HO CHI MINH TRAIL PHOTOS

Posted on February 25, 2014 by asknod

machine-gun-640x508Here’s a great retrospective at ground level of what we tried to bomb back into the stone age. It seems rather odd forty years later to view these relics and recognize what we were seeing from altitude close up. I personally could go the rest of my life without ever seeing another 37 mm AA gun or the dreaded 12.7 mm DShK pictured here.

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VHA BACKLOG REPAIR ORDER–DELETE SCHEDULED EXAMS

Posted on February 25, 2014 by asknod

Well, golly gee willakers. You have to hand it to the VHA. VHA being the highly touted Veterans Health Administration. Every day I hear all manner of kind things about what the VHA has done for Johnny Vet. How he went in to get a cast on a broken leg and walks out without the leg. You know. The run of the mill heartwarming stories like the medical technician sharing his Hepatitis C virus with all those Vets up in New Hampshire. The dentist with HCV who refused to wear gloves in Dayton and shared it with Vets, too. Yep. That VHA.

Seems they’re back in the news again. I hear stories from all of you who tell me you call up for an appointment at your local VA medical Center (VAMC) or Community-based Outpatient Center (CBOC) and discover a three month wait to get an appointment for that funny new heart beat and the tremor/numbness in their left arm. Now we come to find out that if you don’t keep that current, they just push delete and poof- your appointment disappears into thin air. Our member Mark was scheduled to show up for an intake-only appt. to bring him into the VHA system in American Lake last week. It was a Saturday of the three-day weekend. They assured him they’d be there. Mark showed up and the janitor was the only soul about. Seems they do intake Monday to Friday.

I have long held VA in contempt for a wealth of reasons. Outside of the fact the VHA did everything in their power to kill me and failed, they have repeatedly stymied, delayed and obstructed my claims over the last 23 years. Losing a leg is a pretty serious screw up. I guess it could have been worse. At least they amputated the correct leg. But that pales in comparison to this.

The gentleman discussing this points out that VHA get 3,000 appointment requests every month at the LA VAMC but can only accommodate 800. This sounds a lot like the Veterans Benefits Administration, their big brother, who decides who’s broken. Actually, the odds are better on being seen at a VHA eventually than getting a claim approved by the VBA. Living long enough to accomplish either one seems to be the only common denominator otherwise.

I think I would be remiss if I didn’t point out that this practice of “delete and deny” is not a relatively new phenomenon. Like Mark, after calling and making an appointment in June 1993, I attended what I thought was my Agent Orange registry exam on September 21, 1993. It seems there was a little backlog then and it was the earliest they could get me in. After arriving, I discovered I had no appointment. Never did. In fact, the nurse even wrote on my chart “0% chance this Vet had an appointment on this date. Will reschedule doctor’s exam and do labs while he is here today.” I never heard back from them in spite of the fact I never moved or changed my address. In VAland, you will discover that the United States Postal Service, heavily staffed with Veterans, is unreliable and a lot of mail gets lost or stolen. VA cannot prove they mailed something like an exam appointment but the Presumption of Regularity ensures that it did, indeed, occur. Just because you didn’t get it or it showed up at the homeless shelter you lived at in 1979 doesn’t mean they dropped the ball–until now.

How many of you discover via the USPS that VA has scheduled you for a C&P exam which you failed to attend? How many claims were denied where the Vet finds this out in his denial? We are told that this is so rare as to be technically insignificant yet here we have the wholesale slaughter of thousands upon thousands of appointments going back years in order to tidy up the books. Not one word about calling the Vet up and finding out if s/he still desires the appointment. I guess I’d have a hard time finding the right words to use to explain that tardiness. Apparently VA has a stable of able technicians trained in this artifice.

“Hi. This is Shalinda from the West LA VAMC. Am I talking to Johnny B. Vet? Could you give me your last four and your DOB to confirm that?

“4647 and 4/01/1951”.

“Thank you, Mr. Vet, the reason we are calling you is we noticed you made an appointment for a MRI in October of 2006 and we see you still haven’t had that. Is there some reason for that?

“Yeah. I’m waiting for an appointment to be scheduled. The nurse said they’d call when they had an opening. I also asked to be put on a list if anyone canceled on short notice.”

“Mr. Vet, I hope you realize this is a two-way street. You understand these telephones work in both directions. I don’t see anything in the file about you calling back and confirming you still want the MRI. Is that what you are trying to tell me? Can I assume that you do?”

“Yes, ma’m. How soon will that be?”

“We’ll call you back real soon with a date, sir. Thank you.”

Lather, rinse and repeat. A good tech should be able to do about twenty of these an hour for a daily workload of about one hundred or so. One technician could conceivably handle the whole overflow of the 2,200 Veterans per month who did not get an appointment all by themselves if given a suitable bonus. The upside would be if the Vet didn’t answer, it could be inferred as a “no” and thus be stricken from the active list. This would be far more humane and inspire hope in the breasts of many a Vet who would otherwise be crushed to find out he had been summarily deleted without some interaction.

I think the VHA has a long way to go on being proactive in this business. Now that Fox News has identified the problem, the VAOIG can be called and an investigation and tee times can be scheduled for this April before it gets hot and muggy in West LA. Another win-win for Vets everywhere.

P.S. Every good story has a sequel and now we get to hear about it. Oliver Mitchell, a former Marine and now quite possibly a former VA employee, was in the thick of it in all this. As usual, if you notify the VAOIG, eventually they show up. This time it was several years later. They must really be busy with whistleblowers if it takes that long to investigate. Fortunately, by that time, everyone had been promoted or transferred and couldn’t be reached. The MRI records had been deleted and it could not be “substantiated” that any records had been deleted. Here’s the link. And we may want to bookmark Mr. Mitchell’s new blog on this subject.

VAOIG

 YOU REPORT

VAOIG   THE WHITEWASH

IS ON US-FREE

Posted in VA Health Care, VA Medical Mysteries Explained, vA news, VAOIG Watchdogs | Tagged , , , , , , , , , , , | 2 Comments

SHOWDOWN AT THE VARO CORRAL

Posted on February 24, 2014 by asknod

downloadThings have been “brewing” shall we say, between the VA and their slaves down in the galley at the mighty ship Columbia of South Carolina. This has been going on for quite some time but one would think that quarreling siblings could reach consensus on the proper staffing levels at these venues and spare Veterans further delay in their claims.

If one were to think that, one would be horribly wrong. Indeed, VSR, RVSR and DRO positions go begging  for lack of qualified personnel. . . . . or do they? The VA is divided into two camps, apparently, over this enigma.  The VA seems hell-bent  they are going to shrink Regional Offices down to the bone on personnel and  make it appear they are moving Heaven and Earth to speed up the impenetrable backlog.  The American Federation of Government Employees (AFGE union) boys and girls are aghast at what they are being saddled with and by extension, blamed for.  As usual, there are two sides to a coin. I like the attorneys who say “Jeesh. Those neanderthals down at Fort Fumble can’t locate their derriere with a methane witching stick.” I am coming to believe what I am reading here simply because it resonates with what we are all experiencing with our claims. In any business model, if they are short of widget benders on the production line, they move guys up from the warehouse to fill in until the personnel shortage is resolved. But when the boss is laying off widget benders at the height of widget season for no good reason, you have to start asking very pointed questions. We are all euphemistically labeled “stakeholders” in this process. That means we have a vested interest in what is afoot at the VAROs across the fruited plain. If it is obvious that VA is complaining mightily about how there are a dearth of raters or, in the alternative, a plethora of claims deluging them, then it behooves us to ascertain who’s blowing the smoke rings. Our obligation as stakeholders demands it. When the AFGE folks tasked with the job start producing data extracted via the FOIA that conclusively reveals VA is the the miscreant, then we are really in deep doo-doo. Put another way. We’re being bullshitted along with Congress and VA foolishly thinks the AFGE is never going to reveal the depths of their deception. 

The missive is addressed to the good members of Congress tasked with the responsibility of trying to figure out what in Sam Hill VA does with all it’s time, not to mention its money. Now that the bonus bucks party is over and the annual getaway to Orlando has been scotched (no pun intended to those poor souls at Vermin Ave. NW), things are looking rather glum and grim.  There are really no more excuses left other than to fire up the VBMS and get cooking. One little problem seems to be raising its ugly head though. All this time the attorneys have been making cruel jokes about the raters’ ineptitude and we now find out there ARE no raters or damn few of them-inept, or ept, for that matter to blame for all this. Quite simply, the VA has been allowing them all to retire (or quit) and not filling (or eliminating) the positions. All this in the middle of the largest backlog in the history of the organization. Now, does that sound like sabotage? Fundamentally changing the way they’ve done business for centuries by continuing the same program? Innovation that is cutting edge and the Final Frontier of claims?   

stoningofsinnerAll this time we’ve been hurling stones at the wrong sinners. As with most yarns, there is indubitably more than one culprit to blame. VA has done an admirable job of laying the blame at the foot of massive numbers of Veterans filing and the quirks of a ten-year plus war. I would direct the reader’s attention to the fact that the numbers of Vets, as a measure of population, have remained static for the whole time we are discussing i.e. from 2001. Yep. Statistically, there are no more Vets today that there were ten years ago. If you took a cross-section of America and looked at how many were under arms after 9/11 who suffered a disability  and compared it to today’s statistics, the difference in the numbers is insignificant. How can that be? Well, let’s analyze it.

Vets are created every day by virtue of being retired or separating. Judging by past wars and tables, 22 percent are injured on a scale of 0 to 100% in any war. The numbers are marginally lower in peacetime. After Vietnam, we would naturally have expected to see a discernible bulge in the VHA python but it was notably absent. Growth of Veterans with rated disabilities was absolutely flat. There was no extraneous spike in ratings to encompass the para/quadraplegics or those missing bits and pieces of their anatomy. Gradually, a number of World War One/ Two Vets and their wives expired and the ranks of the Korean and Vietnamese War filled in the gaps. Again, there was no discernible change in the numbers statistically of the TDIU/100%ers. Fast forward to the present and view these statistics. Somehow, 100% disabled (as well as all others) are magically dying at the very same rate as those who VA promotes to the rank of 100%. Nothing has changed. Amazing but true.

If you view the VA ratings game in perspective , it makes perfect sense. Imagine a company that only has so many slots for senior management (100% P&T), a larger group of regional branch managers (TDIU) and last but not least, an immense work force made up of journeymen and apprentices (0% to 50%). There are X slots open for advancement. You essentially have to wait for someone to expire to advance to the next ratings level. VA is adroit at this game. With all the tools available in their repertoire, they can delay and deny at will and advance only the most pressing or egregious cases as necessary out of the normal queue awaiting entry or a ratings increase. Think back to your childhood and play Red light! Green light! in your mind’s eye. Now substitute the Central Office in DC doing the same.

What the article reveals is an artificial brake on the process by virtue of an insufficient number of raters to keep up with the volume-i.e. not enough widget benders. If you have been brainwashed into believing this scenario, it goes without saying that you implicitly trust the folks trotting out the numbers. The problem is that the raters weren’t born at night nor were they birthed the night before last. They are being tarred and feathered as being lazy, inept and uncaring when the truth of the matter is that the poohbahs at the Central Office are concocting this “perfect storm” to impede the ratings progress of the ROs. All the while they are patiently explaining that all is well in Mudville at the bottom of the ninth.

Excuses are like assholes and everyone has one as the saying goes. Murphy’s addendum is that they all stink. Here, the VA is pawning off the stink on the few raters left at the ROs and foisting any and all reason for delay on, of all things, an overwhelming backlog. Millions have been spent ramping up training for the new wave of Lean Six Sigma Kaizen with their shiny new green belts when there are no such animals afoot. Or in the alternative, these new green belts are being assigned to work as lowly “gatherers of evidence” with no authority beyond choosing to put cream in their coffee or not.

The Columbia AFGE boys have not read the VA’s Rodney King “Can’t we all just get along?” email. They see the glaring flaw in the system and are unwilling to be the whipping boy any longer. How many Senators and Congressman can file inquiries asking what the hold up is without someone finally spilling the beans?  According to this document, the rubber band snapped. AFGE is mad as Hell and they aren’t going to take it (the blame) anymore. I concur. It’s a sad day when these gentlemen are forced to employ the same FOIA we use to excavate the damning documents from VA excuse mongers. Facetiousness is somehow lacking as a descriptive adjective for this.

The information gleaned from AFGE’s FOIA hunt is self-evident. VA is laying off raters in Wilmington, Delaware (and elsewhere) and at the same time brokering claims to them from other VAROs in a Mad Hatter tea party of  insanity. When Wilmington cries “Uncle”, the Central Office uses this to buttress their claims of inundation and yet another round of hiring. Pardon me if I ask where all the new hires are going. To Nationwide is on your side?  AFGE  sees no relief on the horizon and only further erosion of desperately needed ratings  hierarchy to keep up with the flood of claims. Promotions within VAROs are also stymied for some unknown reason. All I see is a system of too many chiefs and not nearly enough Indians. To add insult to injury, every Regional Office is allowed to make up new rules refusing to to anoint any new warriors (raters) at their own whim.

The VA hierarchy is being repopulated with a new breed trained by the old. They are staid and unbending. They rebel at the mere suggestion of innovation. They will stop at nothing to sabotage this process and keep us in the dark ages. They have evinced this desire continuously since the first calls went out in 1988 to revamp the process at the dawn of the VJRA. Doesn’t anyone find it incongruous that any process could be so unwieldy and impossible to tame for over two decades in spite of all the newfangled innovations like computers, bar codes, QR codes and the like? How do Geico and Allstate do it? What is the mystery? Remember, we’re talking Insurance Company logic here. Either you rear-ended the insured or you didn’t. Or in the VA vernacular, either you had tinnitus in service or were subjected to it by the requirements of your job. . . . or you were not. VA somehow can take this out to a 270- day investigation with a negative finding entailing 4,000 hours of paperwork and time on the clock. The sum of billable hours to make this determination will far exceed the entitlement of $125.00 per month that the VA claimant will accrue for life and no one blinks an eye. That’s if the claimant doesn’t appeal the denial. If this matriculates to the CAVC, I have no doubt that the sum would be far into the millions before VA acquiesced. Sadly, most claims are legitimate and treated in this very same fashion. Worse yet, we ostracize the ones (AFGE) who are hamstrung and prevented from doing the right and honorable thing. Have any of you read the M-21 or even tried to fathom the intricacies of determining if a dependent child is truly a legitimate entitlement? Seems pretty simple until you find out a RO only has one guy assigned to this and he’s 16 months out because each one requires a day of friggin’ paperwork to input one child into the computer.

Granted, there are no dearth of chowderheads manning the 827-1000 Dial a Prayer phone banks. Have mercy on them. They are FNGs. They work off a menu like a phone bank in a boiler room operation. They really know less than you and are constrained to appear knowledgeable. I’m sure they get a lot of flak from irate Vets who are frustrated and it eventually leaks out. I solved this problem by using the IRIS system and it will help you folks too. It may take 5-10 days but the ordnance will land on target and do far more for you.

Here’s The Senior Raters website. It has a wealth of information about why it takes so long. Interestingly enough, it is not a compendium of excuses as to why they can’t get from A to B. It is, however, a damning  indictment of of how VA runs their insurance company. Having no love for unions, I’d be tempted to vote for India to solve the problem but I’d hate to see all those jobs go offshore. Besides that, their accent throws me. How about we subcontract this out to Our good buddies at “Like a good Neighbor, State Farm is there”? They could hire all the raters and it would be like shovel-ready jobs. If and when they ever got caught up, we could bring the upper management to 810 Yellow Brick Road NW and they’d all rate happily ever after…

Posted in VA BACKLOG, vA news | Tagged , , , , , , , , , , , , , , , | 3 Comments

VETERANS HUMOR

Posted on February 23, 2014 by asknod
left clic the pic

left clic the pic

You do see what I mean when I say “Veterans Humor” now, right? Robert Duval’s Lt. Col. “Bull” Meechum in The Great Santini couldn’t top what we have planned for this year.  

My sports car just isn’t going to work, though. First, the colors on the sign clash with the red of the Triumph. And the check is all out of proportion to the vehicle. Looks like I’m going to have to bite the bullet and go with Plan B- spring for the White Denali, Escalade or Excursion from Enterprise Rent-A-Car for 4 hours. The helium balloons would have been a problem with the top down, anyway. Getting a good April Fools joke perfect requires planning.

Robert Duvall The Great Santini

Be prepared to be entertained, gentlemen.

Posted in Humor | Tagged , , , , | 1 Comment

VET CONCERNS ABOUT SVR WITH SOVALDI AND RATINGS

Posted on February 23, 2014 by asknod

downloadI have been contacted about a gazillion times with worries from a lot of you who are preparing for treatment with Sovaldi. The primary concern voiced is that you may lose your ratings or be reduced. Relax.

First of all, those of you who have been granted service connection have innumerable secondary diseases, muscular or gland/organ dysfunctions in addition to the Hepatitis C. Your liver is not about to regenerate itself so you can’t resume that wild and crazy lifestyle we indulged ourselves in back in the eighties. You can’t claim alcohol abstinence as a disability anyway. Shoot, bubba. I was the first one to file for that one. VA ain’t buying.

Some have lost thyroid glands or kidneys to this monster. Others have suffered horrible depression and the mental diseases that accompany it. Still others have DM2-either from the HCV or Interferon treatment(s). Face it. You were damaged-either directly or indirectly-by your infection with this critter. Anything that is secondary to the original infection is legally compensable.

imagesInterferon, in its own right, is probably far more likely to have zapped your more than the Hep. It has been known to be responsible for the majority of thyroid and Diabetes misfires and is strongly associated with a host of other ailments to include tinnitus and deteriorating vision.

HCV has also been indicted in setting off a panoply of autoimmune disorders such as Crohn’s, ulcerative colitis, cryoglobulinemia, porphyria cutanea tarda (PCT) and pruritis. I could go on but the jury is still busy determining a host of other ills that science is only now putting under the microscope as being suspect.

The long and short of this is that SVR, or remission in DickandJanespeak, is more of a paper term and in no way, shape or form means you are ready for the Boston Marathon. The damage done over decades can not be set aright simply by waving the magic Sovaldi wand over you and incanting the magical words “Rise. You are, like, totally healed dude”. VA knows this but has been known to use it negatively in an attempt to portray your health as peachy keen and dandy.

In fact, our very own member Malcolm in the Middle is caught in this maelstrom. VA insists he is now pure as the driven snow, free of the bug and thus not entitled to any remuneration. This fails to explain the host of ills he suffers-the very least of which is DM2.

If and when VA should approach you and ask for a new C&P to measure what condition your condition is in, you will have to comply. This may set off a new round of litigation if they try to go south on you. Stand fast and report here.  We’ll give you the repair order on an individual case-by-case basis because VA never attacks quite the same way each time. They do have a limited repertoire but it is predictable. You will simply have to pick the correct argument off the rack and type it up.

In summary, Hepatitis C remission is not even considered a done deal for years as the bug is incredibly rugged and tenacious. Some have discovered this to their dismay as much as three years later. Relax. The new regimen of Sovaldi/Ledipasvir/Ribavirin seems to shut this puppy down dead in its tracks. For those of us who do not reach sustained virologic response (SVR), the results are now coming in showing the drug combo sets the bug back on its heels so completely that it is all but in remission. This allows the liver to resume a modicum of normalcy. If you are like me (63 and Genotype 3), even if you do not attain SVR, you will at least die of old age instead of a decompensated liver. The other upside is that it appears to decrease the chances of Hepatocellular Carcinoma or HCC- the Farrah Faucett killer.

The Gilead scientists are also optimistic that SVR with Sovaldi, even in the event of a transplant, grants immunity to the new liver. Hallelujah, Leigh and Paul!

geico1jpgNothing is going to cure a lot of the diseases that attached to you over the progression of your unknown illness. Your missing thyroid is not going to reappear like the Geico lizard’s tail that got amputated in the car door. Your DM2 is not likely to go into remission either. As for the fibromyalgia and rheumatoid arthritis? Hard to say. The damage is done and is difficult to reverse. This is why we strongly advocate you seek service connection for these even if you are rated 100% or TDIU for the hep. Call it insurance. We all know what VA is capable of. Be a cub sprout and be prepared.

Posted in HCV Health, Interferon claims, research, Sofosbuvir, Tips and Tricks, Veterans Law | Tagged , , , , , , , , , , , , , , , , , , , , | 51 Comments

FOOTLOCKER–43 YEARS LATER

Posted on February 22, 2014 by asknod
clic the pic

clic the pic

One of the Biggest Little Towns in Laos during the war. The extreme western terminus of the DMZ. The Plain des Jarres Golf and Country Club. Indian Country. 20 Alternate, LS-98, or simply LS-20 A on the map. Whatever you called it, Long Tieng was home to quite of few of us for a while. 

Nestled in the valley below Skyline Ridge and our TRC-28 Microwave shot back to Vientiane, 20 Alternate was a hot town mais non cocottes. If you risked fooling around with one of the beautiful Meo babes, you were headed for a shotgun wedding regardless of whether you had consummated it or not. You had to hitch a ride to Vientiane if you wanted to get laid.

Leaving 20A and going to work

It was the only large airport I’ve ever seen with one way in and the reverse way out- hence the nickname of The one-way runway. You landed on runway 315. You took off on runway 135 which looked and felt remarkably similar. At the end of our runway (landing) were what we called the titty Karsts. Two large unequal, Madonna missile bra-like  projections sprouted up at the end of the runway. They were also referred to as the vertical speed brake and actually stopped a C-123 cold in its tracks in the late sixties.

LS 20 Alternate Approach August '70

Titty Karsts dead ahead

Here’s another, more recent shot looking southeast from the top of the shorter of the two karsts

91785653

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This was General Vang Pao’s last stand and it finally fell in 1973 when it was overrun by the Pathet Lao, aided by the Chicoms and NVA Regulars.

ceeI was there for an incredibly short one month and 14 days but what honestly felt like a lifetime. A very brave pilot I became  friends with departed here on 22 February, 1971 and augered in on his way back down to  L-08 (Vientiane). His tour was almost over. I found out about his passing in 2007 while researching my claim and looking for buddy statements. I was about 500 klics southwest at Operating Location C at T-11 in Thailand with Hepatitis went he went in. I came down with it 89 days after almost finding the Golden BB up near the Plain of Jars (September 1970). I was discharged from the civilian hospital on the 24th of February 1971 and never ran into Chuck again. I assumed he’d DEROSed back to the States.

Forty three years. Seems somehow like last week and at the same time, almost a memory of a dream.

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clic the pic

Posted in All about Veterans, Inspirational Veterans, Vietnam War history | Tagged , , , , , | 2 Comments

VA NEWS RELEASE

Posted on February 22, 2014 by asknod

unnamedVA has finally released a picture of the new Veterans Benefits Management System (VBMS) computer interface hookup at the Oakland Regional Office. Douglas Bragg, the director of the Oakland Veterans Service Center, pictured here in the ”clean room”, demonstrates how the computer drive is engaged on an actual pdf virtual claims file awaiting adjudication. In the appendix attached,  .pdf as defined by VA was “pretty damn funny” but this appears to be a misprint.

Note the handy tray-server modification for transfer to another location. Under Secretary for Benefits Allison Hickey recently confirmed the launch of the VBMS at all 56 Veterans Service Centers and noted that their IT fellows are just now working out the last of the bugs. VBMS is considered to be the Final Frontier in conquering the pesky claims backlog. There was no mention of which Veterans Service Center was still not connected as there are 57.

In keeping with VA raters’ wishes, the new computer files still resemble the same light-brown color of the original c-files as well as the same size and shape so as to ensure comfort and familiarity with them. Extensive testing proved that personnel were reluctant to let go of the “old look” and needed continuity of product. After a two year test of 18 Regional Offices, the change was instituted system-wide with a  proposed launch date of  January 1, 2015. VA promises to keep us informed of any updates.

 

 

 

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VA/MEDICARE RULES FOR SOVALDI

Posted on February 22, 2014 by asknod

downloadHere’s the latest monogram everyone’s been working from to determine who gets the Sovaldi, how much and for how long. Additionally. they are still trying to pawn off the bug juice (Interferon) on those unsuspecting few with Genotype 1A&B who are gently described as “Interferon naive” or virgins. The good news is the the sickest get it first and those with Cryoglobulinemia even get to cut line to the front. Everything in red is as it appears on the circular.

“Sofosbuvir is indicated for the treatment of chronic hepatitis C (CHC) infection as a component of a combination antiviral treatment regimen. Sofosbuvir has established efficacy in subjects with HCV genotype 1, 2, 3 or 4 infection, including those with hepatocellular carcinoma meeting Milan criteria (awaiting liver transplantation) and those with HCV/HIV-1 co-infection.

 

This document is meant to aid in deciding which patients are appropriate for simeprevir or sofosbuvir therapy during the preparation, discussion and vetting of the comprehensive drug monograph and criteria for use. The most important outcome of the current document is to ensure access to treatment with these agents for patients with advanced disease who are at higher risk for morbidity and mortality from their disease and liver status.”

 

 Sofosbuvir: Executive summary

 

Efficacy has been established in HCV GT 1, 2, 3 or 4, including those with HCC meeting Milan criteria (awaiting liver transplantation) and those with HCV/HIV-1 co-infection

Must not be used as monotherapy

Safety and efficacy not established in post-liver transplant patients

Regimen and duration dependent on both viral genotype and patient population

The efficacy of sofosbuvir in a treatment experienced population was done using modeling; a clinical trial was not conducted.

Candidates for all oral therapy with sofosbuvir and ribavirin include genotype 2 and 3 patients, HIV-HCV co-infected patients, persons who are not candidates for interferon-containing therapy and those awaiting a liver transplant

The safety and efficacy of simeprevir and sofosbuvir in combination in the treatment of HCV infection have not been established.

 

Patient Selection during interim period (prior to Drug Monograph and CFU approval/posting)

 

Patients with the highest risk of disease advancement should be prioritized to receive sofosbuvir. This group includes all HCV genotypes with compensated or decompensated cirrhosis and pre- liver transplant patients to prevent post-transplant HCV. Additionally, genotype 1 patients who are deemed interferon intolerant can be considered for a treatment regimen of sofosbuvir/ribavirin given for 24 weeks. Patients who have demonstrated documented ongoing nonadherence to prior medications, medical treatment or failure to complete HCV disease evaluation appointments and procedures are not appropriate candidates for therapy until those issues have been resolved.

Cirrhosis/ALD can be defined as

Biopsy proven cirrhosis

or

Clinical diagnosis based on defined events (i.e.,prior Child class B or C qualifying events) , Fib-4 > 3.25, APRI > 2.0

or

Platelet count  < 100,000 mm3

Or

Fibroscan score >12.5 kPa

In addition, consideration should be given to treating patients with serious extra-hepatic complications of HCV infection such as cryoglobulinemia

Interferon ineligible populations include;

·         Patients with severe thrombocytopenia (platelet count < 50,000 mm3)

·         Patients with severe depression not responsive to medical therapy (documented by mental health provider)

·         Patients with decompensated liver cirrhosis, i.e., Child class B or C

·         Patients with hepatocellular cancer awaiting liver transplant

·         Patients with auto-immune diseases that may be exacerbated by interferon-mediated immune modulation

Dosage and Administration for Sofosbuvir

One 400mg tablet QD with or without food

No response guided treatment

Eliminated primarily via renal clearance, safety/efficacy of sofosbuvir is not established in CrCl<30 ml/min

Hemodialysis removes 18% of the dose.

A dose recommendation cannot be made for patients with severe renal impairment (CrCl< 30 ml/min) or end stage renal disease requiring dialysis

No dose adjustment of sofosbuvir is required for patients with mild, moderate or severe hepatic impairment.

Drug Interactions

Sofosbuvir is a substrate of P-glycoprotein: inducers may decrease sofosbuvir plasma concentrations

No CYP450 involvement, fewer drug interactions would be anticipated

 

 Duration of Treatment with Sofosbuvir, Peginterferon and Ribavirin*

  Regimen Total Treatment  Duration
Genotype 1 or 4 Sofosbuvir + PEG-INF + RBV 1.0-1.2g/day 12 weeks
Genotype 1 or 4 interferon intolerant Sofosbuvir  + RBV 1.0-1.2g/day 24 weeks
Genotype 2 Sofosbuvir + ribavirin 1.0-1.2g/day 12 weeks
Genotype 3 Sofosbuvir + ribavirin 1.0-1.2g/day 24 weeks
Genotype 1-4, pre-transplant Sofosbuvir + ribavirin 1.0-1.2g/day Until time of transplant

*Includes both HCV mono-infected and HCV/HIV co-infected patients

 

 

Posted in Sofosbuvir | Tagged , , , , , , , , , , , , , , , , , , , | 3 Comments

USB HICKEY–WE CAN’T SUPPORT THESE “TRIPS”

Posted on February 21, 2014 by asknod
Waco VSC Drive-Thru Window (circa 2005)

Waco VSC Drive-Thru
Window (circa 2005)

For years and years, the American Legion has had an “action team” that dutifully travels the US and “inspects” the Regional Offices we have now come to know and love as “Veterans Service Centers”. After the millions of dollars spent on the new drive through features for filing in the 90’s,  VA has been proactive and added electronic filing as well. Now VA can lose it and legitimately say they never received it from you. It’s called presti-“digital” manipulation. 

downloadAmLeg considers their Go-Team a much-sought after plumb. You get to travel from city to city. You get to meet with other Vets and show off your hats. AmLeg has a lot of Posts with bars/restaurants and everybody wants to buy drinks for you. It’s a win-win job. There are 57 Veterans Service Centers-not counting the AMC on Eye Street NW. in DC. Imagine taking a trip to Manila, Philippines in December? How about packing the .338 Win-Mag. to Anchorage during the moose rut? If you take three days at each one and allow for vacations and National Holidays, you can start at the first Regional Office you visited exactly one year later and continue this charade parade endlessly. I figure they pack the spinning rod gear, start in Togus in June when the small mouth bass are voracious and work their way over to Fort Harrison, and the Northern Tier trout fishing.  Fall is perfect for Winston Salem and dove/quail hunting. It’s nice to then catch the sunny southern weather in winter and swordfish or blues in the Gulf of Mexico.

Which is why we’re even talking about this. AmLeg showed up as announced at the Seattle Veterans Prize Fulfillment Center recently and got the cold shoulder.  This was not taken well by the AmLeg guys so they retreated to the nearest post, ordered beers and got Alpha 6 Actual on the horn for the “Now what?” briefing. The silvers are running up in the Juan de Fucas and Seattle is being intransigent. A fine how do you do.

Veterans should not find this surprising. As most know, we are renowned for going postal or NASDAQ depending on which part of the country uses which pejorative. That Vets tend to do it inside or in front of VA facilities makes for messy problems and slippery floors. To remedy this, the VAROs have resorted, for the most part, to corraling Veterans into a waiting room with lots and lots of bulletproof glass and easy to clean floors. This is simply for the safety of everyone involved and should not be negatively construed as being adversarial or anti-Vet. In fact, with the way VA hierarchy treats it’s AFGE employees, the B/P glass may be there for them as much as irate Vets.

This “moat around the castle” scenario is just more of the locked cockpit-door idea on  Regional Offices. If Vets can’t get in, they just commit hari-kiri in the waiting area. I’m sure this idea came out of the sixth floor Vermont Ave. hallway suggestion box. The whole idea of the Department of Veterans Affairs is contained in its very name. Perhaps we should gift the VBA a Hooked on Phonics© course and they can learn how to sound out what they’re there for in the first place. We spent three or four years of our lives-some twenty- obeying rules and regulations. When it comes time to cash in the check and collect on the promises, VA tends to pull up the drawbridge and become inaccessible. Kind of like your Service Officer about a day after they get your Power of Attorney.

AmLeg has suddenly encountered the same mentality we get every day and they are shocked. I say shocked. The VA folks are up to their ears in bad publicity, the VBMS is operating more slowly than 1990s dialup or crashing several times a day and the friggin’ AmLeg guys with the funny hats want to come in and wander around unattended. The VA can’t have this. I was there in 2011 on the eleventh floor-the inner sanctum- awaiting my Board hearing. We were assigned a DRO minder who engaged in small talk and tried to ascertain if I was a NASDAQ-kind of guy. The metal detector had already revealed my ballpoint pen daggers and I had been relieved of them before we ascended from the first floor. Imagine having so much adjudication time to burn that they could afford me my very own GS-13 DRO officer? She even brought Cupcake some coffee.

Unfortunately for the AmLeg entourage this year, the VA has tightened up. No more bonuses. No smiles and high-fives in the hallway. Spartan conditions reign. Sequestration probably forced them into using Instant Folger’s in their cup instead of hopping the elevators down to 3 for a Starbucks run. With everyone in such a dour mood, did the AmLeggers honestly believe the VSC Manager was going to greet them with open arms and  “Hail, Fellows.  Well met!” gusto? Wake up and smell that Folger’s , dudes.

VAOIG

click the pic.

We are discovering the obvious truth as VA rearranges the musical chair statistics each month. The backlog is merely growing more tentacles like Medusa. Boldly Going Where No Federal Agency Has Gone Before is beginning look like yet another innovation up on blocks. To add insult to injury, The VA’s very own Office of Inspector General (VAOIG)- the one tasked with unmasking misfeasance- is busy investigating the Veterans Service Center in Cairo adjacent to Denial River. I understand that there are VAMCs and CBOCs throughout the land that are deficient in opioid medication management, but they need to keep hammering on the backlog agenda. From what we’ve read also, I suspect that the OIG should be reviewing VAMC sanitary protocols in their operating rooms .

To be truthful, we need to examine this backlog dilemma like a watchmaker. AmLeg is just one part of the puzzle. If they notice a better way to build a mousetrap while they are there, then the trip was worth it. Remember, they were the first ones to question why there would be a shredder right there in the C-files storage room at the Dayton Veterans Service Center as early as  2006. Once noted, the VAOIG was able to nip the shredding fiasco in the bud by 2009. Nothing gets by the OIG. Eventually they form a posse and head out to investigate.

As for Under Secretary Allison,nobody-least of all her- wants to be holding the bag on January 1, 2015 when they have to start prevaricating and saying “Hold the phone, Congressman Miller. 2015 is 365 days long. We never actually said what actual day in 2015 we’d attain 125-day/ 98% accuracy- so back off. Hear?”

For the record, here’s what Seattle looked like as of February 18th, 2014. Yep. 18,078 Vets. Sounds like much ado over nothing at Fox News.

va

18,076 Vets. 18,077 Vets Vets.18,079 Vets

18,076 Vets. 18,077 Vets.
18,079 Vets

 

For the record, we haven’t had 25,000 Vets waiting since August 08th, 2012. Well, unless you count the ones waiting for a SOC. And the ones waiting for a Board hearing. Or the ones waiting to have their appeals certified to go to DC. If you count all of them, it’s waaaaay over 35,000 but VA doesn’t count them that way. It’s far too depressing and besides, it’ll all be fixed by 2015 anyway so what’s the big hullabaloo?

Posted in VA BACKLOG, vA news | Tagged , , , , , , , , , , , | 6 Comments

CAVC–FRADKIN v. SHINSEKI–IMPLICIT DENIAL IS STILL A NO-NO

Posted on February 20, 2014 by asknod
Reversed and remanded!

Reversed and remanded!

Meet Robert Fradkin. An  American eager to serve his country in 1967 and who ended up with bent brain syndrome. VA fought him tooth and nail over this from his discharge in 1971 right up to 2002 when they relented and granted his claim back to his 1995 filing. This case is his fourth trip to the CAVC-some kind of remand record. Apparently, the BVA was not going to admit to what the common meaning of “is” was in 1971. I liken it to a child who is still cussing after he’s had his mouth washed out with soap four times. Our patron Saint of Veterans, Saint Mary Schoelen of the Holy Shrine of 625 Native Americana Ave. NW, has had enough and raises the “you’re outta here” thumb. 

Fradkin reversal pro se

I think what most of you will find amazing is that Mr. Fradkin did this all by himself. Winning a claim is no small feat in this VA Hall of Mirrors. Winning a CUE claim back to 1971 is like batting a .1000.

As usual, this one boils down to semantics. This is VA’s forte when they are controlling the Kangaroo Kourt. It even succeeds at the BVA where they carefully search for any legal justification for a denial. This time, they run afoul of time, too many frivolous technicalities and a pronounced propensity to lump a wealth of  personality disorders and compensable claims in one pile and blend them into puréed confusion. Mr. Fradkin wasn’t buying. He knew he had a brain owie. VA was willing to concede it as well. What they were not going to discuss was whether anything he had might be compensable. Viewed narrowly, his in-service complaint of schizoid personality was noncompensable. But that was not what he complained of. He was talking anxiety disorder and nervous condition.

I liken this technique to how they phrase your claim. You walk in and fill out the 21-526 and say I’m not a doctor but there is something amiss upstairs. VA will run with it and say okay, which one? There’s a pretty long list with a lot that begin with Schizo-. If you pick the wrong one, you lose.  Mr. Clemmons (v. Shinseki) had this very same problem, too. And like Mr. Clemmons, VA felt compelled to pick a mental disease Bob was not suffering from so as to deny it.

The appellant seeks reversal of the Board’s decision, arguing that the Board clearly erred when it determined that his claims for chronic anxiety and depressive neurosis were implicitly denied in the November 22, 1971, rating decision. He argues that he was not put on notice that VA was denying entitlement to service connection for chronic anxiety or depressive neurosis because there is nothing in the rating decision or notice of disallowance that refers or alludes to either diagnosis.

Bingo. Four trips to the CAVC to discover that implicit denial is still illegal in the lower 48? What’s worse, Willy Gunn finally has to fall on his sword and admit it. But four trips to the Big House to get them to admit they were “interpreting it wrong”? Saint Mary decides this is over the top-hence the reversal. You see this a bit more with the newer breed of judges at the Court- especially the more knowledgeable women like Schoelen and Bartley. I  think the jury is still out on Coral W-P but Hagel is even beginning to get fed up with some of this judicial ineptitude. VA should, by rights, only be allowed to commit adultery X number of times before they get charged with patronizing a prostitute.

Here, you get a feel for that laissez faire VA attitude. VA has screwed this up at the RO (1) the BVA (4) and now we are at the Court for the fourth attempt at determining what the truth is. Willy wants to export it back for one more lather, rinse and repeat at the BVA. Shoo-doggies. Like St. Mary is going to fall for that again?

The Secretary concedes that the appellant’s 1971 claims for chronic anxiety and depressive neurosis were not implicitly denied in the November 1971 rating decision and that the Board clearly erred in its application of the factors identified in Cogburn. Accordingly, the Secretary asserts that “remand of [the a]ppellant’s earlier effective date claim is warranted for readjudication and any necessary development.”

Clearly, the marijuana being smoked at the OGC is of a much higher quality than what is being sold in Washington and Colorado. You can almost see the paraphrasing in the brief:   “Well, Miz Schoelen. We gotta apologize. Seems you have it all figured out so just hand it back to us and we’ll sashay on over to Vermont Ave. and “fix” it.”

Schoelen isn’t that naive. She likes to do summaries and list all those mistakes where the Veterans Law Judge “got the vapors”.

 Upon review, the Court will accept the Secretary’s concession of Board error. The Court agrees that nothing in the language of the November 1971 rating decision nor in the December 1971 notice letter provided sufficient information for a reasonable claimant to know that a claim for any nervous condition, including chronic anxiety or depressive neurosis, was denied…

The Court further agrees that the Board erred when it determined that the first and fourth Cogburn factors also weighed in favor of finding an implicit denial…

Finally, with regard to the fourth factor, the Court agrees with the appellant and the Secretary,that the record does not show that he was represented by an attorney when the November 22, 1971,
rating decision issued. See Cogburn, 24 Vet.App. at 217 (finding that whether a claimant is represented by an attorney is relevant to determining “what disability was initially claimed and how
any decision based on the implicit denial doctrine is interpreted“)

Based on the foregoing, the Court holds that the Board clearly erred in determining that the appellant’s claims for chronic anxiety and depressive neurosis were implicitly denied in the
November 22, 1971, rating decision. Gilbert v. Derwinski  (“‘A finding is “clearly erroneous” when although there is evidence to support it, the reviewing court on the entire evidence is left with the definite and firm conviction that a mistake has been committed.'”  As a result, the appellant’s claims remained pending from October 1971 to March 2002 when the Board awarded entitlement to disability compensation for major depression. R. at 1271-80; see Adams v. Shinseki, 568 F.3d at 960 (“If a claim is left pending, it can be addressed when a subsequent claim for the same disability is adjudicated by [VA], in which case the effective date for any award of benefits will be the effective date applicable to the original claim.”)

Accordingly, the Court will reverse the Board’s decision that the appellant is not entitled to an effective date earlier than April 28, 1995, for the award of disability compensation benefits for major depression and remand the matter for (1) assignment of an effective date applicable to the appellant’s original claim filed in October 1971, which was within one year following his discharge from military service, and (2) a determination of the appropriate disability rating or ratings.

If VA continues to shoot themselves in the same foot again and again, I suppose they shouldn’t be surprised to get this treatment.

Here’s another by Judge Hagel. Same problem. This time the semantic slip up was blamed on the Vet-one Victor Ortiz-Alvarado- for using the word “revise” instead of “reconsider”. Pretty cheeky, huh?

Ortiz-Alvarado reversal on MFR or CUE

Once the misunderstanding was firmly ensconced, VA proceeded to do what Alvarado most definitely did not ask for- a motion to revise. Remember when your older sisters used to play dumb and try to misconstrue what it was you wanted-like maybe to get into the bathroom before you peed your pants? VA is no different. They’ve just taken it a step beyond to an art form. Unfortunately, CAVC judges usually can see through the ruse unless they are pro-VA jerks like Davis and Kasold are rumored to be.

FradkinAs I point out on these Cliff Notes® forays into reversals, VA usually has done something egregious and repeatedly, or the error is so prejudicial and a deprivation of all that is judicially holy as to warrant the ultimate sanction. Reversals are a repudiation of any redeeming judicial mores in a decision. It is the complete refusal to read into the VLJ’s aspirations any glimmer of nonadversarial justice. In Fradkin’s case the Court gave them three opportunities to do the right thing. When they couldn’t (or wouldn’t), the wrath of Khan was foreseeable.

Posted in CAVC Knowledge, CAVC ruling, CAVC/COVA Decision, Implicit denial | Tagged , , , , , , , , , , , | 4 Comments