Sunday, May 22, 2016



A short essay outlining how the Veterans Administration
might reorganize its Medical system

We have heard the problems. Now, let’s get a viable solution. The United States Congress seems unable to figure this out, perhaps because so few of them have served in the Armed Forces. Those few who have served are in positions where they will never have to personally encounter the Department of Veterans Affairs medical system.
It is certain nice to have Congress appropriate funds to run the system. The fix involves a restructuring of the medical system from the bottom to the top. If you change the basic structure, you will change the culture. It is the culture, which stems from the structure, which has pushed the VA Medical System over the cliff. Why must Veterans put up with a medical system that hasn’t evolved since its inception under Herbert Hoover: July 21, 1930

The second consolidation of federal Veterans programs took place July 21, 1930, when President Herbert Hoover signed Executive Order #5398 and elevated the Veterans Bureau to a federal administration—creating the Veterans Administration—to "consolidate and coordinate Government activities affecting war veterans”. At that time, the National Homes and Pension Bureau also joined the VA. [1]

Note Bene: Check out the number of “Executive Orders” enacted by President Hoover!

Surprisingly, the fix is relatively simple, as all the necessary parts already exist within. I understand that Congress loves to create new stuff and put their signatures on it. But, there is no reason to re-invent the wheel. The structure of a typical VA Medical Center looks like, if you will, a large farm field with a row of grain elevators: aka Silos. The field represents the whole Medical Center. Each Silo represents a specific department within that larger farm field. Call the farm field the “system”. Let’s take a look at the relationship between the Silos.                  

VA Medical Center’s Silo Structure

Field of Dreams
This may not look like it is relevant to this argument on the surface, but, remember, this a bottom up scenario.

If you are a nurse, you work for the Director of Nursing [the Nursing Silo]. In your department you may have a specific Supervisor. Where you are placed in the Hospital depends on where your Supervisor and Director want you to go. Supervisors and Department Directors seem to allocate Human Resources without regard to any Nursing Specialty you may possess, so you chance ending up in a position for which you have little, or no, skill. Once in your allocated position, the Medical or Mental Health Department Directors and Supervisors have no effective say in what your role is in that specific Department. Any changes to your routine be initiated by your physical workplace Supervisor; must travel up the chain to that Department’s Director, then laterally to the Nursing Department Director, and then down that chain to your Nursing Department Supervisor. The final decision on any change, whatever that may be, goes back through the same channels it took to get to your Nursing Supervisor. This means that the person you work with on a daily basis is part of an entirely separate Silo and has no say over your duties, hours, or responsibilities in your actual workplace. This, then, translates into the inability of the Director of any specific medical or mental health Department to format and control the normal workday of the people who work in his/her department.

This type of Personnel insulation/isolation is detrimental to anyone trying to run any VA Medical Center program effectively. The history of how this became the norm is not important, any more. What is important is that a solution be found before the entire Department of Veterans Affairs is purposely allowed to implode and become “privatized”.
One technique of solving industrial, commercial, or institutional problems that I am familiar with is the application of the “Six Sigma”/”Kaisen” theory of looking at one scenario. You draw on all your human resources to implement the most lean, streamlined, efficient way to deliver your product.

You the work out any bugs, and, when you are satisfied you have problem solved, you simply duplicate the new structure as many times as you need to. In this case, you take one VA Medical Center and work your magic on just that unit. Once you have it running correctly and efficiently, you simply go Medical Center by Medical Center and duplicate the first restructuring in each of the remaining Medical Centers.

I want to include one excerpt from:
Eric Whitney, Montana Public Radio and Michael Tomsic, WFAE
“Despite $10B 'Fix,' Veterans Are Waiting Even Longer To See Doctors” [2]
Congress and the VA came up with a fix: Veterans Choice, a $10 billion program that was supposed to give veterans a card that would let them see a non-VA doctor if they were more than 40 miles away from a VA facility or they were going to have to wait longer than 30 days for a VA provider to see them.

This winter, when Montana Sen. Jon Tester sent his staff to meet with veterans across the state, Bobby Wilson showed up at a session in Superior. Wilson, a Navy vet who served in Vietnam, is trying to get his hearing aids fixed.
But he says he's mired in bureaucracy. "The VA can't do it in seven months, eight months? Something's wrong," he says. "Three hours on the phone," trying to make an appointment. "Not waiting," he says, "talking for three hours trying to get this thing set up for my new hearing aids”.

........Meanwhile, though, Veterans continue to wait. "If I knew half of what I knew now back then when I was just a kid, I would've never went in the military," says Bobby Wilson. "I see how they treat their veterans when they come home."
This is part of collaboration with NPR's Back at Base project, local member stations, and Kaiser Health News.

Many Veterans, me included, have friends and acquaintances who could sit down at a table for a week and hash out the details of a solution to this mess. Almost to a person, they have said, “All the Government has to do is ask.” Believe me! If I can identify the problem and start the ball rolling toward a solution, then far better minds than mine would have no problem, whatsoever, in completing the task of restructuring the Department of Veterans Affairs in very short order.
Some may ask why Veterans are trying to hold on to the VA Medical system. The answer is both simple and complex. The simple part is that most Veterans feel more at ease dealing with their medical and mental health conditions when they are in the company of other Veterans. The complex part is Veterans don’t feel the “private sector” (civilians) necessarily understand what they’ve been through and the types of conditions involved. The “privatization” of the VA system will discourage any Veteran from seeking medical, or mental health, treatment. Consider what is already happening; the break-up of families, substance abuse, the venting of anger and frustration, and suicide. Is this what we really want for those men and women, who volunteer to defend this Country?

And, what will be the inevitable larger, big-picture problem? Young men and women will see how Veterans disrespected, mistreated, and lied to. The resultant plummeting of Armed Forces recruitment and enlistment will leave this Country without a means of defending itself, let alone others.

further suggested reading:

1)  More Than Medicine (Why the VA matters), by Joseph J. Frank - The       American Legion Magazine, June                                                                 2016

Are These Men and Women Really Less Than Honorable?

From: The American Legion Magazine, June 2016
Booted after battle

By Ken Olsen

Max Fernandez was arrested for a bar fight the first weekend after he came home from Iraq. The Marine Corps machine gunner didn’t think twice about the altercation. 
“Coming back, my mindset was so aggressive,” he says. “I thought it was funny.” 
No one pressed charges and Fernandez’s commanders ignored the incident, he says. He and his buddies continued partying and fighting until Fernandez was booted out of the military, without getting treatment for an IED blast that damaged his vision and hearing – or the nightmares that followed him home from combat.

Today Fernandez is living in a homeless shelter in Los Angeles, undergoing treatment for addiction, pursuing a VA claim for PTSD and TBI, and trying to rebuild his life under the shadow of a bad discharge. It’s the story of thousands of former service members who don’t get help when their combat injuries fuel misconduct. Instead, they are discarded with involuntary discharges that prevent them from receiving military retirement, medical care, disability and GI Bill benefits – all in the interest of speed and cost savings.

“According to current DoD and service branch regulations, it’s permissible to separate service members who have committed misconduct, even if they are suffering from a mental disorder that makes them unfit to serve,” says Thomas Moore, manager of the Lawyers Serving Warriors project at the National Veterans Legal Services Program. “I believe this is a big problem.”

There’s a cultural issue at work, too, says Kathleen Gilberd, executive director of the Military Law Task Force. Sick or injured troops are considered troublemakers simply because they are not fit to deploy. “That means getting rid of them, usually without medical benefits, for misconduct or other designated mental and physical conditions,” she says. 

Being dismissed from the military leaves an indelible stain on a veteran’s pride – and his or her future. 
“An other-than-honorable discharge usually means something went awry with you in the service”, says Waldo Tapia, an attorney who recently left the Inner City Law Center on Skid Row in Los Angeles and is representing Fernandez. “It’s a difficult stigma to overcome, particularly if it’s tied to PTSD.” 
Civilian jobs are often unavailable once a prospective employer sees a problem discharge on a veteran’s DD-214. 

“If you get caught using drugs at a warehouse job, you might get fired,” Tapia says. “If you get caught using marijuana in the military, the other-than-honorable discharge follows you forever.”

Many of these veterans end up homeless. Many have no access to health care even though VA has the discretion to provide medical benefits on a case-by-case basis. Veterans who are kicked out of the military for misconduct related to PTSD, TBI and other invisible wounds are also excluded from receiving help from many nonprofits, says Kristina Kaufmann, executive director of the Code of Support Foundation. 
In other words, the people who most need help often are the least likely to receive it. 

Involuntary discharges have been a volatile issue since at least the Vietnam War. A 1980 Government Accountability Office (GAO) investigation recommended that service members have the right to a hearing before being tossed out of the military. But the boards that review these cases are usually sympathetic to the wishes of commanders eager to get rid of service members, and the service members are often convinced that they are better off if they waive their right to a hearing, Gilberd says. There is also a persistent myth that other-than-honorable discharges are automatically upgraded if service members stay out of trouble for six months after leaving the military, which may give them an incentive not to pursue a hearing that would help their case. It’s unfair to just blame commanders, who are dealing with the realities of fighting long wars with an all-volunteer force. 

“I get it,” Kaufmann says. “I was a commander’s wife during the surge from ’06 to ’08. I remember the pressure on my husband to have a battalion that is at full strength and ready to deploy.” And similar pressure to get rid of people who aren’t. Involuntary discharges again became an issue during the wars in Iraq and Afghanistan. A litany of negative media prompted Congress to order the military to carefully review the combat experiences of service members before discharging them for misconduct. Yet another 22,000 soldiers have been involuntarily discharged since that 2008 legislation was passed, according to an investigation by National Public Radio. Today the Army Inspector General is conducting its own investigation, again under pressure from Congress.

Involuntary discharges for misconduct are only part of the problem. A significant number of U.S. service members who are discharged for personality disorders or adjustment disorders are also diagnosed with combat-related mental health issues such as PTSD during military medical exams.

“We’ve reviewed cases where service members have been consistently diagnosed with PTSD, yet one diagnosis of personality disorder results in their administrative separation,” Moore says. “Many are then consistently diagnosed with PTSD by VA examiners after discharge from service.”
Service members separated for personality disorders may receive honorable discharges, but they do not have access to key benefits associated with medical retirement. 

“The most valuable retirement benefit is access to the military’s health-care program, TRICARE, which provides medical care for the veteran and the veteran’s dependents,” Moore says.

Service members are reluctant to seek help, even when they know they’ve been injured – particularly when it comes to mental health issues. “There’s a kind of attitude that PTSD is a weakness – that a good soldier, a strong soldier, just works through it,” Gilberd says.

Fernandez is but one example of that attitude. The physician who examined his squad after their armored cargo carrier was hit by an IED near Fallujah in February 2006 recommended they spend a week on light duty as part of their recovery. They refused. “None of the Marines I was with or knew wanted to leave the field,” Fernandez says. “Any injury I had, I had to push out of my mind.”

That attitude is pervasive, Tapia says. “A lot of guys don’t want to report an illness or injury because they worry they will be viewed as holding their unit back.”
As a result, many aren’t diagnosed until they get out of the service, Kaufmann says.
Once back in the United States, Fernandez continued to deny he’d been injured. “I was having nightmares and intrusive thoughts,” he says. “I had the option of seeing people (medical staff), but that would have been frowned upon.”

Instead, Fernandez self-medicated. He and his buddies “drank day and night.” He flunked a random drug test and was stripped of a promotion. But the Marines allowed him to stay after he pleaded his case to a non-judicial punishment board. That is, until he got in yet another fight that left one man in a coma. He went from proud Marine to homeless addict with an other-than-honorable discharge in a matter of months.
“I was bitter,” he says. “Instead of looking at the paperwork – drug abuse – what about the two years that I served? They need to reform the rules and regulations to deal with the epidemic of psychological issues people are coming back with.”

Society shares the blame for the military’s attitude. “I think it’s a complete misunderstanding of PTSD and TBI,” Kaufmann says. “But it’s not just the military. We’re terrible with mental health in this country. We have such a lack of understanding and fear any anything mental health-related.” 

Fernandez might not have fared any better if he had sought help for his injuries. Service members who seek treatment for PTSD and other mental health issues are often harassed to the point of career-ending misconduct, Gilberd says. 
Michael Wells knows this territory firsthand. He says he encountered hostility at Fort Gordon, Ga., when he sought help for PTSD and TBI following his second tour in Iraq in 2008. His acting first sergeant tried to prevent him from getting mental health treatment; he sneaked off to his psychiatric appointments anyway, he adds. The repercussions escalated.

“He tried to take away my security clearance,” Wells says of the first sergeant. “He threatened me with physical harm.” Amber Wells, who met her future husband at Fort Gordon during this ordeal, worried Michael would kill himself. “They wouldn’t let him go to the hospital,” she says. “They would say, ‘Real men don’t get PTSD.’”
The first sergeant also blocked his attempts to apply for medical retirement, Wells says. He reported the harassment to a command sergeant major from another unit and the Army Criminal Investigation Command (CID) without result, he says. Then, finally, he just left Fort Gordon.

“He had actually gone to his psychiatrist – it’s in his records – and said, ‘If you don’t help me, I’m going AWOL,’” Amber says. “His psychiatrist basically laughed at him.’”
Fort Gordon referred questions about Wells’ case to U.S. Army Medical Command, which did not respond. However, the office of Sen. Dean Heller, R-Nev., confirmed that it is working on the case.

Once he reached the point that he couldn’t look at his uniform, Wells left Fort Gordon and traveled the country until he was certain his unit had dropped him from the rolls. He then turned himself in at Fort Knox, Ky., where he was given an other-than-honorable discharge. He spent the next three years scraping by with Social Security disability and low-income housing while fighting to get help for PTSD, TBI, and neck, back and hip injuries. An Idaho employer fired him when it discovered he had PTSD, on his third day on the job. Other help was off-limits. “There were a lot of outreach programs and veterans services I couldn’t use because I had an other-than-honorable discharge,” Wells says. “We survived on just over $1,000 a month for a couple of years.”  

Amber filed VA disability claims on his behalf and scoured the Internet for help. She connected with Reno, Nev., radio host Boone Cutler and his wife, who raised the money to bring the Wells family and their two children to Reno. There, Michael finally got his first treatment at the local VA, but only after threatening to kill himself.
“It took me getting hospitalized for PTSD, survivor’s guilt and suicidal thoughts,” he says. 

Cutler also connected Michael with Heller, whose staff was instrumental in getting his discharge upgraded to general under honorable conditions because of his PTSD. And VA eventually granted Wells a 90 percent disability rating for PTSD and hip problems. Today, he and his family are living in Texas, where he is undergoing a series of hip
surgeries. Heller’s office is helping him pursue a 100-percent disability rating.
It’s been an arduous and dispiriting journey, Amber says. “Even after you fight for your country, you have to come home and fight for your benefits,” she says. But they believe Michael’s case shows that with persistence and the right advocate, other service members can overcome a bad discharge. 

“It took five years,” he says. “But I want other soldiers to know that it’s possible. No matter what, keep trying.”  
 Ken Olsen is a frequent contributor to The American Legion Magazine [1]
This is a link and a PDF for the form needed to initiate an upgraded discharge:

Another Government Agency in Distress

From: The American Legion Magazine, June 2106

More than medicine
By Joseph J. Frank

Until the land mine went off, it was a pretty routine assignment. I was directing a truck loaded with sandbags to a bridge site at Tam Ky, in what was then South Vietnam. The road from base camp to the river had been swept for mines, but the truck swerved left, off the main path. There was an explosion, but I didn’t hear it. The next thing I remember is lying flat on the ground, sensing my legs were still in the air. A medic was immediately upon me, pushing painkillers through my skin, to go along with numbing shock. Strange thoughts entered my mind. Someone was giving me last rites. Was I dead? No, I did not think I was dead. Then I heard the beat of Huey blades in the tropical air. 

I will never forget the date. It was Jan. 14, 1968, 48 years ago – the height of the Vietnam War. I had begun that day as a strapping young soldier in the Army’s 39th Engineer Battalion (Combat). It was the last morning I would rise and feel my feet hit the ground beneath me. 

I came back to the United States paralyzed from the chest down, a T4-5 paraplegic. The hardest part of a spinal injury, for many of us, is psychologically accepting the reality that no matter how hard we try, we’re never going to get up and walk again. The human brain is not easily convinced of this and continues, almost involuntarily, to attempt to solve a problem for which there are not yet any medical answers. 

For me, this new and different life began at the Hines VA Spinal Cord Center in Chicago. There, I had doctors and counselors who understood not only my condition but my context. Healthy soldier one day and paralyzed veteran the next, I had suddenly returned to the United States to begin the yearlong rehabilitation from an injury in a war that most Americans misunderstood or hated. Some would look at me and see an illustration of political viewpoints I did not necessarily share with them. 

In a ward with 32 other paralyzed veterans I learned to get dressed in the morning, take care of myself, operate my wheelchair, keep my upper-body muscles strong and drive a vehicle without the use of lower limbs. I also learned what it means to have health-care services specific to my status as a veteran, delivered in the company of others who have served in uniform. As a young veteran in need, I realized that VA care is a cherished benefit reserved only for those of us who pledged our lives to defend our nation. It’s something we get in return for what we have given.

As the VA privatization movement rattles through Washington heading into the fall elections, I think back to that year I spent at Hines. After I got used to my wheelchair, I started helping other paralyzed veterans in the ward as some had done for me when I arrived. I made several discoveries that first year of major adjustment, and those discoveries have guided my career as a champion for veterans and people with disabilities alike. 

I discovered, for instance, that veterans need caregivers who understand the post-military journey, whether we are looking for relief from post-traumatic stress disorder, trying to figure out a new prosthesis, hunting for a job, filing a claim, buying a house or getting checked for hepatitis C. As an American Legion member, and later as a counselor and service officer in the St. Louis VA system, I also discovered why it’s important to be both a constructive critic and a tireless advocate of VA health care. We address the system honestly and demand improvements when needed because VA health care belongs to us, the veterans who use it. Too often today, I find that the biggest supporters of VA privatization are not VA patients at all. Many are not even veterans.

Too often, veterans’ criticism of VA has been misinterpreted as condemnation. And our calls for change and reform within the system have been erroneously translated into a perceived demand for its transfer to the private sector. The American Legion has supported the 2014 Choice Act and its provisions only as a temporary measure for veterans whose VA facilities are unreasonably distant or overbooked. The Legion opposes permanent use of non-VA providers, as well as expansion of vouchered care to the private sector, for a number of relevant economic reasons, including lower average cost per patient – but there’s much more to it than that.
More importantly, VA consistently outperforms other providers in terms of patient satisfaction and quality. That was certainly the case for me in VA’s spinal cord program, which is superior. A VA health-care provider is far more likely to know where to turn for answers on claims applications, disability ratings adjustments, or college and career help. VA health care is more than medicine. It’s a network of people – providers and patients alike – who care about veterans in ways non-VA medical practitioners can’t be expected to understand, let alone provide. Why would we ever want to take this benefit – a health-care system that understands the context of our lives as veterans and can help us in multiple ways – and hand it off to private providers whose quality probably ranks lower and cannot fully understand our needs and the services available to meet them? Outsourcing is only preferable when veterans have no other choice, such as those who live in rural areas distant from VA facilities.

I was honored to serve on the presidential committee of people with disabilities that brought into existence the Americans with Disabilities Act (ADA), which improved the lives of millions and continues to do so. Not only did the ADA open doors and make upper floors accessible to people who use wheelchairs, it changed perceptions. I remember vividly that, in 1968, children were often frightened by wheelchairs. Today my grandkids want to ride on mine. My work on the ADA, and its success, proved that revolutionary positive changes can be accomplished even when dealing with the federal government, and greater understanding can be achieved on a bigger scale about people outside the average U.S. demographic, like those of us who use wheelchairs and military veterans.

The year I was elected national commander of The American Legion, Congress passed the Veterans Health Care Eligibility Reform Act of 1996, which opened up VA to all who honorably served our nation. Priority groups were established to ensure that those with the greatest needs and service-connected conditions would move to the front of the line should demand exceed capacity. As demand grew and capacity did not, today’s access problem understandably arose. The movement to expand privatization because we haven’t solved the access-demand problem seems to suggest that veterans don’t deserve the quality care we fought to achieve in our VA system. Now that quality is great, we will need to go someplace else. That’s pretty hard to accept, regardless of your service-connected disability rating.

A couple of years ago, I went back to the Hines VA center, where this journey began. This time, I was on a completely different mission, conducting an American Legion System Worth Saving site visit. The chief of the center met our group there, and he brought with him a yellowed file from 1968. It was mine. In it was a written chronicle from my arrival as a frightened, young and newly discharged soldier whose future was irreversibly changed, through my wheelchair training, weightlifting, psychological counseling and driving lessons. I was carried into that VA facility and I drove away from it, back to my family in Missouri where I would start a new life. I have been independent, happy and productive ever since, with the benefit of great family support. I knew then, from my experience at Hines, that what lay ahead for me wasn’t always going to be easy, but there are ways to solve almost any problem.  

Joseph J. Frank served as national commander of The American Legion from 1996 to 1997. He also worked as a benefits officer for Paralyzed Veterans of America and as a peer counselor in the Robert Woolsey Spinal Cord Center, attached to the St. Louis VA Health Care System. He often speaks at schools and veterans events about his career in advocacy.