from Colonel Dan AMA on veterans healthcare article

The battle at home: Struggling for VA health care access
Veterans are encountering administrative barriers, waiting lists and staffing shortages when they try to use the VA's health system.
By David Glendinning, AMNews staff. Dec. 3, 2007.

http://www.ama-assn.org/amednews/2007/12/03/gvsa1203.htm


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For some veterans, the fight didn't stop on the streets of Iraq or in the mountains of Afghanistan. Despite the promise that world-class medical care would be there for them when they arrived home, some are running into a bureaucratic battlefield and a stressed system struggling to give aid.

Recent congressional and public attention has focused on access problems at the Dept. of Veterans Affairs, which provides medical care to servicemen and women once they have left active duty in a time of war or an official period of hostility. Although investigators note that improvements are under way, they say the VA has a long way to go.

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Topic: The uninsured
Nearly 700,000 active-duty personnel and reservists who served in Operation Iraqi Freedom and Afghanistan's Operation Enduring Freedom have been eligible for VA health care since 2002. More than 200,000 have sought it out so far, the Congressional Budget Office reported in October. While this represents only a small fraction of the nearly 8 million veterans from all conflicts who are enrolled, the impact of veterans from today's wars on the system is great.

Thanks to recent advances in battlefield medicine, more servicemen and women are surviving severe injuries, CBO said. But they require more costly medical care when they return. The rapid influx of new enrollees has helped strain a system that already was under pressure from caring for the veterans of yesterday's wars. In 1995, fewer than 3 million veterans received VA health services. That number had increased to 5 million last year.

Many of the resulting access problems start at the very beginning of the enrollment process, said Donna E. Shalala, PhD, president of the University of Miami and former Dept. of Health and Human Services secretary. She co-chaired a presidential commission on care for America's "wounded warriors" that convened earlier this year after news reports exposed substandard conditions and a mass of red tape at Walter Reed Army Medical Center in Washington, D.C.

Although the Dept. of Defense and VA need to work together to foster a patient-centered continuum of care for each veteran, the commission found evidence that returning personnel were not experiencing a smooth transition from military health care to the veterans system, Dr. Shalala said.

There are nearly 8 million veterans in the VA system.
Without designated care coordinators to plan the best treatment path for new patients, an untold number ended up lost.

In addition, injured combatants must go through two antiquated disability assessments -- one by the military and one by the VA -- to determine what treatment options are available. This means that many are forced to jump through bureaucratic hoops that might not even get them to the right place, Dr. Shalala said.

"For veterans' families to give up everything just to coordinate this care themselves is fundamentally unfair," she said. "The process is too old-fashioned. It has nothing to do with modern medicine, and we ought to be embarrassed."

The Bush administration scrambled to correct several problems identified in the commission's July report. The Defense Dept. and VA in October agreed on an initial plan to place at least 10 care coordinators at four military medical sites that often serve as the first stop for wounded veterans. The Army also announced in October the formation of "warrior transition units" consisting of primary care physicians, nurse case managers and mental health professionals that would serve a similar purpose.

But Dr. Shalala said progress is still slower than she would like, and some of the commission's recommendations would require tough congressional action. The proposal to consolidate and modernize the disability review process, for instance, quickly became mired in partisan bickering.

Delays and headaches
For veterans who make it through the VA's bureaucratic gauntlet, the care they need might not be immediately accessible or available.

The department has more than 150 hospitals and nearly 900 outpatient clinics. While the number of facilities has increased in recent years, it is not nearly enough to provide VA services everywhere in the country. Many patients in rural or remote areas must travel hundreds of miles to reach the nearest department facility -- an impossible prospect for many.

The VA has more than 150 hospitals and nearly 900 outpatient clinics.
Jeffrey Scavron, MD, a former Navy doctor who practices at a community health center in Springfield, Mass., has seen this problem firsthand. Veterans in his area can get basic services at the Northampton VA Medical Center in nearby Leeds, Mass., but often must travel to Boston or Connecticut if they need to see certain types of specialists through the system. Some simply cannot make the trip and go without the care rather than pay for it, he said.

When veterans decide to stick with the VA, the system does not always respond quickly. Advocacy groups have complained to lawmakers that some enrollees seeking appointments, non-emergency surgeries or other medical care have been placed on waiting lists when facilities have been unable to meet demand.

In recent years, Spokane (Wash.) VA Medical Center implemented waiting lists when lean federal budgets forced it to cut back on services, said Joseph M. Manley, the center's former director. At one point, more than 3,000 veterans were waiting for more than a year just to receive their initial medical appointments.

The VA strives to see all patients within 30 days of when they call for an appointment. Out of the roughly 39 million appointments processed in a year, about 4 million exceed the 30-day threshold, said Michael J. Kussman, MD, the VA's health under secretary. While this leaves room for improvement, the department is proud of its nearly 90% record, especially because these appointments are not for urgent or emergent medical situations, he said. "I'm not aware of people being hurt in any way by some of the delays."

The VA's record is disputed by the department's inspector general, who in September released an audit that found the VA analysis likely understated wait times.

Not enough doctors to go around
Some facilities have little choice but to make patients wait for treatments or to refer them elsewhere because they do not have enough medical personnel. The department has struggled, along with many private health systems, to provide quick access to such in-demand subspecialists as dermatologists, ophthalmologists and otolaryngologists, Dr. Kussman said. Mental health professionals also are at a premium, the VA reports.

Some experts on the ground say the situation can be particularly difficult for the department when it attempts to treat veterans who have complex and specialized wounds, such as traumatic brain injuries -- the signature injury of today's wars.

1.8 million veterans were uninsured in 2004, up nearly 300,000 since 2000.
The VA polytrauma rehabilitation center in Palo Alto, Calif., is touted as a flagship for taking care of the most severely wounded veterans but still faces major staffing concerns. The center works hard to attract and retain physicians and others in a very competitive market, but it has fallen short of recruitment goals for physiatrists and other medical professionals, said its director, Elizabeth Joyce Freeman.

Veterans advocacy groups say the way the VA receives federal health funding is largely to blame for many of its shortfalls. Unlike Medicare and Medicaid, which receive mandatory funding every year based on projected costs, the department gets its money from the discretionary budget. This process is much less predictable and more prone to political tinkering.

Although Congress in recent years has kept up a steady stream of funding that has satisfied many advocates, the process has not been without missteps.

The department weathered an embarrassing episode in 2005 when then-Secretary R. James Nicholson went to Congress with a request for $2.6 billion in additional funding because it had vastly underestimated the number of Iraq and Afghanistan veterans who would require care.

The budget unpredictability makes it hard for VA facilities to plan ahead on hiring physicians or buying equipment, said Joseph A. Violante, the Disabled Veterans of America national legislative director.

Veterans can be waitlisted or shut out as a result.

"If the VA was able to get the funding on time and was able to know beforehand what that funding level was going to be, a lot of those access problems would be solved," he said.

The department opposes mandatory funding because the process would not easily adapt to changes in clinical practice or enrollee demographics, said W. Paul Kearns III, VA chief health financial officer.

Finding care outside -- or not at all
For some veterans, accessing VA health care simply will not be the best option because of their circumstances, locations or the specialized care they need. Some, especially those who plan to return to active duty, will continue to receive care from the military. Others will enroll in private insurance or receive coverage through another government program once they re-enter private life.

The department has boosted the amount it spends on private-sector care for veterans who remain enrolled in the VA but need to receive care outside the system. In fiscal year 2007, the department committed $2.2 billion out of its roughly $35 billion health budget to such fee-for-service care, a figure that has doubled since 2000.

For others, accessing VA health care is not an option at all. In 2003, the Bush administration decided to cut off new enrollment for many Priority Group 8 veterans, the department's lowest disability rating. These veterans are deemed to have sustained no service-connected disabilities and have yearly incomes that exceed predetermined limits, about $28,000 for an individual.

All combat veterans who have served in Iraq and Afghanistan are still guaranteed two years of free VA care after they return, and Priority Group 8 combat veterans who enroll during that window can keep receiving the care beyond that timeframe by making set co-payments. But those who fail to enroll in time risk losing access unless they later can prove they actually sustained a disability during their service.

Lawmakers have proposed extending the free combat veteran care from two years to five years, a move the White House supports. The Bush administration, however, opposes any plan to reopen new enrollment to non-combat Priority 8 veterans because the new enrollees would cost tens of billions over the decade and could hurt access and quality for higher priority patients, Dr. Kussman said.

But as long as this and other barriers exist, veterans who can't afford or obtain private coverage will go without needed care, said Steffie Woolhandler, MD, MPH, a Harvard Medical School professor and co-founder of Physicians for a National Health Program, a single-payer advocacy group. An October study she co-authored concluded that 1.8 million veterans from all conflicts were uninsured in 2004, up nearly 300,000 since 2000. Nearly half of them had not seen a physician in more than a year.

Dr. Scavron, the former Navy physician, said the uninsured veterans he sees in his clinic are evidence that the government is not fulfilling its responsibilities

"It's only the government that can take you into military service," he said. "So it seems to me that it's only the government who can take responsibility for the people that they take into service."

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ADDITIONAL INFORMATION:
Strains on the system
A higher percentage of servicemen and women are surviving injuries in today's wars than they did in the past, thanks largely to extensive body armor use, improved battlefield medicine and immediate aerial evacuation of the wounded.

In the Vietnam War, there were 5.2 wounded for every service member who died; in Iraq, that ratio is 7.6 to 1.

More Iraq and Afghanistan veterans are accessing the VA health care system each year, and the price the government pays for each patient increases:

Veterans treated Average annual
cost per patient
2005 101,000 $2,310
2006 155,000 $2,610
2007 209,000 $2,740
2008 263,000 $2,860

Note: Data for 2007 and 2008 is projected.

Source: "Projecting the Costs to Care for Veterans of U.S. Military Operations in Iraq and Afghanistan," Congressional Budget Office, October

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How many disabled veterans does the VA have working for them?

They deleted the old facts sheet. However, as I recall only about 26% of VA employees were vets.

The new facts sheet is quoted below, Colors and comments are mine:

VA Employees

As of April 30, 2007, VA had 244,032 employees on the rolls. Among all departments and agencies of the federal government, only the Department of Defense has a larger work force. Of the total number of VA employees, 216,658 were in the Veterans Health Administration, 12,684 in the Veterans Benefits Administration, 1,562 in the National Cemetery System, 3,254 in the Veterans Canteen Service and 426 in the Revolving Supply Fund. The rest 9,448 employees are in various staff and facilities offices.


VA is a leader in hiring veterans. About 60 percent of all male employees are veterans. (Less than 50% of VA employees are male!) As of April 30, 2007, VA had 17,346 women employees who served in the U.S. armed forces. More than 24 percent of all veterans in the VA are disabled veterans (I believe that's factual) and three hold the Medal of Honor

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Citizen Journalism in the Washington Post

Washington Post article on "citizen journalists aka "Bloggers"

I wrote on this at Daily Kos today and I am going to cross post the diary here as well: enjoy

With trepidation the Washington Post published an article on "bloggers" and what impact they are having on the "news".

Storming the News Gatekeepers
On the Internet, Citizen Journalists Raise Their Voices

is the title of the article, Daily Kos even managed to get a mention

Anderson at Large is nowhere near as widely read or heavily linked as RedState or Daily Kos, the popular conservative and liberal blogs. Technorati, which tracks a site's number of links, says Anderson's blog has received 236 blog mentions, while RedState and Daily Kos, by contrast, have received 21,000 and 107,000, respectively.

Gee, with remarks like this do we think Daily Kos will be around for awhile? the link to the article sorry I forgot to add it CRS ya know?

The main body of the diary:

I don't see myself as a "citizen journalist" I am a person with a point of view, and issues that are important to me and I like to think, some other people. I tend mostly to deal with veterans issues, and how the politics affect our wallet issues, healthcare and the nations "PROMISE" to the military, that if you are "hurt or killed while on active duty" we will take care of you and your family, medically and financially, even President George W. Bush used it as a campaign slogan in 2004's election cycle we all remember "A Promise Made Is A Promise Kept" and this year we get the front page stories about Walter Reed and the VA claims system that is overwhelmed and has 800,000 claims on appeal and it takes this nations veterans 2 or more years to get a decision of their claims.

That doesn't mean the claim is decided to a veterans satisfaction, it just takes that long to be told "denied" again and then the veterans have to appeal to the Court of Veterans Appeals which in all can take 5-7 years before they get a decsion from the "final court" many times it is a "remand" which just means the VA has to relook at the medical evidence, obtain more and make another decision, which starts the "roller coaster" all over again.

I write about it, and PTSD which is a prevalent problem amongst veterans and their families, and PTSD DOES affect the entire family, not just the veteran, it touches mothers, fathers, brothers, sisters, wives, husbands, children and then it enters the workplace and the community.

The article on "citizen journalism" led me to write this response to the article and posted it online

I post at daily Kos as testvet6778 and have since 2005 I also write my own blog
http://vets4politics.blogspot.com/

Which is listed by my local paper http://www.thestateonline.com/bloggers/politicsblogs.html as Military& Veterans: Politics for the Deserving which deals with issues that pertain mostly to veterans, but which we all know active duty military will become. I deal with all kinds of links to MSM and write many opinion pieces. They are probably as factual as anything Fox news produces. If memory serves me right, Fox won a lawsuit against a "journalist" in a Florida Court last year based on the facts that Fox news edited the piece and ignored facts, cut out factual pieces to slant the news the way they wanted it presented and the court sided with Fox, stating that "news" did not HAVE to contain facts to be aired. So is MSM really credible just because they are on the air waves or cable? How accurate were they on the run up to the war? What happened to objectivity? Investigative journalism is a dying art, and the nation is suffering for it, the corporate boardroom is dominating "facts" and the unwillingness to anger advertisers, for veterans and the military one of the strongest voices was Don Imus, he asked the hard questions, remember when he confronted John McCain about Walter Reed, and he asked him "don't you have eyes" couldn't you see it? He at least asked the people with influnce the right questions, and they kept coming back on his show, because he gave them air time, despite the fact he does ask "hard questions", we the citizens need the "truth" not the Faux version either, real facts and regardless of a citizen journalist gets to the core of it or a MSM reporter does, the nation wins.

It is my opinion the country is better off with sites like Daily Kos, it lets average citizens speak their piece in a way that MSM never thought about, and fellow citizens can recommend it so it gets read by many other people. The "blogosphere" like it or not is here to stay, and YES we will impact "MSM" and their influence and at times their ridicule.

This article is not "blogosphere friendly" not real smart by WAPO in my opinion.

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Karl Rove blames Congress for Iraq War

With a big hat tip to TxSharon for her e mail sending me this link to her blog which has a link to Texas Blue which has the you tube clip of Charlie Rose interviewing Karl(Turdblossom)Rove only someone from Texas could think a turd like this would even float, I bet Texas wishes Rove would move somewhere else, he is embarassing to all the bulls in Texas.......



watch this inane piece of historical rewrite if you can stomach it

It is a truly astounding argument and it is divorced from reality in such a way that is almost majestic in just the scope of the willful ignorance on display. What did Congress have to vote on, if not an approval of the war Bush had been rattling sabers for? What president in history has enjoyed the legislative energy Bush did in the 107th Congress, other than Bush with the unified GOP-led 108th and 109th? The idea that the Bush administration was ever forced or coerced to do something it would rather not have during the run up to the Iraq War is patently and utterly ludicrous.

Oh, and PS: During that 107th Congress, the Senate was controlled by Democrats. So don't be surprised if Karl starts trying to shape some message for blaming the Iraq War debacle on the Democratic Senate that year.

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Fort Stewart soldier denied a Memorial Tree

This VA Watchdog.org article took me by surprise, I have seen the trees at Fort Stewart, they started this during the First Gulf War as a way to memoralize the posts soldiers who died in service to the nation and as members of Fort Stewart, the 24th Infantry Division started the honor in 1991. The 3rd Infantry Division chose to continue this during the Iraq War.

The family members of Pfc. Ryan D. Christensen feel like they have been slapped in the face

Pfc. Ryan D. Christensen died at a South Carolina hospital on Thanksgiving Day in 2005, a victim of a bacterial infection contracted while working as a communications specialist with the 3rd Infantry Division. But since it was an illness — rather than an improvised explosive device or suicide bomber — that claimed his life, the Army has declined to plant a tree in his honor along what is known as Warriors' Walk at Fort Stewart.

"Unless you're shot or blown up, you don't get a tree," said Christensen's stepfather, Mark Detulio. "It is a major, major slap in the face."

By all accounts, Christensen should be a poster child for a war now in its fifth year of combat operations. Spurred on by the terrorist attacks of Sept. 11, 2001, he carried a collection of photos of ground zero with him at all times and enlisted in the Army at age 19, eager to do his part to defeat terrorism.

Over less than three weeks in the fall of 2005, however, his health failed him. What began as a salmon-colored skin rash rapidly progressed into liver failure and eventually, a fatal brain hemorrhage.

"It was all so fast, especially for someone who never had a health problem," Mark Detulio said.

After months of appeals for a tree planting at Warriors' Walk, the couple received a letter from an Army official in February stating their son's death was officially considered "non-combat" related, thus making him ineligible to receive a planting.

Refusing Christensen what the family views as an entitled place of honor alongside his fellow fallen brethren has been hard to accept and complicated the grieving process.

"You just can't get any closure,"Mark Detulio said.

The no-tree edict is especially puzzling, the couple says, in contrast to dozens of support and condolence letters received from military officials and politicians, including President Bush and Army commanders.

"You can't have it both ways. You can't say, "Thank you for your service and sacrifice for your country,' and then say it's not related to combat," Suzette Detulio said. "He died because he was there."

There has been support for the effort to include Christensen in the Warriors Walk from local politicians. Rep. Christopher H. Smith, R-N.J., has advocated strongly for it, the Detulios say, but to no avail.

"The military has consistently come back and said, "No,' " said Smith's district director, Pidge Carroll. "We'll keep working on it, and hopefully it will come to fruition."

Most frustrating and puzzling, Carroll said, is the military's focus on the semantics separating Christensen's death from others deployed in theater.

"It's just words," she said.

Come on Army, honor the man and plant a tree in his name on Fort Stewart, if they die in service while assigned to the post it's the least you can do, why insult the families this way?

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American Medical Association Magazine Article

The AMA has an excellent article this month about VA healthcare and the Bush Administrations positions, towards Category 8 veterans (those without service connected medical issues, and whose income is over 28,000 a year) I will snip and clip a few of the most telling quotes

Thanks to recent advances in battlefield medicine, more servicemen and women are surviving severe injuries, CBO said. But they require more costly medical care when they return. The rapid influx of new enrollees has helped strain a system that already was under pressure from caring for the veterans of yesterday's wars. In 1995, fewer than 3 million veterans received VA health services. That number had increased to 5 million last year.

Many of the resulting access problems start at the very beginning of the enrollment process, said Donna E. Shalala, PhD, president of the University of Miami and former Dept. of Health and Human Services secretary. She co-chaired a presidential commission on care for America's "wounded warriors" that convened earlier this year after news reports exposed substandard conditions and a mass of red tape at Walter Reed Army Medical Center in Washington, D.C.

Although the Dept. of Defense and VA need to work together to foster a patient-centered continuum of care for each veteran, the commission found evidence that returning personnel were not experiencing a smooth transition from military health care to the veterans system, Dr. Shalala said.

then this is a memory most disabled veterans will NOT ever forget

Although Congress in recent years has kept up a steady stream of funding that has satisfied many advocates, the process has not been without missteps.

The department weathered an embarrassing episode in 2005 when then-Secretary R. James Nicholson went to Congress with a request for $2.6 billion in additional funding because it had vastly underestimated the number of Iraq and Afghanistan veterans who would require care.

Washington State Senator Patty Murray attempted twice in 2005 to get the Senate to give 2 billion dollars for healthcare and PTSD, Secretary Nicholson will be forever remember stating to the Senate VA Committee "We have plenty of money" in March 2005 at a Senate VA Hearing then in June he came back hat in hand not once but twice, once for 1 billion and the second time for 1.5 billion.

Veterans can be waitlisted or shut out as a result.

"If the VA was able to get the funding on time and was able to know beforehand what that funding level was going to be, a lot of those access problems would be solved," he said.

The department opposes mandatory funding because the process would not easily adapt to changes in clinical practice or enrollee demographics, said W. Paul Kearns III, VA chief health financial officer.

I am not the smartest person in the room, but why would the agency OPPOSE mandatory funding, similar to what Medicare gets, to ensure they have the funds to treat the nations veterans, after all that is the only reason they exist, is to care for the veterans who served this nation, they are not giving out "aid" they are paying a debt we as a nation promised these men and women who served in the military, it is what is known as the "PROMISE" remember President George W Bush's 2004 campaign slogan "A Promise Made Is A Promise Kept" well it's time to keep it.

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Editorial on PTSD by the NY Post

NY Post Editorial

So it's good - for veterans, their families and everyone else - that the Defense Department and the Department of Veterans Affairs now do two screenings of veterans returning from the Persian Gulf and the Hindu Kush. Veterans are first evaluated upon their return from active duty. Then, three to six months later, they are contacted and urged to be screened again. Veterans' groups have been calling for several years for better ways to uncover and treat mental illness, and they have welcomed this new policy. It shouldn't have taken so long to get it up and running.

The new practice was adopted after a study conducted at the Walter Reed Army Institute of Research and published this month in the Journal of the American Medical Association found that examining soldiers twice may help clinicians catch far more mental health problems.




The process helps identify those who need further treatment at VA hospitals. All VA hospitals, among them the highly regarded medical center in Northport, have geared up to deal with the outcome of the new policy.

The predictable result is that the number of veterans needing health care has risen sharply. Last month, the VA said that more than 100,000 soldiers were being treated for mental health problems, half of those specifically for PTSD. In the study, initial screenings of nearly 89,000 veterans uncovered 4.4 percent needing treatment. Six months later, after a second look, the total was 11.7 percent.

The new policy addresses a problem that should have been solved long ago. Large numbers of veterans have lacked proper treatment so far. That's a great disservice to those who have served this country.

My response is quoted below:

This is a great first step in getting active duty troops treatment, there is still the problem with National Guard and reservists that go home to small towns and their regular jobs who will fall thru the cracks with this program. Then there is also the stigma attached to PTSD and many soldiers will not be fully forthcoming about the problems due to perceived weakness, distrust among fellow soldiers, the tendency to say" I don't have a problem, other people have problems, they don't react to me the way they used to, they treat me different".

But, I applaud the government finally stepping up to the plate, even if it is five years to late, they knew this was possible due to the studies of Vietnam veterans, so to throw 2 wars and not plan for mental health care, was as irresponsible as planning the invasion of Iraq, without planning the occupation.

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