Health Care Happenings

“Shocking!”

          “A National Disgrace!”

“Veterans and Their Families Suffer Repeated Indignities!”

          “VA has yet to explain why a 90-year-old veteran needs to “save” 20% or 30% of his monthly payments for ‘future needs’ when he cannot afford prescribed medicines and already has over $1000,000.00 in his name!”

The above quotes come from a pretty intensive House Veterans’ Affairs Subcommittee hearing I attended yesterday where witnesses described to lawmakers case-after-case and detailed examples of flaws and failures in the Department of Veterans Affairs Fiduciary System.

To put things in perspective, VA’s Fiduciary System has been under scruitiny on a number of fronts in recent years and there has been much concern about the efficiency, effectiveness, and efficacy of a system that is suppose to be looking out for the best interests of veterans and their beneficiaries. 

To many veterans and caregiver-family fiduciaries, the VA Health Administration (VHA) care and case management is far superior than the support they receive from the VA Benefits Administration (VBA) who manages and oversees the Fiduciary System.

Here’s some facts from the hearing:

• The system was establish in 1926 and has been operating off regulations dating back to 1975.
• VA oversees approximately 95,000 fiduciaries, managing the financial affairs of more than 121,000 beneficiaries, paying about $53.5 billion in compensation and pension benefits in 2011–fiduciaries managed approximately $171 million in VA benefits.
• Several hearings, Government Accounting Office, and VA Inspector General reports and investigations as far back as 1998 pointed to a number of deficiencies in managment controls and oversight, insufficient  staffing, training, and workload management. 
• Not until April 2011 did veterans and their beneficiaries get much needed relief and control of their finances and futures, “the day the U.S. Court of Appeals for Veterans Claims (Veterans Court”) held that the appointment of a VA fiduciary is appealable to the Board of Veterans’ Appeals and to the Veterans Court thereafter (Freeman v.Shinseki).  No longer are veterans’ fiduciary-related questions and disagreements discarded with a terse VA letter asserting that such issues are ‘within the sole descretion’ of the Secretary.”

While VA management has reorganized and consolidated their Fiduciary System, added more funding, personnel and accountability and oversight, witnesses cited a number of cases in the field, where the program still operates as before, and veterans continue to have their money taken away from them by VA-appointed fiduciaries who will not talk to them or their beneficiaries–veterans are suffering because they can’t get additional funds on an emergent or timely basis, and are unable to obtain basic account information regarding ‘their VA funds.” 

One caregiver, the mother of a severely injured servicemember who sustained multiple injuries in 2005 as a result of an IED blast in Iraq, was appointed as her son’s fiduciary in 2007. 

She told lawmakers she was stunned to receive three letters from the VBA citing her failure to submit timely accounting information as a breach of her fiduciary duty, threating to remove her as a fiduciary, even after her repeated efforts to communicate with VA and be proactive in her duties.

“From the perspective of a mother of a very severely wounded warrior, VBA communications like this–suggesting that with the stroke of a pen I could be deemed ‘unqualified’ and lose the right to manage my son’s finances–are very stressful.  Despite my being a loving caregiver, this program operates in a manner that leaves me feeling as though something threatening is always hanging over my head…I understand the need for methodical recordkeeping and reporting [as someone with a college degree in business/accounting] in the interest of documenting appropriate financial management of my son’s compensation.  But I do not understand an agency that is so quick to threaten, so unresponsive to questions, so much of a ‘black hole,” said the mother.

 Needless to say the stories were heart-breaking, including a number of cases two attorney witnesses shared with the Committee:

“After 10 years of ‘excellent’ account reports, a VA Field Examiner in Texas made a personal home visit and summarily removed the spouse-payee of one of my clients because of supposed accounting discrepancies.  That very same day the Examiner appointed a paid fiduciary and stopped the veteran’s direct deposit of monthly VA funds.  It was another 10 days before the veteran received a letter informing him of these actions.”

“Today, the VA will determine that a wife of more than 60 years with her full mental faculties is not qualified to make financial decisions for her veteran husband.”

“Today, VA will decide a veteran’s financial needs for the next 3-years based on a single hour-long interrogation by a VA ‘field examiner’ who possesses no discernbable expertise in finance, social work, mental health, or any other discipline reasonably viewed as pertaining to such a task…”

…and these kind of stories are being lived out every day by our most vulnerable veterans and their families.

MOAA appreciates the Congress’ attention on this very important matter and applauds the action the Committee took at the close of the hearing to get answers from VA officials to address these grievous and unconscionable actions against our nation’s heroes.

MOAA intends to do all we can to help veterans, their families, the VA, and Congress put veteran’s first and right these system failures. 

“At our hearing in July I requested that Department of Veterans Affairs (VA) survey their frontline mental health professionals about whether they have sufficient resources to get veterans into treatment…The results that came back were not good.

               Nearly 40%  said they cannot schedule an appointment in their own clinic within the VA mandated 14-day windo

               70% said they did not have adequate staff or space to meet the mental health needs

               46% said the lack of off-hour appointments prevented veterans from accessing care.”

                     Chairman Patty Murray, Senate Committee on Veterans Affairs

    

Yesterday, Chairman Murray held a follow-on hearing to address the VA survey and continue to probe barriers preventing veterans from getting the mental health services in VA Health Administration (VHA) they need and want.

As the hearing progressed, it became clear that there was a disconnect between wait times data being reported by mental health providers and VA Central Office Mental Health Operations officials.

One withness, a Coordinator for Post-traumatic Stress Disorder (PTSD) Services and Evidence Based Psychotherapy at the Wilmington VA Medical Center and a representative for the American Federation of Government Employees, provided dozens of examples of VA employee comments that expressed similar concerns highlighted in the VA survey mentioned above:

• “Social workers at my facility universally feel extremely overworked and overwhelmed…
• She is overbooked every day–her caseload of more than 200 patients, including high risk patients, is simply unrealistic…
• Poor staffing in the general mental health clinic makes it difficult if not impossible to refer veterans for ongoing general mental health services.”

On the other hand, VA officials told the Committee that the Department believes it has unprecedented resources to adquately execute the mission but will continue to aggressively follow the data in order to make good predictions on needed resources and funding.

Additionally, VA’s response to the survey results was to put together an action plan and conduct more focus groups, audits and to implement more policy and guidelines.

MOAA agrees with Chairman Murray and the Committee members.  The issues of access and the barriers that prevent veterans from getting the care they need are not new.  And, they need to be fixed NOW!

Isn’t it time VA stopped playing catch up and start addressing the massive numbers of veterans entering their system and the ones who will soon be coming back from Iraq and Afghanistan.  Or will it take another 10 years to catch up to the challenges that exist in VA now?

On Tuesday the Defense Health Board met here in Washington DC to discuss several findings and to review an interim report on Psychotropic Mediction and Complementary and Alternative Medicine.  The Defense Health Board is a Federal Advisory Committee to the Secretary of Defense.  It provides independent scientific recommendations on matters relating to operational programs, health care policy development, health research programs and requirements for the treatment and prevention of disease and injury, and the delivery of health care to DoD beneficiaries.  It is a board comprised of the country’s top leaders and medical specialists.

One of the charges of the group was to examine the prescription practices and psychotropic medication use of troops and to take into account the context of specific military-unique challenges that might impact the well-being and psychological health of Service members.

One of the key findings was that was identified was that our troops experience a plethora of sleep problems and issues.  This is not suprising when you consider that troops in combat zones must maintain themselves in a hyper-vigilent state and are under constant pressure to perform as needed.  Under these circumstances it must be very hard to relax and take a “power nap”.  Think how you feel when you do not get a good nights rest….now imagine that multilplied over an extended period in austere conditions. 

The problem of sleep (and rest) was reflected in the pharmacy data studied.  Sleep medications are the predominant prescription psychotropic drug used in theater.  Specifically the drug Ambien was identified as the most popular.  There also appears to have been a trend towards an increased use of psychotropic drugs in theater over the past three years.

Recognizing that good sleep is the foundation of good health and troop readiness, one of the recommendations that will come out sometime in the near future will be the establishment of a Task Force on Sleep. This Task Force will be essential to identify emerging scientific findings and define the best operational and medical practices to optimize our troops readiness and performance.  One promising area is to explore alternative treatment strategies such as accupuncture and other mindfulness practices which can be employed to reduce combat stress and pain.

As sleep and adequate rest are of the utmost importance, we can look forward to a lot more focus and study in this area and hopefully some advances in treatment.

This past Wednesday I had the opportunity to sit in and observe the Senate Armed Services Personnel Subcommittee’s hearing to consider the Defense Health Program (DHP) and the Administration’s proposed FY-2011 Defense budget. The Subcommittee was chaired by Senator Jim Webb (D) Virginia and the ranking minority member Senator Lindsey Graham (R) South Carolina. Testifying for the Defense Health Program was acting OSD/ Health Affairs, Dr. Charles Rice MD, RADM Chris Hunter for the TRICARE Management Activity, each of the service Surgeons Generals, and the Medical Officer of the Marine Corps.

Senator Webb opened the meeting expressing tremendous support for military medicine and noted that “..we have been at this war now for 9 years and we are now in unchartered territory”. This was in reference to the challenges our troops face with multiple deployments, rotational cycles and generalized stress on the force. He continues to maintain his focus on the deployed forces and in this respect he expressed great concern on the reported increased use of precription drugs by both active and the deployed forces. An alarming statistic he quoted was 1 in 6 of our active forces are on psychiatric type drugs such as anti-depressents, sleep aids and pain killers. Understanding this problem is imperative.

Echoing this concern, we also heard testimony from Senator Ben Cardin (D) Maryland. Noting that this is an extremely sensitive issue, and this may be a reflection of how the troops are dealing with deployment. He noted that in 2005 the use of prescription drugs was about 1% and in 2007 the use of prescription drugs of this nature was up to 5%. He expressed concerns with respect to the proper medical monitoring of the effects of these drugs especially during the first 6 weeks of prescribing. He also stated that DOD must drill into this further to gain understanding and develop policy. Also, there is a need to understand this in relation to the increase in suicides.

Bottom line is that Congress is highly concerned and has charged the Defense Health leaders to provide the very best data on the issue of psychiatric prescriptive drug use and to provide clarity of the magnitude. You can bet on a required report out on this!

Even though the DHP is fully funded for this year (2011) in the budget, concerns were noted that the cost of the program continues to go up and is putting strain on the total defense budget. Senator Graham was interested to know if the department was doing everything it could to control costs and asked if they were employing all the strategies they could. He explicitly stated that before any notion of a premium increase would be entertained he wanted to ensure the department was aggressively pursuing system efficiency measures.

The department’s testimony noted that it is under mounting financial pressure. The DHP has more than doubled since 2001 – from $19 billion to $50.7 billion in 2010. The majority of DoD health spending supports healthcare benefits for military retirees and their dependents. The department projects that up to 65% of DoD healthcare spending will be going toward retirees in FY 2011, this is up 45% from FY 2001. As civilian employers’ health costs are shifted to their military retiree employees, TRICARE is seen as a better, less costly option and they are likely to drop their employer’s insurance. These costs are expected to grow from 6 % of the Department’s total budget in FY 2001 to more than 10% by 2015. Since 2008 the number of enrollee’s has increased by 370,000.

The Department discussed the many initiatives and ways that they are addressing costs. Some of these include identifying and understanding variations in clinical practices across geographic areas and the many efforts they are undertaking in the area of patient safety and quality. In addition, when the electronic health record becomes fully utilized, this will provide a great deal of efficiency and medical management. In addition initiatives to encourage patient utilization of appropriate venues of care with a focus of decreasing inappropriate emergency room usage.

Also of the many issues touched on, lastley Senator Webb questioned the current disability evaluation (DES) pilot program which is underway. Noting that there remain system challenges he suggests a concept of a joint VA/DoD disability board. Something needs to happen to improve these two systems which at times are antiquated and adversial!
Well said.

On May 20, I had the opportunity to represent MOAA and The Military Coalition testifying on health care before the Senate Armed Services Personnel Subcommittee.

That’s always a little frustrating, because we’re asked to condense our 40+ pages of written testimony into a 3-minute oral statement.   In my case, I was asked to cover both health care and retired pay issues.  Try summing those up in 3 minutes!

You can check out my 3-minute statement on MOAA’s Web site or view the video of the whole hearing (I was the next to last witness), including the question and answer session after the formal statements, on the Senate Web site.