How Congress and the VA left many veterans without a ‘choice’ (NPR)
NPR — together with member stations from across the country — has been reporting on troubles with the Veterans Choice program, a $10 billion plan created by Congress two years ago to squash long wait times veterans were encountering when going to see a doctor. But as we reported in March, this fix needs a fix. Around the nation, our joint reporting project — called Back at Base — has found examples of these problems. Emily Siner of Nashville Public Radio reported on troubles with overcrowding in Tennessee. And Monday, we reported on hospitals and doctors not getting paid in Montana and veterans getting snarled in the phone systems trying to make appointments in North Carolina. Congress and Department of Veterans Affairs officials are in the middle of overhauling the program. … Amanda Wirtz, who was discharged from the Navy in 2003 after developing a rare tumor, began having headaches last November. When the VA couldn’t get her in to see a specialist, it offered to send her to a neurologist in the community, using the new Veterans Choice program. This was the type of situation Congress envisioned when it created the program in 2014: If the VA couldn’t schedule a patient within 30 days, or if the vet lived more than 40 miles from a VA clinic, the vet could see a nearby private doctor. “This is Feb. 23, for an appointment scheduled March 23,” Wirtz said, holding up a letter she received from the company handling the Choice program. “[In] January I’m considering suicide because I’m in so much pain. I’m asking for relief and the Choice program is giving me an appointment in March.” Her experience isn’t new to government officials, but the question is whether Congress or the VA should have anticipated there would be problems. Two years ago, Congress was hearing about the VA concealing wait times at VA hospitals and clinics, and about the veterans who were suffering as a result. “If you don’t think, in 2014, that was the time to stand up a program like Choice, I don’t know when you would find a time,” said Rep. Jeff Miller, R-Fla., the chairman of the House Veterans Affairs Committee. … Congress worked at a frantic pace. The House passed a bill on June 10, 2014. The Senate passed its own version within days. By Aug. 7, President Obama had signed the Veterans Access, Choice and Accountability Act of 2014. It gave the VA $10 billion to set up a program that would give qualified veterans the option of seeing a private doctor. There was confusion from the beginning. The law required the VA to distribute 9 million Veterans Choice Cards to vets receiving VA care as of August 2014, even though all vets who use the VA already have a VA card. … Impatient lawmakers gave the VA only 90 days to set up the national program. The first decision that VA officials made was that they couldn’t run the program themselves. … So the VA shopped around. It invited 57 companies to a VA-sponsored event in September 2014 to gauge interest in possible bids. But nearly all of them turned down the VA. “Only four companies said they were interested in continuing some conversation,” Yehia, who wasn’t with the VA when Congress mandated the Choice program, said. “And then two of those companies made it crystal clear that given a November, or a 90-day, time frame, they’re not interested.” That left two companies the VA had under contract to help it manage a portion of the roughly $4 billion a year the agency was already spending on outside providers. TriWest and Health Net were building a program called Patient Centered Community Care, or PC3. The network of private doctors and hospitals was meant to help the VA streamline the relationships local VA medical centers had with community providers. The VA decided to build the Veterans Choice program by building it on top of PC3. But PC3 was having its own problems. The VA’s inspector general found that in the summer of 2014, while Congress was debating the Choice program, VA administrators were scrambling to find appointments for hundreds of vets, after the companies couldn’t find doctors for them in their networks. Some of the problems that would emerge later with the Choice program were apparent in PC3. For example, within three months, TriWest returned referral authorizations of 172 out of 192 gastroenterology cases, and 57 of those patients had to be seen immediately because they had symptoms of significant ailments, such as cancer. The VA was also making the process difficult because it was taking the agency an average of 19 days to submit appointments to the contractors, according to another VA inspector general report. Yehia stressed that PC3 was new and smaller than Choice but also acknowledged that the VA didn’t have any other alternatives. … Health Net did not respond to requests to be interviewed. It runs the Choice program mostly in the Eastern portion of the United States. TriWest covers 28 states in the Western half of the country. TriWest created 10 call centers, including one in San Diego that opened in September. The company has hired more than 3,000 employees. … Sometimes VA rules created obstacles. Until recently, the VA would not let the companies call veterans directly to schedule an appointment. The vet had to call them, which sometimes left vets waiting by the phone. … TriWest believes it has a handle on the problems. In San Diego, TriWest went from a ribbon-cutting in September to more than 300 employees answering veterans’ calls. … But it may be too late. The VA is now reconsidering whether it should have outsourced so much of the program — especially customer service. Adrian Atizado, with the Disabled Veterans of America, said putting a contractor between the VA doctor and the outside physician may always cause problems. … Congress is looking at revamping and expanding the Choice program to cover most of what the VA spends on outside care. Considering it was born out of a scandal involving VA scheduling, some in Congress are not eager to allow the VA to take on a greater role. The GAO report released this month says the VA’s system for processing claims relies mainly on paper files — a process that adds months to the amount of time it takes to pay doctors. Whatever the outcome, the pressure is on to figure out how to get veterans the care they’ve been promised, without all of the confusion.
Agent Orange benefits for deep-water Navy vets languish on Capitol Hill (Stars and Stripes)
A proposal to extend health coverage for Agent Orange exposure to Vietnam-era Navy veterans has the type of backing in Congress that normally would make supporters hopeful. In the House, a bill granting the benefits has garnered a whopping 320 sponsors – almost 75 percent of all members have signed on in support. Nearly half of all senators also support extending benefits to the so-called “blue water” sailors who served aboard ships in ports and surrounding ocean during the Vietnam War. “If you served just offshore, you don’t have presumed coverage,” said Rep. Chris Gibson, R-N.Y., a retired Army colonel who sponsored the House bill. “Members of Congress have to fight case by case … It should not have to be that way, they should get presumed coverage.” But the legislation has collected dust for a year, failing to move past House and Senate veteran affairs committees that serve as a crucial first step on the road to making the benefits law. The Republican chairmen of these committees are skeptical of the science behind the exposure claims and concerned about the cost of new benefits. This has held up the proposals, frustrating supporters. The window for Congress to act might be closing – despite the support — as lawmakers face the long summer recess, a fall schedule dominated by the presidential election and the end of the legislative session in December. Gibson, Senate lawmakers and veterans groups, including Vietnam Veterans of America and Veterans of Foreign Wars, were set to rally on Capitol Hill on Wednesday in hopes of finally moving the bills ahead. The expansion of coverage has been sought by veterans for a decade. “We’ve never been in a stronger positon to get it passed,” Gibson said. Some veteran sailors contend dioxin-tainted herbicide runoff was sucked up through their ships’ water filtration systems and piped to crew, sometimes at concentrated levels. Gibson said it is “very clear” that sailors were exposed and that their medical records show similar elevated risks for diseases such as cancer, diabetes and Parkinson’s disease as ground troops. But the Department of Veterans Affairs in February reviewed its policy and decided it will continue to deny Agent Orange benefits to about 90,000 sailors who served aboard aircraft carriers, destroyers, cruisers and other Navy ships. The VA does assume herbicide exposure and provide health coverage to the vast majority of Vietnam veterans who were deployed on the ground or in rivers and inland waterways during the war. But the agency found no basis to cover the sailors. With the VA unwilling to change its policy, convincing the chairmen of the veterans committees to let the bills move forward could be key for supporters. … Rep. Jeff Miller, R-Fla., said he believes the science is uncertain on whether the blue-water veterans should be eligible for Agent Orange benefits – a position shared by the VA following a recent independent study, according to committee staff. In 2011, the Institute of Medicine examined whether sailors could have been exposed to herbicide but the results were inconclusive. Potable water systems in warships could have collected seawater polluted by land runoff and concentrated the dioxins in Agent Orange through distillation, the institute found. … Miller has asked the Defense Department to search for any residue in the ship filtration systems and records showing if the vessels were supplied with water from the Vietnamese mainland. The findings could sway the debate over benefits in the future, staff said. Meanwhile, the cost of expanding benefits is a sticking point on the Senate Committee of Veterans’ Affairs, which is chaired by Sen. Johnny Isakson, R-Ga. It will cost about $90 million yearly to expand health coverage to the veterans, according to the Congressional Budget Office, and fiscal hawks in Congress require such new spending to be accompanied by cuts elsewhere. “Chairman Isakson has consistently required all bills to be paid for before the committee can move on them, and S.681 has an estimated cost of $1 billion without any offsets,” the committee spokeswoman Lauren Gaydos wrote in an email response, referring to the estimated cost of the Senate version of the bill for 10 years.
Read More: Brown Water and Blue Water Navy Veterans
Lawmakers again rally for VA medical marijuana in budget bills (Stars and Stripes)
Lawmakers will take another shot this week at allowing doctors at the Department of Veterans Affairs to prescribe medical marijuana, reigniting a smoldering debate over veteran access to the drug. Rep. Earl Blumenauer, D-Ore., said he will propose the change as part of the department’s annual budget bill during a vote on the House floor expected as early as Wednesday. The Senate was also set to vote on its version of the department’s annual budget bill, which includes the same proposal by Sens. Steve Daines, R-Mont., and Jeff Merkley, D-Ore. The proposals to give veterans access to medical marijuana through the VA in states where it is legal put Congress on the verge of making a major policy shift for the second year in a row. “We received more support to fix this situation than ever before last year. I hope we can build on that support and that my colleagues will show compassion and do what’s right for our veterans,” Blumenauer said in a released statement. His proposal last year was defeated in a 213-210 House vote. House lawmakers were scheduled to take a new vote on adding it to the VA appropriations bill late Wednesday or Thursday. The Senate was debating Tuesday and preparing for a final vote on the appropriations bill including the marijuana provision. It approved the measure last year but the reform was ultimately stripped from the bill during congressional budget negotiations. House passage this week could make it more likely that the proposal giving veterans access to medical marijuana will survive and be passed by Congress in a final budget. However, another defeat in the House would not bode well for its chances of being included and signed into law later this year by President Barack Obama. The Obama administration asked prosecutors not to pursue medical marijuana sellers and the Department of Justice announced in 2013 that it would not challenge states that have decriminalized or legalized pot. Medical marijuana has been approved by 23 states and the District of Columbia for treatment of glaucoma, cancer, HIV and other afflictions. The VA refuses to allow its doctors to prescribe pot in those states and D.C., and instead only provides abuse treatment to veterans due to federal law that still lists it as an illicit drug. Veterans are advocating for access to marijuana to treat post-traumatic stress disorder, which might affect about 20 percent of the 1.8 million servicemembers deployed to the wars in Iraq and Afghanistan, according to the National Center for PTSD.
Bill introduced to protect combat-injured veterans (Bladen Journal)
Congressman David Rouzer (R-NC) recently introduced H.R. 5015, the Combat-Injured Veterans Tax Fairness Act of 2016, to ensure veterans who suffered service-ending combat-related injuries are not being wrongfully taxed on their severance packages from the Department of Defense. Under federal law, veterans who suffer combat-related injuries and who are separated from the military are not supposed to be taxed on the one-time lump sum disability severance payment they receive from the DoD. However, due to an accounting error, more than $78 million is owed to an estimated 14,000 veterans. H.R. 5015 corrects this problem by instructing the DoD to identify those who were wrongfully taxed so that they can be reimbursed. “Our soldiers, sailors, airmen and Marines risk their lives every day to protect our freedoms. My bill is a common-sense solution to ensure that every veteran who has had their severance payments improperly taxed receive every penny that they are rightfully owed. These veterans deserve no less for their service and sacrifice to our nation,” said Rouzer. The bill has been assigned to the House Armed Services Committee and the House Ways and Means Committee. Co-sponsors of H.R. 5015 include: U.S. Representatives Marsha Blackburn (R-TN), Tom Cole (R-OK), Bob Gibbs (R-OH), Vicky Hartzler (R-MO), Duncan Hunter (R-CA), Walter B. Jones, Jr. (R-NC), Martha McSally (R-AZ), Robert Pittenger (R-NC), David P. Roe (R-TN), and Chris Stewart (R-UT). This problem was originally identified by the National Veterans Legal Services Program (NVLSP), an independent, nonprofit veterans service organization that has served active duty military personnel and veterans since 1980. NVLSP estimates that over 13,800 veterans potentially have been denied full severance pay as a result of wrongful taxation, including 565 veterans in North Carolina. “The government knew about this problem for decades yet continued to take this money from thousands of disabled combat veterans. After exploring all legal options, we concluded that the only viable path to recovery of these misappropriated payments was through legislation. We hope other Representatives will support the bill so these combat-disabled veterans can receive the disability severance pay that they earned and their country owes them,” said Tom Moore, attorney and manager of the Lawyers Serving Warriors project at NVLSP.
Commentary: The U.S. needs to revisit our PTSD treatment guidelines (MilitaryTimes)
Bret A. Moore, Clinical Psychologist who served two tours in Iraq: Post-traumatic stress disorder is arguably the most challenging problem combat veterans face. Estimates vary, but experts believe that between 10 and 20 percent of Iraq and Afghanistan veterans suffer from the disorder. This puts the actual number of men and women affected in the hundreds of thousands. Considering that PTSD wreaks havoc on the veteran and their loved ones, and costs billions of dollars each year, finding and using the most effective treatments are critical. Historically, medications and talk therapy have been considered “first-line treatments.” This basically means they should be used first, and if they fail, then you try something else. In fact, the joint treatment guidelines published by the Department of Defense and Veterans Affairs Department puts medications and psychotherapy on equaling footing. The same is true for the American Psychiatric Association. Not all agree. Organizations from the United Kingdom and Australia and the World Health Organization take the position that trauma-focused psychotherapies such as prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing are most effective when it comes to PTSD treatment. Basically, their stance is that the evidence for meds is just not as strong. A recent study carried out by military and VA researchers, and published in the journal Depression and Anxiety, supports this position. After weeding through more than 60,000 possibilities, the researchers identified 55 psychotherapy and medication studies for PTSD. This added up to around 6,300 total study participants. What did they find? Trauma-focused psychotherapies outperformed psychotherapies that do not specifically discuss the trauma. They also beat out medications. This does not mean other psychotherapies are useless. For example, the researchers noted that stress inoculation training is effective for PTSD. SIT is a credible talk therapy that has been around for decades. It just may not be as effective as the trauma-focused therapies. The same is true for medications. Zoloft and Effexor are commonly used for PTSD, and they do work for some people. But again, they may not be as useful as certain psychotherapies. The bottom line is that the current United States-based treatment guidelines for PTSD may need to join the ranks of their European and Australian counterparts. Specifically, medications likely need to be identified as “second-line” treatments. In other words, they should only be used if an effective talk therapy is not available. The results of this study challenge the current status quo with regard to treating our combat veterans. It is time to take a close look at how we prioritize PTSD treatments and make adjustments to our national treatment guidelines as necessary.
VA expands telehealth access for veterans (mHealth Intelligence)
The nation’s largest healthcare network is launching a new telehealth initiative. The Department of Veterans Affairs is putting the focus on behavioral health with a network of Mental Health Telehealth Resource Centers, designed to tackle a growing population of veterans dealing with PTSD, chronic depression and bipolar disorder, among other issues. “We are in the midst of the largest transformation in the history of VA with MyVA, which means we are reorienting what we do around the needs of our veterans and providing care when, how and where they want to receive that care,” David J. Shulkin, the VA’s Undersecretary for Health, said in announcing the initiative Monday at the American Telemedicine Association conference and trade show in Minneapolis. “These mental health telehealth resource centers will provide our veterans in underserved areas the expert mental health providers they may not otherwise be able to obtain locally. We know that we are doing more in telehealth than any other healthcare system and connecting mental health providers to areas hard to recruit and retain.” Adding to the VA’s existing facility in New Haven, Conn., the department is creating resource centers in Charleston, S.C., Pittsburgh and Salt Lake City, as well as an online network connecting centers in Boise, Idaho, Seattle and Portland, Ore. Speaking at the ATA conference, Shulkin said telemedicine can address an ongoing healthcare access issue with the nation’s veterans, at least 40 percent of which move away from urban areas when they’re discharged in favor of quieter, rural locations. By reaching out to them with digital health platforms, he said, the VA can extend care into the veteran’s home – where he or she is most comfortable – and reduce the need to build new clinics or hospitals. Shulkin – a first-time visitor to the ATA’s annual conference – said the telepsychiatry initiative follows two years of heavy public criticism and exposure, much of which has focused on veteran access to and wait times at existing VA facilities. According to VA officials, more than 675,000 veterans access healthcare through the VA’s telehealth network, representing some 12 percent of the nation’s 5.6 million veterans who receive VA care. That has helped to reduce the number of days that veterans spend in a VA hospital by some 56 percent and spawned more than 45 specialty telehealth platforms. Shulkin further noted that the VA is bolstering its online presence, with some 32 mHealth apps now available and an enhanced patent portal accepting 1.7 secure messages from veterans to their providers in the past year, all designed to “encourage self-management among veterans.” On the horizon are a kiosk program and a text messaging program for medication management. Stung by coverage of access issues at VA hospitals over the past two years, Shulkin said the department has launched what he called a “Declaration of Access.” And that effort, he said, includes a “significant enhancement of our telehealth capabilities.” The department’s primary telehealth programs now are its Clinical Video Telehealth (CVT) platform, which uses real-time interactive video conferencing, sometimes with supportive peripheral technologies, to assess, treat and provide care to a patient remotely; the Home Telehealth (HT) platform, treating veterans with chronic conditions with health informatics, disease management and technologies such as in-home and mobile monitoring, messaging and/or video technologies; and Store and Forward Telehealth (SFT), an asynchronous platform in which clinical information in which data, images, sound and video are gathered and forwarded to or retrieved at another VA location for clinical evaluation.
VA edges closer to rollout of new health record platform (FCW)
The Department of Veterans Affairs is edging closer to full deployment of a web-based modular electronic health record platform that promises to build on improvements in interoperability within VA and between VA and the Defense Department. Officials hope to have the Enterprise Health Management Platform up and running by the end of this summer. EHMP is a dynamic, web-based way to organize, display, search, filter and share patient data from VA’s open-source VistA health record. EHMP provides a virtual space to develop and deploy specialized health and wellness applications for use by VA providers. The goal of EHMP is to create “a state where we have a veteran-centric record” that allows doctors and veterans to access medical information on demand, said David Waltman, chief information strategy officer at VA’s Veterans Health Administration, during a demo for reporters at VA’s Washington headquarters. “The interoperability between the VA and the [DOD] record system exceeds any electronic health record systems that are anywhere in the nongovernment environment,” he added. EHMP also lets users customize the interface — which displays information on patients’ clinical encounters, vital signs, medication history, lab results, allergies and medical conditions — to allow doctors to spend more time interacting with patients. Waltman estimated that 110,000 users at VA facilities have access to the Joint Legacy Viewer, a system developed by the DOD/VA Interagency Program Office. He called JLV “a great incremental improvement” that provided the “pipes” that allow developers to work much faster now that the interoperability groundwork has been laid. Although EHMP was built in-house, “the key is we don’t want to be our own vendor forever,” said Jonathan Nebeker, VA’s deputy chief medical informatics officer. “We want to work with industry, we want to help lead industry to get to this place,” he added. “We’re hoping that industry will co-opt what we’ve built here, and maybe even commercialize what we’ve built because it’s open-sourced.” VA designed and published a software development kit, available publicly for download, that includes instructions on how to use and connect the software with other platforms, such as EHR systems from Cerner and the Fitbit consumer fitness tracker. Waltman said the interface will be fully deployed and available at all VA facilities by the end of the summer but added “that doesn’t mean everybody everywhere will be able to use it.” He said the department expects EHMP to fully replace the Computerized Patient Record System, VA’s long-standing system that only allows individual facilities to view patient records, by the end of 2018.