Thomas W. Stoddert, US Army Retired, is right on every point and I applaud his courage to write a very exacting letter.  My tenure at Madigan Army Medical Center as the NCOIC of the Department of Medicine made me aware of mismanaged policies and management issues.  I worked with a wonderful staff of professionals and paraprofessionals who conducted themselves very appropriately and courteously, with politeness, knowledge, experience and timeliness.  However, all of our efforts were frequently clouded by the frustrations of personnel shortages, ancillary demands of personnel, frustrations secondary to multi-echelon mismanagement issues, and numerous other problems.

The Department of Medicine includes 13 separate sections, clinics, and sub-departments, each with specific medical missions comprised of doctors, PA's, nurses, medical technicians, and support personnel, including military and civilian staff.  Some clinics have direct access through central appointments while many others required a referral from the primary care provider.  All too often miscommunication between various services and ancillary personnel would complicate scheduling problems.  An appropriate example: Patient "A" might be scheduled to see doctor "Z" in a specific clinic, but Dr. Z had to cancel all appointments because he/she had to support another military mission somewhere else on post or deploy to another country.

Frequently, the appointment schedule confusion was not because of medical staffing, but due to Central Appointments or Tri-Care issues for providing less than appropriate information to the patient and the provider.  Regardless who was at fault, the senior enlisted member of each clinic, section or department always tried to resolve relevant matters at the lowest level before involving the members of the Patient Representative Office and Patient Affairs Office. 

As the NCOIC or the department, I coordinated with the Patient Representative Office and Patient Affairs Office and designed placard's which identified the OIC and NCOIC of each clinic, section and department with a current photograph and a customer service statement bent on resolving problems or complaints at the lowest level.  The commanding general at the time accepted the design and ordered that it be implemented throughout the hospital.  The implementation was done in 2000 and I hope it is still in place. I am confident that the NCO's and OIC's at each level are fully capable of resolving conflicts and complaints, providing they get support from the senior management of medical care at Madigan Army Medical Center.

On the other hand, I and many others have all too often witnessed many frustrated and dissatisfied patients and family members who lack the patience to allow the system to work as it is designed.  These patients complain every chance they get and they become very loud and ugly about it, making treats, breaching the chain of command, and writing letters and memos to anyone who will listen.  The members of the Patient Representative Office and Patient Affairs Office do everything possible to bring providers and patients to a equitable arrangement, resolve appointment conflicts and ultimately bend-over-backwards.  Still, the patient complains and will ultimately use the same tactic every time they feel the need, regardless of how well or how often they have been treated with the same professional level of care that all patients and family members are given.

I am not blind and I do not wear rose colored glasses.  I know there are problems with the management of care at Madigan Army Medical Center and other military medical facilities.  However, there is no single mission in the military service that is as resource intensive as the medical mission on a daily basis.  Then the medical facilities must comply with and satisfy military and civilian laws, protocols, standards, inspections, and funding agencies.  All of this while still supporting the military missions of deployments, training, education, reassignments, and command emphasis issues. 

So, yes, a problem exists, but it will take the collective initiative of the soldier's at each facility to make the improvements, with the support of the Army Medical Corp senior management and mass influence of money and personnel.

Sincerely,
Alan B. Candia
U.S. Army (Ret.)   

Reader's Response Below
Thank you for your courage to tell it like it is!   The General is a good person but what can one person do?   Do you know who the members of her so-called command group are?   The Deputy Commander for Administration is ineffective, disinterested, weak and lame.   The Deputy Commander for Clinical Services is pretty smart but he is a poor leader, has no clue what his subordinates are supposed to do and he is leaving in a few weeks.   The Deputy Commander for Nursing is also lame and she is about to retire.   The Hospital Sergeant Major is also about to retire!    In addition to the problems you described, there are many others.   For example, I wish someone would approach Mr. and Ms. Horrell  and ask them what they know about nepotism and the merit system!   Madigan is a wonderful institution and has many great people but the fat, ineffective and overstaffed upper management needs to replaced and realigned now!  

Husband of a very concerned member of the Madigan Team  
Question:
I am rated 100% unemployability. My ratings are as follows.
30% for chlorache from Agent Orange exposure
30% for PTSD
40% for diabetes
It also says on my award letter, "No Future Exams."
My question is do you think they can re-examine me in the future and take away my benefits?
Thank You,
Bob Clark

Answer:
Bob, Thanks for writing in to the "Veteran's Voice."

The VA can require a future exam at any time  if they feel there may be an issue of fraud or if a   gross mistake was made. But generally in cases like yours where they say no future exams,
they mean just that.

The VA can, if they have sufficient reason, propose to lower a rating percentage only if they        believe you may have gotten better or something has happened and they have to review
certain awards. This can happen as an example as the result of a mandate from Congress. The   issue of PTSD, was getting a lot of nasty attention by the national press and the VA went back   and started looking at this issue when it was awarded to  non-combat veterans.

However, the general rules are basically after five years, service connection can not rescinded,   but the rating percentage can be lowered; after ten years there can be no reduction in the rating percentage or severance of a service connected condition unless there was fraud.

All this to say, if you got a fair rating and they have said no future exams, just run with it. The  VA does not like to hassle vets when they do not need to.

Now, the down side, FYI. The VA does  routinely check up to see if you are working and so does    the Social Security Administration. They both allow you some grace in making some extra income because they know staying home vegetating is harmful. However, 100% unemployability is just that and both agencies frown on a veteran receiving benefits because they can not work and then go out and work full time. So check carefully and see what they allow you. I was told recently that these rules may have changed not too long ago.

Assuming you are not working you may want to consider doing volunteer work in the community and/or working with veterans. Here is where the fun starts. The VA, through the education department,  will sometimes purchase items to make a veteran's life more meaningful. In my case they helped me purchase computer equipment so that I can write like I am now and aid other veterans. Now that there is a war on, there are many opportunities to use your talents and experiences for others, particularly other vets.

So good luck and welcome home.
Thom
Thom Stoddert
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Stoddert Assignment Berlin
Special Cases of Unemployability

By Thom Stoddert


For those special veterans like Butch C. from Missouri, a few words about a federal regulation of the VA called 38 CFR 4.16, or the extra scheduler benefit. Butch is a Viet Nam veteran who represents many veterans that get stuck between reality and hard regulations. However, Butch is both smart and articulate.  First, he got some skilled service officers who have worked with him. Second he did his homework well; he learned the regs.

Though he is service connected for Diabetes at 20%, this doesn’t show his true impairment due to military service. He has been a truck driver most of his life with an impeccable record. However, federal regulations unrelated to the VA deny him his all important Commercial Drivers License because he takes insulin to control his disease. In other words once he has been prescribed insulin injections he could no longer drive a truck/commercial vehicle and earn a living.

So now in his early 60s and he is unemployable at his usual career. He is not likely to find gainful employment in a related career field and the present economy is only making things worse for him and probably a lot of other veterans.

Therefore with the 1) loss of earning potential, 2) his longevity at the present career, 3)overall education, and 4) the present economic climate, all make the likelihood of gainful re-employment with his service connected medical issue(s) unlikely. Thus the need for an extra-scheduler rating for unemployability because Butch does not meet the normal criteria for individual unemployability and he did learn about 38 CFR 4.16 which reads:

“ 38 CFR 4.16(b) It is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled.  Therefore, rating boards should submit to the Director, Compensation and Pension Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) of this section.  The rating board will include a full statement as to the veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue.”

Normally a veteran must be rated at 60% for a single medical issue OR have a total of 70% for several issues and one of which must be rated at least at 40%. The Rating Board must consider the issue of Individual Unemployability (I/U) when these percentages exist and there is reasonable evidence of lack of employment. In most cases the VA informs the veterans -  that if in fact he or she is actually not working, a VA form 21-8940, request for unemployability, should be filed.

State specifically that you know that you don’t meet the normal requirements under 38 CFR 4.16 for I/U, but that you are in fact not working and not employable because of service connected issues. Do request an extra-schedular rating and provide the evidence they will need. My suggestion here is to not only submit  the VA form 8940, but send in any information from your former employer(s) indicating why they let you go and when. The VA will try to verify the information documented on the 8940.

Act fast and don’t assume your former boss still has the information the VA needs; do provide what you may already have. Many small shops discard employee information after the completion of the first tax year, and the new secretary hired after you left can’t think beyond his or her fingernails. So take responsibility here and do not rely on a former boss to rapidly address the need for verification.

The word “gainful” in relationship to employment was deliberately high-lighted, because it is a key word. A job paying more than minimum wage supplied by sympathetic family members is not considered to be gainful employment. The veteran in this case would be unemployed if it were not for family. This is often true for charities that find work for the disabled; if it were not for the charity and a sympathetic employer, the vet would not be working.

Another thought to consider when gathering your evidence for the VA; are there any benefits coming in from the Social Security Administration or other such agencies? This is useful information to building and supporting your claim.

So tying this all together: do get all pertinent evidence of actual unemployment, do have the medical records and/or statements show that that the results of your military service do prevent  gainful employment. Finally do identify where all the medical treatment records are so that the VA can attempt to get them. By law they have to try or notify you of their failure to get them.

As for Butch there are many more issues he has to deal with that are not discussed here, but he and I would like to hear from you and let us know of any of your experiences with an extra-schedular rating claim; what worked and what didn’t. Have a great holiday season.

Thom Stoddert, former VA Rating Specialist
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