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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The Rating Schedule and Special Monthly Compensation
By Thom Stoddert


How does the VA come up with those wonderful percentages that often seem so stupid or doesn’t make any sense? The answer is very easy; it’s all very complicated.

Remember this concept “lack of function.”  Lack of function comes in many forms. It is when a vet can no longer extend his leg fully to 140 degrees. Lack of function can also be measured by laboratory values; this is true for respiratory diseases. The VA always tries to rate a disability that a veteran has by the amount of the loss of function it has caused.

The VA has a manual, the Rating Schedule, to aid them in determining how much function is lost and what the appropriate rating percentage should be. This manual is larger than a New York City telephone book and covers most medical conditions. So when the VA medical examiner measures the amount of movement a joint has, it is recorded and read by a member of the Rating Board who assigns a percentage from the manual. 

A higher level of compensation paid can be considered if there is a complete loss of use for a hand, foot, or a knee, just as if it was amputated. This is called Special Monthly Compensation; more about this later.

There are many laws that must also be considered that can cause a higher percentage at the time the rating is made. For example: is the other paired organ injured, what other organs are affected by the primary condition, and what are the social and occupation involvements that are involved? These are some of the questions that must be looked at. Read and reread your rating letter carefully. It is supposed to tell you how you were evaluated and how a higher percentage of rating can be considered. If you think something was missed, find somebody who knows the laws, there are many good online sources as well as your local Service Officer. You have one year to dispute any rating before it becomes final, just by sending in additional evidence and an explanation.

Another question, what about those medical issues that can not be readily seen. The vet looks fully functional, but is rated/paid at the 100% level. These are usually mental health problems, such as PTSD and/or Traumatic Brain Injury. There is no loss of physical movement, but there is a major impairment to the veteran’s social and occupational efforts.

These issues are rated after the veteran explains to a doctor what is going on in his or her life. The examining physician is supposed to probe the veteran for the issues hurting them and then describe the symptoms in his report to the Rating Board. The Rater will assess the report and compare it to the list of symptoms in the rating manual. The Rater uses the veteran’s statements, medical treatment records, examinations, and other records to form a picture of the vet and then provide the rating percentage.

The veteran really does need to prepare for a mental health related exam, not so they can exaggerate a story, but to be able to explain what is happening. So many vets think everything is not that bad and until you talk to their spouse or friends, you may not realize how bad it is.

I said earlier there are rating percentages that are assigned based on laboratory values. A good example of this are AIDS related illnesses and cancers. The amount of the body’s red cells and white cells found in the blood are the discriminating factors in this portion of the rating scheme because they reflect disability. Keep in mind that abnormal laboratory values are not a service connectable condition; they are only measurements of a medical condition that can or cannot be granted service connection.

There are special considerations for a veteran’s rating called Special Monthly Compensation. There are cases where a veteran is just 20% for his back. This engenders a mild loss of movement range, yet in reality the veteran is on several medications for pain and muscle spasms. The vet can not walk to the mailbox without tiring, nor can he drive very far. Essentially the vet is confined to his house. With medical evidence he or she may be considered for House Bound benefits. There are also even higher benefits that can be added to the rating called Aid and Attendance if the veteran is in need of special higher level medical care for daily needs. 

Special Monthly Compensation is paid out in addition to your rating percentage.

Other issues that are considered for Special Monthly Compensation are bilateral loss of hearing or sight, hospitalization greater than 21 days for a service connected condition, or loss of a reproductive organ. A veteran may receive a 60% rating for a medical condition after already being awarded total and permanent for other conditions. This is often seen in cases where the veteran is considered unemployable for PTSD and several years later the arthritis in his or her back is so disabling on its own as to warrant another 60% or higher.

So just because you are already considered to be 100%, do think about and claim those issues that have gotten worse over the years. They can lead to additional compensation and benefits that may carry over to your spouse.

To help ensure that you have all the information, use the VA website, www.warms.vba.va.gov. When you get there in the first box type your query and in the lower box select either “Compensation or Pension 21” or “38 Code of Federal Regulations.” This website is very thorough so patience and time are essential.

I hope this month’s article helps you understand a rating decision is more than how much money you will or will not get.

Thom Stoddert, former VA Rating Specialist
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