Category Archives: VA Puget Sound

Researchers call for more study on Agent Orange effects on vets and their kids.

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'Ranch_Hand'_run agent orange By Mike Hixenbaugh, The Virginian-Pilot, and Charles Ornstein, ProPublica

More than two decades of studying Agent Orange exposure hasn’t produced a solid understanding of how the toxic herbicide has harmed Vietnam War veterans and possibly their children, according to a report released Thursday.

Additional research is long overdue, the report said, but the federal government hasn’t done it.

Those are among the conclusions of a committee of researchers that, since 1991, has been charged by Congress with reviewing all available research into the effects of Agent Orange, which the U.S. military sprayed by the millions of gallons in Vietnam to kill forests and destroy enemy cover.

Over the years, the biennial reports produced by the committee have identified numerous illnesses linked to the herbicide, in some cases leading the Department of Veterans Affairs to extend disability compensation to thousands more veterans.

But in its tenth and final Agent Orange report 2014 with most Vietnam vets now well into their 60s or older 2014 the committee concluded there’s still much to learn and not enough research underway, especially related to potential health consequences for the children and grandchildren of veterans who were exposed.

“Although progress has been made in understanding the health effects of exposure to the chemicals,” the committee members wrote near the end of the 1,115-page report, there are still “significant gaps in our knowledge.” Continue reading

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Ailing Vietnam vets hunt through ships’ logs to prove they should get benefits

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'Ranch_Hand'_run (1)

by Charles Ornstein and Terry Parris Jr., ProPublica, and Mike Hixenbaugh, The Virginian-Pilot

During the Vietnam War, hundreds of U.S. Navy ships crossed into Vietnam’s rivers or sent crew members ashore, possibly exposing their sailors to the toxic herbicide Agent Orange. But more than 40 years after the war’s end, the U.S. government doesn’t have a full accounting of which ships traveled where, adding hurdles and delays for sick Navy veterans seeking compensation.

The Navy could find out where each of its ships operated during the war, but it hasn’t. The U.S. Department of Veteran’s Affairs says it won’t either, instead choosing to research ship locations on a case-by-case basis, an extra step that veterans say can add months 2014 even years 2014 to an already cumbersome claims process. Bills that would have forced the Navy to create a comprehensive list have failed in Congress.

As a result, many ailing vets, in a frustrating race against time as they battle cancer or other life-threatening diseases, have taken it upon themselves to prove their ships served in areas where Agent Orange was sprayed. That often means locating and sifting through stacks of deck logs, finding former shipmates who can attest to their movements, or tracking down a ship’s command history from the Navy’s historical archive.

“It’s hell,” said Ed Marciniak, of Pensacola, Fla., who served aboard the USS Jamestown during the war. “The Navy should be going to the VA and telling them, 2018This is how people got aboard the ship, this is where they got off, this is how they operated.’ Instead, they put that burden on old, sick, dying veterans, or worse 2014 their widows.” Continue reading

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Veterans’ hospital performance similar to other U.S. hospitals | Reuters

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veteran-affairs-seal-vaFor older men with heart attack, heart failure or pneumonia, being treated at a Veteran’s Affairs (VA) hospital carries similar risks of death or hospital readmission compared to other facilities, according to a new study.

Rates of death from any cause within 30 days of admission were slightly lower at VA hospitals, and hospital readmission rates were slightly higher, but the differences were very small, researchers found.

Source: Veterans’ hospital performance similar to other U.S. hospitals | Reuters

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US to pay for Agent Orange claims – AP

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veteran-affairs-seal-vaEnding years of wait, the government agreed Thursday to provide millions of dollars in disability benefits to as many as 2,100 Air Force reservists and active-duty forces exposed to Agent Orange residue on airplanes used in the Vietnam War.

The expected cost over 10 years is $47.5 million, with separate health care coverage adding to the price tag.

Source: News from The Associated Press

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VA distance requirement will no longer be “as the crow flies”

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A black crowWashington — In order to expand eligibility for the Veterans Choice Program, the Department of Veterans Affairs (VA) today announced that it will change the calculation used to determine the distance between a Veteran’s residence and the nearest VA medical facility from a straight line distance to driving distance.

The policy change will be made through regulatory action in the coming weeks.

The method of determining driving distance will be through distance as calculated by using a commercial product. The change is expected to roughly double the number of eligible Veterans.

Continue reading

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VA makes it easier for you to get your benefits

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See the changes to VA benefits
Its now faster, easier and more efficient to file claims
See the changes to VA benefits

Today, claims become faster, easier and more accurate

Starting today, March 25th, VA is streamlining claims processes; to deliver benefits faster and more accurately.

See the changes to VA benefits

Three important changes are now in affect.

Informal claims have migrated to a new intent to fileprocess.

Use of standardized forms is now required when filing for benefits.

Initiating an appeal requires a standardized notice of disagreement form.

To learn how the new standardized forms and intent to fileprocess affects you:

See the changes to VA benefits
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New, easier, online way to apply for VA benefits

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Online Tools, Standardized Forms, and More

veteran-affairs-seal-vaEffective March 24th, 2015, VA is implementing improvements to make it easier for you to apply for benefits.

Online application tools, standardized forms, and a new intent to file process will create faster and more accurate decisions on your claims and appeals.

As part of the VA’s full-scale transformation in 2015, these new changes will:

  • Streamline the benefits process, making it faster and easier
  • Use standardized forms to file disability claims and compensation appeals
  • Establish a new intent to file a claim process

See how the changes affect you:

See the changes to VA benefits
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VA eliminates net worth as health-care eligibility factor

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Instead of combining the sum of Veterans’ income with their assets to determine eligibility for medical care and copayment obligations, VA will now only consider a Veteran’s gross household income and deductible expenses from the previous year.

From the Department of Veterans Affairs

veteran-affairs-seal-vaWashington – The Department of Veterans Affairs is updating the way it determines eligibility for VA health care, a change that will result in more Veterans having access to the health care benefits they’ve earned and deserve.

Effective 2015, VA has eliminated the use of net worth as a determining factor for both health care programs and copayment responsibilities.

This change makes VA health care benefits more accessible to lower-income Veterans and brings VA policies in line with Secretary Robert A. McDonald’s MyVA initiative which reorients VA around Veterans’ needs.

“Everything that we do and every decision we make has to be focused on the Veterans we serve,” said VA Secretary Robert A. McDonald. “We are working every day to earn their trust. Changing the way we determine eligibility to make the process easier for Veterans is part of our promise to our Veterans.”

Instead of combining the sum of Veterans’ income with their assets to determine eligibility for medical care and copayment obligations, VA will now only consider a Veteran’s gross household income and deductible expenses from the previous year. Continue reading

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Health news headlines – October 24th

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Silhouettes of U.S. Soldiers at night in Iraq

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Veterans’ needs ‘should drive where they get their care,’

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On Capitol Hill, lawmakers resume work this week to resolve differences over legislationaimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointments and that some VA staff falsified records to cover up excessive wait times.

Five senior VA leaders – including former department secretary Eric Shinseki –have resigned in the past six weeks.

Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.

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Dr. Kenneth Kizer

Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outsideproviders for medical care.

Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.

An edited transcript of that interview follows. Continue reading

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Poll: Americans bristle at penalties in ‘wellness’ programs

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By Jordan Rau
KHN

Workers believe employer wellness programs should be all gain but no pain, according to a poll released Tuesday.

The poll from the Kaiser Family Foundation found employees approve of corporate wellness programs when they offer perks, but recoil if the plans have punitive incentives such as higher premiums for those who do not take part. (KHN is an editorially independent program of the foundation.)

Wellness programs, which are encouraged under the federal health law, are structured in various ways. In some plans, the worker has to join a particular program, such as an exercise class, while others focus on outcomes, such as the employees’ blood sugar or cholesterol.

Evidence is mixed about whether any substantially improve workers’ health or lower costs to employers and insurers.

The poll found 76 percent of workers thought it was appropriate for employers to offer wellness programs that promote healthy behavior.

But a majority opposed wellness plans that had financial repercussions for workers:

  • 62 percent did not think employers should charge higher health insurance premiums to workers who did not participate, and
  • 74 percent said management should not charge more to those who did not reach health goals.

after-hearing-arguments-most-say-its-not-appropriate-for-employers-to-charge-workers-higher-premiums-for-not-meeting-health-goals-polling

The Obama administration is allowing employers to link up to 30 percent of health premiums to wellness programs. Penalties and rewards for participating in a tobacco cessation program can be as high as 50 percent of the insurance plan cost. Continue reading

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Nearly 1,500 hospitals penalized under Medicare quality program

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hospital magnify 300By Jordan Rau
KHN Staff Writer

More hospitals are receiving penalties than bonuses in the second year of Medicare’s quality incentive program, and the average penalty is steeper than it was last year, government records show.

Medicare has raised payment rates to 1,231 hospitals based on two-dozen quality measurements, including surveys of patient satisfaction and—for the first time—death rates.

Another 1,451 hospitals are being paid less for each Medicare patient they treat.

For half the hospitals, the financial changes that started last month are negligible: they are gaining or losing less than a fifth of one percent what Medicare otherwise would have paid. Others are experiencing greater swings.

Gallup Indian Medical Center in New Mexico, a federal government hospital on the border of the Navajo Reservation, will be paid 1.14 percent less for each patient. Arkansas Heart Hospital in Little Rock, a physician-owned hospital that only handles cardiovascular cases, will get the largest bonus, 0.88 percent.

The bonuses and penalties are one piece of the health care law’s efforts to create financial incentives for doctors and hospitals to provide better care. They come at a tumultuous time as the technical problems of the healthcare.gov insurance portal and premium prices are stoking questions about the law’s viability. The incentives are among the law’s few cost-control provisions that have kicked in, but it is too early to tell how effective they will be in making hospitals operate more efficiently.

“This program is driving what we want in health care,” said Dr. Patrick Conway, Medicare’s chief medical officer. He said most hospitals have improved since the program began a year ago. However, even some hospitals that have gotten better are still losing money because they are not scoring as well as others or have not improved as much.

Across the country, hospital executives say they have put renewed focus on excellence in the areas that are judged. Some have clamped down on nighttime noise, one of the questions patients are asked about, by replacing squeaky wheels on food carts and discouraging nurses and workers from chatting on cell phones outside of rooms.

Others have scrambled to ensure heart attack patients always get an angioplasty within 90 minutes of arrival because that is part of the scoring. Some private insurers have adopted similar incentives.

“The thing about the government, if they start paying attention to it, we have to scramble around to pay attention to it,” said Dr. Leigh Hamby, chief medical officer at Piedmont Healthcare, a hospital system in Georgia. “It gets us moving.”

Hospitals in Maine, Massachusetts, Nebraska, New Hampshire, North Carolina, Utah and Wisconsin are faring the best, with 60 percent or more of hospitals getting higher payments, according to a Kaiser Health News analysis.

Medicare is reducing reimbursement rates for at least two-thirds of hospitals in 17 states, including California, Connecticut, Nevada, New Mexico, New York, North Dakota, Washington and Wyoming, as well as the District of Columbia.

How A Hospital Is Rated

Under the program, known as Hospital Value-Based Purchasing, Medicare reduced payment rates to all hospitals by 1.25 percent. It set the money aside in a $1.1 billion pot for incentives. While every hospital is getting something back, more than half are not recouping the 1.25 payment they initially forfeited, making them net losers.

The payment adjustments are applied to each Medicare patient stay over the federal fiscal year that started Oct. 1 and runs through September 2014. The potential bonuses and penalties were higher than they were last year, when the maximum at stake was 1 percent.

To assess quality, Medicare looked not only at how hospitals scored in comparison with each other, but also how much each improved from two years ago compared to other hospitals.

A hospital is judged on whichever score is higher, so some hospitals with subpar quality rankings are still getting more money because they showed vast improvement.

It won’t be clear how much any hospital’s bonuses and penalties amount to in dollar figures until next October because it depends on how much a hospital ultimately bills Medicare.

This year, 45 percent of a hospital’s score is based on how frequently it followed basic clinical standards of care, such as removing urinary catheters from surgery patients within two days to decrease the chance of infections. Thirty percent of the score is based on how patients rate the way they felt they were treated in the hospital, such as whether the doctors and nurses communicated well.

Medicare added its first measure of a medical outcome, looking at death rates of patients admitted for heart attacks, heart failure or pneumonia.Those mortality rates, calculated from the number of Medicare patients who died in the hospital or within a month of discharge, count for 25 percent of a hospital’s score.

The incentive program has received a mixed reception among hospital executives. Some complain that patients’ views sometimes are swayed by the swankiness of the hospital, and that hospitals that treat the very sickest patients often get the worst evaluations.

Physician-owned hospitals that focus on just a few specialties have tended to do particularly well in the program, as evidenced by the Arkansas Heart Hospital’s record bonus this year. Some leaders also object that even if they show improvements, their hospital can lose money if the improvements are not as great as others.

Will Penalties Bring Change?

Researchers are unsure whether the penalties are significant enough to trigger major improvements, especially in areas such as mortality, where there’s no definitive explanation for why some hospitals do such a better job than others in keeping patients alive.

“Shame and penalties, I don’t know if that’s the best way to get organizations to change,” said Leslie Curry, a researcher at the Yale School of Public Health.  Her work has found that hospitals with low mortality rates are the ones where it is a priority of executives and where there is a culture where front-line workers such as nurses and lab technicians feel comfortable raising concerns to doctors and devising better methods.

“The fiscal penalties are nominal, frankly, in the scheme of things,” she said.

Others say even small differences in payments provide strong encouragement for hospitals to improve. “Sometimes institutions may think they’re performing excellently until they see outside data that compares to your peers,” said Dr. Richard Bankowitz, the chief medical officer of Premier, a group that works with hospitals to improve quality. “People are motivated to excel. Nobody wants to be in the bottom quartile anymore.”

The addition of mortality rates into the scores provides hospitals with their biggest challenge yet. Amanda Berra, a consultant at The Advisory Board, a Washington health care consulting firm, interviewed 40 chief medical officers at hospitals about mortality rates.

“They were very split. About half of them said you could not have a more powerful measure. On the other side we heard people who were really unenthusiastic,” she said. “We heard that the data is not super meaningful. They felt they had drastically improved in recent years and have kind of gotten where they could go.”

The average penalty grew to 0.26 percent, up from 0.21 percent in the first year of the program. North Georgia Medical Center in Ellijay is the only hospital besides Gallup to lose more than 1 percent of its reimbursements: it will lose 1.04 percent.  Denver Health Medical Center, a highly respected safety-net hospital, is losing 0.71 percent of its reimbursements.

The hospital that was penalized the most last year, Auburn Community Hospital in upstate New York, reduced its 0.90 penalty, but will still lose 0.55 percent.

The average bonus was 0.24 percent, almost the same as last year’s 0.23 percent. Large bonuses are going to some major teaching hospitals, such as Thomas Jefferson University Hospital in Philadelphia and Duke University Hospital in Durham, N.C. Most are being distributed among smaller institutions, such as Pikeville Medical Center in Kentucky.

“The dollars are less important in terms of impact than the fact that the nation is sending a signal through the payment mechanism that there’s something to be worked on in the care we deliver,” said Nancy Foster, an executive at the American Hospital Association. “It’s a national symbol to health care providers that here is an area where you can do better.”

Many Past Winners Continue To Get Bonuses

Most winners from last year stayed winners and losers stayed losers. But there were some switches. Oaklawn Hospital in Marshall, Mich., improved its score the most from last year. In place of a 0.26 penalty, Oaklawn will receive a 0.65 percent bonus. A number of prominent academic medical centers also turned around their scores.

Vanderbilt University Medical Center in Nashville, Massachusetts General Hospital in Boston, New York-Presbyterian Hospital in Manhattan, Cedars-Sinai Medical Center and Ronald Reagan UCLA Medical Center, both in Los Angeles, and Yale-New Haven Hospital were among the 300 places that went from a penalty to a bonus.

A total of 416 hospitals that won bonuses last year will be penalized this year. Centura Health-St. Thomas More Hospital in Canon City, Colo., dropped from a 0.08 percent bonus to a 0.72 percent penalty, the largest decrease.

This program is one of several Medicare has launched to make hospitals and doctors pay more attention to how their treatments compare with other hospitals, and to be more careful with public money.

Medicare gives bonuses to the private Medicare Advantage insurance plans that score well on quality metrics. In 2015, the health law calls for the government to begin a quality payment program for physician groups of 100 professionals or more, and that is to be expanded to all doctors by 2017.

The goal of all these programs is to replace the current financial incentive in Medicare, in which the only way for a hospital to get paid more is to perform more procedures and take on more patients.

For hospitals, the quality payments come on top of Medicare’s penalties on 2,205 hospitals with higher than expected readmission rates. The agency is doling out a maximum punishment this year of 2 percent.

As a result two out of three hospitals are losing money starting last month from the combined effects of the quality and readmissions programs. Pineville Community Hospital in Kentucky is losing 2.57 percent of its reimbursements, the largest penalty in the country.

Twenty-one other hospitals are losing 2 percent or more. These cuts come on top of reductions in special payments that go to hospitals that treat large numbers of low-income people.

Only 729 hospitals will end up with an increase in payments from the combined readmissions and value-based programs. Maine Coast Memorial Hospital in Ellsworth fared the best, gaining 0.80 percent.

Hospitals that are designated as critical access facilities, certain cancer hospitals and places with too few cases to be accurately measured were excluded from both programs.

Maryland hospitals are exempt because that state has a unique payment arrangement with Medicare.

Medicare relies on information found on hospital bills to determine the quality of care. In judging death rates, Medicare looked at patients admitted from July 2011 through June 2012, and compared those rates with how the hospitals performed between July 2009 and June 2010.

For the clinical and patient satisfaction measures, Medicare assessed hospital performances from April 2012 through December 2012, and compared them with scores during the same months in 2010.

The amount of money at stake increases to 1.5 percent of payments in October 2014, and continues to grow by a quarter percent until it reaches 2 percent.

Medicare is planning to add new measures next year, including comparisons of how much patients cost Medicare at different hospitals and rates of medical mishaps and infections from catheters.

In addition, the maximum readmission penalties grow to 3 percent next year, and Medicare is launching a third incentive program that takes an additional 1 percent of payments away from hospitals with the most patients who suffered injury or infection during their stay.

Combined, these three quality programs have the potential to strip away as much as 5.5 percent of Medicare payments from the worst performing hospitals starting next October.

“We’re moving more toward outcomes measures,” Conway said. “We’re moving away from volume and toward quality.”

Read More:

jrau@kff.org

This article was produced by Kaiser Health News with support from The SCAN Foundation.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Jerral Hancock and Stacie Tscherny Portrait

Finally home, injured vets face new lives as VA faces costs

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By Jessica Wilde, News21

This report is part of a project on post-9/11 veterans in America produced by the Carnegie-Knight News21 program.

Jerral Hancock wakes up every night in Lancaster, Calif., around 1 a.m. dreaming he is trapped in a burning tank. He opens his eyes, but he can’t move, he can’t get out of bed and he can’t get a drink of water.

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

Hancock, 27, joined the Army in 2004 and went to Iraq, where he drove a tank. On Memorial Day 2007 — one month after the birth of his second child — Hancock drove over an IED. Just 21, he lost his arm and the use of both legs, and now suffers from post-traumatic stress disorder.

The Department of Veterans Affairs pays him $10,000 every month for his disability, his caretakers, health care, medications and equipment for his new life.

Jerral Hancock and Stacie Tscherny Portrait

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

No government agency has calculated fully the lifetime cost of health care for the large number of post-9/11 veterans of the wars in Iraq and Afghanistan with life-lasting wounds.

But it is certain to be high, with the veterans’ higher survival rates, longer tours of duty and multiple injuries, plus the anticipated cost to the VA of reducing the wait times for medical appointments and reaching veterans in rural areas.

“Medical costs peak decades later,” said Linda Bilmes, a professor in the Kennedy School of Government at Harvard University and coauthor of “The Three Trillion Dollar War: The True Cost of the Iraq Conflict.”

As veterans age, their injuries worsen over time, she said. The same long-term costs seen in previous wars are likely to be repeated to a much larger extent.

Post-9/11 veterans in 2012 cost the VA $2.8 billion of its $50.9 billion health budget for all of its annual costs, records show. And that number is expected to increase by $510 million in 2013, according to the VA budget.

Like Hancock, many veterans returning from Iraq and Afghanistan have survived multiple combat injuries because of military medicine’s highly advanced care. Doctors at Brooke Army Medical Center in San Antonio repaired Hancock’s body with skin grafts and sent him to spinal-cord doctors for the shrapnel that ultimately left him paralyzed. He still has his right arm, but he can only move the thumb on his right hand.

Injuries like Hancock’s likely will lead to other medical issues, ranging from heart disease to diabetes, for example, as post-9/11 veterans age.

“So we have the same phenomenon but to a much greater extent,” Bilmes said. “And that drives a lot of the long-term costs of the war, which we’re not looking at the moment, but which will hit in 30, 40, 50 years from now.”

Veterans like Hancock with polytraumatic injuries will require decades of costly rehabilitation, according to a 2012 Military Medicine report that analyzed the medical costs of war through 2035. More than half of Iraq and Afghanistan veterans are between the ages of 18 and 32, according to 2011 American Community Survey data. They are expected to live 50 more years, the Institute of Medicine reports.

About 25 percent of post-9/11 veterans suffer from post-traumatic stress disorder, and 7 percent have traumatic brain injury (TBI), according to Congressional Budget Office analyses of VA data. The average cost to treat them is about four to six times greater than those without these injuries, CBO reported. And polytrauma patients cost an additional 10 times more than that.

Post-9/11 veterans use the VA more than other veterans and their numbers are growing at the fastest rate. Fifty-six percent of Iraq and Afghanistan veterans use the VA now, and their numbers are expected to grow by 9.6 percent this year and another 7.2 percent next year, according to a VA report from March 2013.

Jerral Hancock Drinking Water

Hancock drove over an IED in Iraq in 2007. Hancock’s stepfather, Dirrick Benjamin, helps him take his medication. He and Hancock’s mother take care of him full time, helping him with everyday tasks like getting dressed and drinking water. (Photo by Jessica Wilde/News21)

 

In response to multiple injuries suffered by Iraq and Afghanistan veterans, the VA established its polytrauma care system in 2005, creating centers around the country where veterans are treated for multiple injuries, ranging from TBI and PTSD to amputations, hearing loss, visual impairments, spinal-cord injuries, fractures and burns.

Post-9/11 veterans make up around 90 percent of polytrauma patients, said Susan Lucht, program manager of the polytrauma center at the Southern Arizona VA Health Care System in Tucson.

Each polytrauma patient costs the VA on average $136,000 a year, according to a CBO report, using VA data from 2004 through 2009. And many of their medical issues will never go away.

One TBI patient at the Tucson center, Erik Castillo, has received speech, physical, occupational, psychological and recreational therapies for all of the paralysis, cognition and memory issues associated with injuries he received in a bomb blast in Baghdad.

But Castillo’s treatment is exactly what medical professionals and economists say could potentially be cost-saving as well as life-saving.

If the VA treats primary injuries early on and creates a community and family support system, it might be able to lower costs later, said Dr. James Geiling, Dr. Joseph Rosen and Ryan Edwards, an economist, in their 2012 Military Medicine report.

“And those are the costs that we’re trying to reduce by giving the care that we do,” said Dr. G. Alex Hishaw, a staff neurologist at the Tucson center.

Castillo has been living with TBI for nine years, and he still goes to the VA three times a week for therapy. “I’ll utilize the VA for the rest of my life,” he said.

The shrapnel that entered Castillo’s brain from a bomb in Baghdad in 2004 burned a portion of his frontal lobe, which had to be removed. Doctors told his parents that he wouldn’t survive and that if he did, he would need care for the rest of his life.

Slowly, Castillo started to re-create himself. He learned to talk again, to eat again, to move his left arm and leg. Now, he is going to college.

“We want them to graduate,” Lucht said. “But they always know that this is their foundation. This space is here. And their needs will change as they age.”

As Hancock and other post-9/11 veterans age, they will need increased medical care and will become more expensive for the VA. The injuries they have now will likely lead to more complicated and expensive medical issues. TBI, for example, may lead to greater risk of Alzheimer’s disease, psychological, physical and functional problems, and alcohol-abuse disorders.

Doctors and economists argue that today’s conversation should not only be about the primary wounds of war, but about the medical issues that are often associated with them. PTSD, for example, is often associated with smoking, substance abuse, depression, anxiety, heart disease, obesity and diabetes. Amputations are associated with obesity, cardiovascular disease, osteoarthritis, back pain and phantom limb pain.

“We should help an amputee to reduce his cholesterol and maintain his weight at age 30 to 40, rather than treating his coronary artery disease or diabetes at age 50,” Geiling, Rosen and Edwards wrote.

“Society is not yet considering the medical costs of caring for today’s veterans in 2035 — a time when they will be middle-aged, with health issues like those now seen in aging Vietnam veterans, exacerbated by comorbidities of post-traumatic stress disorder, traumatic brain injury and polytrauma,” they wrote.

Polytrauma centers have expanded across the country. But that doesn’t mean that all veterans live close enough to access them. In many parts of country, health care is hampered by distance because veterans who use the VA live far away from their closest VA hospital.

For Army Spc. Terence “Bo” Jones, it is more important that he live near his family.

U.S. Army Spc. Terence “Bo” Jones stepped on an IED in Afghanistan in 2012, and lost both of his legs. Now an outpatient at the VA polytrauma center in San Antonio, Texas, Jones is learning to walk on prostheses and drive an adapted car with only his hands. (Photo by Jessica Wilde/News21)

Jones lost both of his legs to an improvised explosive device blast in Afghanistan in 2012. Like Hancock, Jones woke up at Brooke Army Medical Center with his family by his side.

He was 21 when he stepped on the IED. It shot him 10 feet into the air and he landed in a nearby well. He doesn’t remember it, but his friends told him he was conscious and trying to climb out.

Now an outpatient at the VA polytrauma center in San Antonio, Jones is learning to walk on prosthetic legs, provided to him by the VA. The VA also provides adaptive driving equipment for his car, and he is taking driver education to learn how to drive with only his hands. One day, he hopes to get a service dog, and the VA will pay for veterinary care and equipment for the dog to help its owner.

“We can get them anything that they need,” Lucht said.

The VA provides other assistive accommodations for injured veterans — from grab bars and walk-in showers to wheelchairs and specialized seating. And a lot of veterans wear out their prosthetic limbs because they’re active, Lucht said.

When Jones finishes rehab, he plans to move home to Idaho, go to college and open his own shop doing custom cars and motorcycles. But in Idaho, Jones won’t be near a polytrauma center anymore.

One of the most rural veteran populations in the country is served by the Reno, Nev., VA hospital, said Darin Farr, the hospital’s public affairs officer. “We’re actually considered frontier,” he said.

The hospital’s patients come from as far away as 280 miles. More than 29,000 veterans are enrolled in the Reno hospital, staffed by 1,200 employees, only 40 to 50 percent of whom actually provide medical care.

Many VA hospitals fall behind in entering data from private health records or following up with patients, especially mental health patients for whom follow-up care is particularly important, according to VA Office of Inspector General reports.

The VA doesn’t always provide timely mental health evaluations for first-time patients, and existing patients often wait more than the recommended 14 days for their appointments, the OIG reported last year.

Veterans have complained for many years about long wait times to schedule appointments. “Long wait times and inadequate scheduling processes at VA medical centers have been long-standing problems that persist today,” the U.S. Government Accountability Office reported in February. Inconsistent scheduling policies, staffing, phone access and an outdated scheduling system make the problem worse.

Meanwhile, both the GAO and OIG have reported that VA’s data on wait times for medical appointments is unreliable, and some schedulers entered incorrect dates or changed them to meet performance standards.

Farr says the Reno hospital faces unique challenges that might contribute to wait times. The hospital competes with other hospitals for employees who might pay more than the government does.

“We don’t have a lot of space,” he added. The hospital schedules more than 373,000 outpatient visits and 4,200 inpatient visits every year. But it only has 64 hospital beds — 14 psychiatric, 12 ICU and only 38 for general use.

When Terence Jones finishes rehab at the polytrauma center in San Antonio, he hopes adaptive equipment will help him return to a normal life. Jerral Hancock, on the other hand, knows that he never will.

Hancock misses the adrenaline rush of life before his injury. He longs for a wheelchair that will go faster than 5 mph. He described the time he fell out of his hospital bed as exhilarating. He busted his cheek open, but he loved it.

With the $100,000 the Defense Department gave Hancock for his injuries when he was discharged, he bought two mobile homes outside Los Angeles, one for him and his two children, ages 9 and 6, and one for his mother and stepfather, who take care of him full time. Hancock supports all of them with his monthly disability check from the VA.

The VA bought him a wheelchair and put a lift into his front porch. They widened the doors in his mobile home so his wheelchair could fit in and out. They will pay for his medications and all of his medical care for the rest of his life.

When Hancock arrived at his new mobile home, he couldn’t fit his wheelchair in the front door. So he kept one wheelchair inside, and his stepdad carried him through the door and down the steps to a second wheelchair that he paid for himself. It took eight months for the VA to pay him $1,000 for the second wheelchair, and four months to put a lift into his front porch.

“I was stuck in the house for six months over this fight,” Hancock said. “I had a wheelchair upstairs and I had a wheelchair downstairs. And my caretaker carried me up and down the stairs from wheelchair to wheelchair. It was ridiculous.”

The VA also bought Hancock an $85,000 arm that he could attach to his shoulder to use. But he can’t seem to get it to work.

The VA gave Hancock $11,000 toward a car, but his mother said that doesn’t come close to the cost of a handicap-equipped vehicle. Instead, he bought a seven-passenger bus with a lift for his wheelchair.

Even with all of the money that the VA spends on Hancock’s medical and family care, he still lives in a mobile home, and his bedroom has little extra space with a hospital bed and a wheelchair in it. He can’t fit into his kids’ bedrooms. He can’t drink a glass of water on his own. And his air conditioning hardly works, even though he can’t be in the heat for too long because his burns prevent him from sweating.

Hancock’s children also have had to adjust.

“My son watched me walk off — he was going on 3 — and I jumped on a bus with a couple hundred pounds of gear,” he said. “The next time he saw me, I lost 100 pounds … I looked like a skeleton and I had tubes coming out everywhere … My daughter, this is all she knows.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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