles from the closest VA medical facility; if they reside in a state without a VA medical facility that provides hospital care, emergency medical services, and surgical care rated by the Secretary as having a surgical complexity of standard, and they reside more than 20 miles from a medical facility that offers these services in another state; 

The words “VA medical facility” defined: 

A “VA medical facility” is defined as a VA hospital, a VA community-based outpatient clinic (CBOC), or a VA health care center.

For example, if a veteran needs cardiac care and lives 10 miles from a VA community-based outpatient clinic (CBOC) that only offers primary care and mental health care, but 50 miles from a VA medical facility that offers cardiac care, the veteran would not be eligible based on his or her proximity to the CBOC.

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hi ho, hi ho, it’s off the VAMC we go….. Image: Wikipedia Commons

It’s a sore point with New Hampshire veterans that the state doesn’t have a real full-service* VA hospital.  They must travel to Boston, White River Junction (VT) or use a contracted private NH hospital for complicated medical services.  In winter, it’s safer to snow shoe, ski, or dog sled than risk driving on roads coated with black ice in and around the White Mountains, notches, valleys, ranges, and forests of NH’s varied geography.

But at last, a wee 20-mile break for eligible NH vets thanks to its Senators Ayotte and Shaheen who both serve on the Senate Committe on Armed Forces.  These vets, if they live more than 20 miles from a real VA medical facility, get a choice card. I find the VA’s discussion confusing but here it is:

Under § 17.1510(b)(3), a veteran is eligible if the veteran’s residence is in a state without a full-service (*meaning that it provides, on its own and not through a joint venture, hospital care, emergency medical services, and surgical care having a surgical complexity of standard) VA medical facility and the veteran lives more than 20 miles from such a facility. As of the publication of this rule, veterans in three states would qualify under this standard: Alaska, Hawaii, and New Hampshire. No veteran residing in Alaska or Hawaii lives within 20 miles of a full-service VA medical facility in another state, but some veterans residing in New Hampshire do live within 20 miles of a full-service VA medical facility that is located in a bordering state.

Now the VA uses this provision to illustrate a nasty and absurd loophole that it blames on Congress.

We note that this specific, special eligibility for veterans in states without full-service VA medical facilities further supports our view that the Act requires VA to find veterans ineligible who live within 40 miles of a VA medical facility, even if such facility cannot provide the specific care required...When read as a whole, the Act specifically addresses the ability  of a facility to provide care only in section 101(b)(2)(C).

Source for most quotes: Federal Register: Expanded Access to Non-VA Care Through the Veterans Choice Program (published Nov. 5, 2014)

The 40/20 mile rules (straight-line trespassing or fantasy travel, not by actual public roadways) to any VA medical facility is just another kick in the head to veterans.  When the folly and meanness of this particular rule is understood by stakeholders, I hope Miller and Bernie and his replacement get earfuls. Live too close to a VA medical clinic? Be fanatical about those wait-times!  I’m happy for the vets in NH, AK and HI but their access problems are far from unique.  This new rule severely limits veterans ability to opt into local non-VA healthcare.

_____________________________________________________________

Ed. note: I have the new Tacoma Narrows Bridge ($6.00 trip) between me and VAMC American Lake. My actual distance to the VAMC is 31.2 miles. At the current remuneration rate of .41 per mile, one would think VA might equate that to 14.6 more miles worth of “distance” traveled. Consider also that they deduct six dollars for each foray under the aegis of some obscure claw back until you make four or more trips to the VA facility, you are financially in the hole under any scenario. I suspect the panacea is to report an hour or two early for your cardio appt. at the nearest CBOC and ask them to transport you to the VAMC. I’d wager that might get you some unwanted attention from VA’s vaunted jack-booted thugs. A warm thank you, also,  to Kiedove for unraveling this VA medical mystery.

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Kiedove response to Editor–There will be more bitter illogical VA interpretative rules to discover as they roll out.  If you need a cardio apt., they have to make one for you somewhere within whatever wait-times they deem clinically necessary.  But guidance about wait-times for specialty care is hard to find.  And the “geographically challenged” definitions the VA will apply, in my sane view, should include transportation.  Again, demanding telehealth technologies to be installed for certain conditions, may help.  One ASKNOD member wrote that he was in the program and it was helpful.

mt washington

Mine did–in summer.

Because the program only runs for three years (unless reauthorized) it’s vital that we focus on the Choice Program, pick it apart and make it work. VA studies have shown that the VA saves money per patient on non-VA appointments. So instead of increasing clinic hours, and paying overtime, refer out and co-ordinate care with the vet’s VA PCP. The savings will be a big plus for taxpayers and veterans. Money saved should be used to house homeless vets (not for VA bonuses and parties (conferences).  Back to NH, for a moment.  In New England states, these bumper stickers are often seen.  It’s an awesome and scary experience.  Here are conditions on the summit now.  But severe winter weather is only one geographic challenge that veterans face all across the country.

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Veterans’ Choice Card program’s new contractors

coffeeFinding official information about the implementation of the Veterans’ Choice Cards and call centers has been frustrating but I can now report that Tri-West and Health Net have been hired to administer the program.  Health Net’s press release, Tri-West’s press release, and Secretary McDonald’s blog post were not released until yesterday, November 5th, the deadline.  We posted about these companies last month.  I’m going to cut the VA a little slack today because the people who have been working on this have probably been burning the midnight oil.  We now have a few precious specifics.  For example, Secretary McDonald writes: 

The Choice Card will be issued in three phases. The first group of Choice Cards along with a letter explaining eligibility for this program is currently being sent to Veterans who may live more than 40 miles from a VA facility. The next group of Choice Cards and letters will be sent shortly thereafter to those Veterans who are currently waiting for an appointment longer than 30-days from their preferred date or the date determined to be medically necessary by their physician.

The final group of Choice Cards and letters will be sent between December 2014 and January 2015 to the remainder of all Veterans enrolled for VA health care who may be eligible for the Choice Program in the future.

The contracts with Tri-West and Health Net also make sense because the VA just had to modify existing contracts with the two firms.

The VA has also released a very simple app, Veterans Choice Explorer, that asks yes/no eligibility questions. 1.  Are you enrolled in the VA for healthcare benefits? 2. Were you enrolled on or before August 1, 2014? 3. Are you unable to schedule an appointment with a VA provider within 30 days?  If YES, “Based on your responses, you may be eligible for benefits under the Veterans Choice program.”  And a toll-free number is provided: 866-606-8198.

ferry

photo: Stormy Charette; location: Lake Superior source: AARP

If you answered NO (not enrolled), you get a new set of eligibility questions: 2. Was your date of discharge from the military less than five (5) years ago?  If you answer NO to question 2, you’re out of luck; answer YES and proceed. 3. Did you serve in a theater of operations after November 11, 1998 (e.g. Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn)?  If you answered NO, bye.  4. Do you travel by air, boat, or ferry to reach your VA medical facility?  YES and you’re in.

Now this question is somewhat deceptive; they should give as an example the 40-mile condition.   Instead they give an uncommon example. 5. Do you face an unusual or excessive travel burden (i.e. you cannot travel to a local VA due to a body of water or land barrier that cannot be crossed by road or highway)?  Yes, you’re probably good.  No, maybe.  This group of veterans can enroll by phone.

The app is too simplistic.  For example, if you need to see a cardiologist, you don’t have to wait 30 days for an appointment.  But we are finally getting details in dribs and drabs.  So for today, and today only, how satisfied am I with the VA Media Room strategists? Not satisfied; somewhat satisfied;  satisfied, or very satisfied?  I’m satisfied because they honored the due date and the news is pretty encouraging for thousands vets. 

 

 

Ed.note  I’m getting the  same kid gloves treatment from the VA dental clinic at American Lake up here in the other Washington. I called up November 2nd @ ODark30 and did my usual request for a teeth cleaning. As usual, she said “The earliest we have sir is January 9th, 2015. I said that wouldn’t work because I have to have my HCV-infested choppers polished every 90 days. Since they normally only schedule from 30 days out, we are forced to call in on the first of the month or the first Monday. January 9th would put me 39 days over my 90 day cycle. I happened to mention that if they are, by chance, over 30 days out, rumor from Call me Bob  had it that we could go to the private sector on VA’s nickel. She admitted as much and promptly set me up with my old dentist that is repairing all their other mistakes over the last six years. I now have 6 appts. in less than a month where I was only given one in 14 months due to VA “scheduling snafus” which, fortunately no longer infest the system. Funny when the VA scheduling gal realized I was onto the 30 days or 30 miles warranty, the story changed that they hadn’t been doing business like that (having to call on the month you hoped to get the appt. in) in years… Man they must really think we are Flat Earth Society members.

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VAOIG–WE WERE UNABLE TO SUBSTANTIATE…

vaoigI always get a bang out of VA’s Office of Inspector Gadget terminology and descriptive adjectives. They are worthy of being hired as the President’s Press Secretary apologists. I refer to both parties’ press secretaries-not just the current ones we’ve experienced in the last several years. No party has ever had a corner on the market for incredible interpretations of current events. However , the steady drumroll of events described by our VA Office of Incredible Goings on beggars the imagination.

I share with you this incredibly incisive review of a medical mishap-completely unforeseeable apparently. A vet is bleeding out in January and says “Help!” VA schedulers promptly triage him as “routine” assuming his (and all Vets) volume of blood (10 pints) is an endless supply.

We confirmed that almost 8 months elapsed between the patient’s initial
gastrointestinal-related complaints in January 2011 until his colonoscopy in August.

We did not find that this 8-month time frame represented a clinically significant delay in care. The patient’s clinical presentation was unusual for a patient with  colorectal cancer (CRC) for both the early age of onset as well as the short time period from initial symptoms to the discovery of advanced cancer. None of the providers were suspicious for CRC given the patient’s age at presentation and no known family history. Because the symptoms of inflammatory bowel disease are similar to CRC, providers reasonably considered inflammatory bowel disease as the more likely cause of the patient’s symptoms. At each visit, providers evaluated the patient’s condition and initiated appropriate laboratory and other diagnostic tests as indicated. [Well, except for a butt tractor exam or a CAT scan]

Gosh, when you’re bleeding out the butt at my gastrodoc’s shop, you’re thrown on the table the next day to find out what in Sam Hill is afoot. VA has a different metric and the OIG apparently defers to the VHA’s much more knowledgeable medical assessment. Read on.

VAOIGWhen the patient reported recurrence of blood-streaked diarrhea in April, his primary care provider requested a routine Gastroenterology (GI) Clinic appointment, which was scheduled in early June. The emergency department provider told us that he attempted to expedite the GI appointment (via an “added comment” in the consult) because of the patient’s anxiety (not because there was a clinical urgency); we found no documented evidence that the request was reviewed and considered by a GI provider at the time. At the time of the June visit, the GI provider evaluated the patient and ordered a routine colonoscopy, which was scheduled for mid-August. We could not say with certainty that the patient’s outcome would have been different had he received the diagnostic colonoscopy sooner. The colonoscopy and subsequent computerized tomography scan revealed the patient had a large mass and advanced CRC with metastasis to the liver. As CRC is typically a slow-growing cancer, the patient likely had advanced CRC at the time of his initial presentation with symptoms. The patient subsequently transferred his medical care to a non-VA provider. He died a little over 2 years later. 

Shoo, doggies. The Vet was a walking dead man so no flies on us. What kind of medical diagnosis is that? “We did nothing for eight months but it wouldn’t have made any difference if we had. Therefore you cannot accuse us of malpractice after the fact”. This is exactly what is wrong with the VA style of medical excellence we read of. Excuses are like assholes and the VA OIG is careful to make sure every one of their brethren over at the VAMC has one. I might expect this of the New York Police department and their “Blue Wall” but hardly from a government agency tasked with the responsibility to provide us with the most up to date medical advances available. To have the VA’s OIG as the designated apologists at every turn so as to deflect criticism is alarming. Nevertheless, no one bats an eyelash and this modus operandi has been ongoing for almost a century. If you had never cracked a book on VHA’s fabled shortcomings, you would be forced to assume they are above reproach.

June 2009This sounds like what happened to me. “We reviewed Mr. Graham’s Computerized Tomography Scans and were unable to ascertain any free air in the abdomen. Therefore we surmised that the fact he was swelling up like Octomom was due to post -surgical edema and not the shit that was piling up in his abdominal cavity due to the inept surgery we performed. As soon as we realized there was a problem, we performed another surgery and corrected the septicemia. We were unable to substantiate that the septal infarction and permanent T-wave abnormality following surgery was in any way related to the septicemia experienced for eight days that damn near killed him.”  Next?

Here’s another excuse template followed almost to a T.

We substantiated that the nursing staff did not perform patient rounds in accordance with the Medical Center policy, which requires a patient to be checked every 30 minutes. In addition, we found no documentation of actions taken when non-nursing staff notified Spinal Cord Injury staff of a change in the patient’s condition.

But…

We could not determine whether a failure to immediately assess the patient for possible problems led to this patient’s death.

We recommended that the Hampton VA Medical Center Director initiate a review to
evaluate patient rounds and medical record documentation policies, train and educate
appropriate staff to ensure consistent adherence to patient assessment and documentation procedures, and consult with Regional Counsel regarding institutional
disclosure.

download (1)It appears the VAMC Hampton boys concurred with the OIG’s findings and promised that VA nurses wouldn’t update their Facebook pages during normal working hours to the possible detriment of the patients. What is wrong with this picture? VA is trying to cast it in the light of “We were unable to find Waldo in spite of a diligent search. However, we were able to find that nothing Waldo did was untoward or caused anyone to reach room temperature on his watch.” No harm, no foul. Give dat man a bonus!

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