PVA From the Top

Courtesy of Al Kovach Jr.
Reprinted from PN/Paraplegia News June 2016

Talking about veterans' issues

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As the political landscape changes in this presidential election year and veterans’ issues take a backseat to campaign rhetoric, an open dialogue between Paralyzed Veterans of America (PVA) and our nation’s policymakers is particularly important.

May marked PVA’s 70th Annual Convention, as well as an opportunity to engage Rep. Corrine Brown (D-Fla.), the ranking member of the House Veterans’ Affairs Committee. Held in Jacksonville, Fla., within her congressional district, the convention provided PVA with an opportunity to invite Brown to be our keynote speaker. 

I delivered PVA’s annual testimony before the House Committee on Veterans’ Affairs in February, and Brown asked insightful questions about the future of veterans’ health care and the Department of Veterans Affairs’ (VA) accountability.  

I wanted to take this opportunity in my monthly PN column to thank Brown for keeping veterans’ issues at the top of the congressional agenda and to continue the dialogue between her and PVA. I believe it’s the first of many critical conversations we’ll have with Brown.

PVA: Do you support a permanent extension of the VA Choice Act [The Veterans Access, Choice and Accountability Act of 2014] or do you believe veterans should be free to choose when and from what doctor they get health care services?  

Brown: I believe the VA is the best forum for our veterans to receive care. The Choice Act was a good temporary option to relieve the stress on the scheduling system that had built up over many years. Because the VA is the best care for veterans, I believe the VA should be the first choice for that care.

However, if that specialty isn’t available to the veteran in a timely manner, and right now that threshold is 30 days, the VA has a duty to make sure care is available to the veteran in the community. Even before Choice, the VA was able to authorize care in the community.  It’s important to remember that the VA isn’t an insurance company. Veterans have earned their care at the VA through their service.

To require the same business outcomes at the VA does a disservice to the same veterans.  If anyone does, members of PVA understand that veterans receiving care at the VA are suffering from a multiplicity of ailments. And VA providers have the training and experience to recognize these ailments might be pointing at a totally separate diagnosis.

It’s important for the VA to be the primary caregiver for our veterans and to have primary oversight of its patients.

PVA: Do you believe that the VA secretary [Robert McDonald] has the necessary authority to hold VA employees — from senior executives to frontline staff — accountable for inappropriate actions that warrant reprimand? 

Brown: Title 5 of the U.S. Code provides the tools to reprimand, demote or remove an employee from the federal civil service for poor performance. VA managers haven’t always done a good job of using this current legal authority to fire bad employees, but they do have the tools they need to do so.

We’ve seen problems when the VA has applied its new authorities under the Choice Act to fire senior executive service (SES) members, in part because Congress didn’t lower the burden of proof needed to uphold an SES firing on appeal to the Merit System Protection Board (MSPB), and in part because we didn’t allow the MSPB to mitigate an individual’s punishment (let’s say from removal to demotion), so some VA decisions have been overturned by the MSPB.

Although these situations have led to reports that it’s too hard to fire people from the VA, what we’re really seeing is that bad actions don’t always necessitate removal. Often, demotion or another reprimand is sufficient to correct bad actions.

In sum, VA supervisors need to do a better job of applying their existing authorities to better manage their employees, to use existing tools to provide feedback so that employees can improve, and when removal becomes necessary, to follow the requisite steps outlined in Title 5 to fire those employees.

Overall, veterans tell me they’re happy with the care they receive at the VA. And given that a third of VA employees are veterans themselves, and many more come from military families, it’s important to remember that the vast majority of VA employees are doing a good job serving our nation’s veterans.

Like all other members of the federal civil service, VA employees deserve the due process protections guaranteed by our Constitution before they lose their jobs under the reactionary pretext of “accountability.” 

PVA: Do you support legislation that would expand access to the VA’s Comprehensive Family Caregiver program to veterans who are catastrophically injured, regardless of the era that they were injured?  

BrownI’ve supported the caregiver program since it was first passed in the 111th Congress. Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn veterans had been surviving catastrophic injuries that would have been fatal just a decade earlier. Something needed to be done to help those families.

We passed the Caregiver Support bill for those families. However, the language ended up limiting care only for those seriously injured. The focus at the time was for post-9/11 veterans who had been catastrophically injured to get the care they need. It was important at the time to begin a program. 

It’s time we again look at the program to figure out how to expand it, incrementally if necessary. I support extending coverage for those suffering from a catastrophic illness and those who served this country previous to 9/11, regardless of when they served.  

The program has been very successful, and no one has said that administering this program has been a burden. In fact, the opposite is true; all family members are working with the VA to make the program better and more responsive to veterans’ needs.

Brown: Has your membership been able to take advantage of the Choice program and what has their experience been?

PVA: Many have tried but face the reality that there aren’t comparable specialized services to the VA’s Spinal Cord Injury (SCI) system of care in the private sector. 

Some PVA members, including members of our leadership, have attempted to utilize the Choice program when timely VA appointments weren’t available, and a growing number of them have reported overwhelming negative experiences that we can share with you. 

While there are systems of care in the private sector that provide care to individuals with spinal-cord injury or disease (SCI/D), the standard of care drastically differs from [the] VA in terms of length of acute rehabilitation, pre-discharge planning and caregiver support.

Private providers who don’t specialize in SCI/D simply aren’t focused on comprehensive and coordinated care that’s sustained from time of injury to end of life for veterans with SCI/D.

Moreover, there are complications and common issues with SCI that most providers in the private sector aren’t fully trained to recognize, much less treat. Understanding the nuances of SCI/D, which includes the baseline information of an SCI/D patient, is critical to timely and accurate diagnosis especially in an emergency situation.

In the private sector, providers triage services on a case-by-case basis, treating a problem the patient is most obviously presenting, versus providing the multifaceted care that an SCI/D patient requires. Too often, veterans with SCI/D have been treated in the private sector and ended up in the VA SCI system due to life-threatening complications, such as bed sores and infections, from substandard care.  

For these reasons, the VA SCI system of care will continue to be critical for PVA members.

Brown: One of your priorities is the reinstatement of the Annual Capacity Report. Why is this report so important to your membership?

PVA: The VA hasn’t maintained adequate capacity to provide for the unique acute and rehabilitative health care needs of severely disabled veterans — veterans with SCI/D, blindness, amputations and mental illness — as mandated by the Veterans’ Health Care Eligibility Reform Act of 1996.  

The law required the baseline capacity of the VA SCI system of care to be measured by the number of staffed beds and the number of full-time equivalent employees assigned to provide care. It was designed to protect specialty care services within the VA because Congress recognized that the VA SCI system of care was the best option for SCI/D patients.  

When the law expired in 2008, the VA began to reduce mandatory staffing, and therefore the number of patient beds was reduced. Eight years later, there are numerous reports of VA hospitals with insufficient available beds to keep pace with SCI/D patient demands. And that demand is only increasing.

Without capacity mandates, the access to care for our members is compromised. Acceptable capacity reductions are being determined solely by fewer occurrences of spinal-cord injuries in recent wars. This model short-serves the continuum of care for PVA members injured in World War II, Korea, Vietnam [and] the Persian Gulf, as well as during stateside training exercises and non-combat deployments, which accounts for the majority of our members.

Thanks to advances in modern medicine, these SCI/D patients are living longer. But the aging process brings additional complications that require more intensive medical treatment. Their needs are higher, and VA staffing needs to keep pace to honor the nation’s commitment to these veterans. Congress can’t just look at the numbers, determine spinal-cord injury is no longer the signature injury of war and abandon the needs of older veterans.  

That’s why PVA recommends renewing the Veterans’ Health Care Eligibility Reform Act. We believe it’s critical for Congress to have oversight of this specialty system of care and hold the VA accountable to maintain capacity and meet demand. 

Brown: What’s unique about your membership’s health needs that the VA needs to address?

PVA: As explained in the first answer, the complex medical issues of SCI/D patients require comprehensive holistic treatment plans that involve every bodily system. The VA provides the only model with expertise to deliver such care over the course of a paralyzed veteran’s lifetime.

Afflictions, including neuropathic pain, spasticity, neurogenic bowel and bladder, complete or incomplete paralysis, genitourinary infections, pulmonary conditions, decubitus ulcers and renal complications, are normally treated among the SCI/D population. 

These same men and women also require treatment for non-SCI/D specific conditions such as diabetes and cancer, and some may need hospice care. These issues are systematic, meaning one system affects another, and they require a team approach. Experts trained to understand a model of care that provides treatment from time of injury to end of life are critical to SCI/D patients. 

This is why tertiary care must accompany specialized services. Specialized services that are coordinated, integrated and multidisciplinary have proven to be the standard of care necessary to sustain the life of someone with spinal-cord dysfunction. Congressional oversight is needed to ensure veterans with SCI/D are receiving these critical specialized services. 


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